Combined versus Sequential Pars Plana Vitrectomy and Phacoemulsification for Macular Hole and Epiretinal Membrane: A Systematic Review and Meta-analysis

Author: Daud F, Daud K, Popovic M M, Yeung S, You Y, Cruz Pimentel M, Yan P

Geographical coverage: North America, South America, Europe and Asia

Sector: Cataract extraction

Sub-sector: Treatment comparison

Equity focus: Not reported

Study population: Patients undergoing cataract surgery with co-existing macular hole (MH) or epiretinal membrane (ERM)

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background:

Macular holes and epiretinal membranes are common in older adults, arising from vitreous traction and leading to blurred or distorted vision. Standard treatment is pars plana vitrectomy (PPV), but many patients subsequently develop visually significant cataract. Performing PPV and phacoemulsification together (combined surgery) may avoid a second operation, yet reported visual and refractive outcomes are inconsistent.

Objective:

To compare the efficacy and safety of combined phacovitrectomy with those of sequential PPV followed by later cataract extraction in eyes with MH or ERM.

Main findings: The review included 10 studies (2 RCTs and 8 nonrandomized retrospective comparative), comprising 855 eyes (420 in the sequential group and 435 in the combined group). The included studies were conducted in North America, South America, Europe, and Asia. Most evidence was of low to moderate certainty due to the predominance of retrospective studies and high risk of bias in some included studies.

The results showed no significant difference in 12-month best corrected visual acuity (BCVA) between the combined and sequential surgery groups (mean difference, MD: +0.02 logMAR, 95% confidence interval [CI]: -0.04 to 0.08, P=0.51). Similarly, there were no significant differences in absolute refractive error (MD: -0.06 diopters, 95% CI: -0.39 to 0.28. P=0.76), MH nonclosure rate (risk ratio, RR: 0.67, 95% CI: 0.17 to 2.67, P=0.57), or most complications, including cystoid macular oedema (RR: 1.56, 95% CI: 0.85 to 2.88, P=0.15), retinal detachment (RR: 1.22, 95% CI: 0.49 to 3.05, P=0.67), posterior capsule rupture (RR: 1.59, 95% CI: 0.53 to 4.78, P=0.41), and endophthalmitis (P=0.54).

However, at the 6-month follow-up, the combined group exhibited better BCVA (MD: -0.21 logMAR, 95% CI: -0.30 to -0.12, P<0.00001), though this finding had substantial heterogeneity. The review concluded that combined and sequential surgeries yielded comparable visual and safety outcomes for MH and ERM patients.

Methodology:

CENTRAL, MEDLINE and Embase were searched to May 2022 for English-language studies comparing combined PPV + phacoemulsification with sequential surgery in MH or ERM. Reference lists of included papers were hand-searched. Three reviewers screened titles and abstracts; two assessed full texts, extracted data and evaluated risk of bias (RoB 2 for RCTs, ROBINS-I for non-randomised studies). Random-effects meta-analyses generated pooled estimates; heterogeneity was assessed with χ² and I² statistics. Subgroup and sensitivity analyses explored indication (MH vs ERM) and study quality. Evidence certainty was graded with GRADE.

Applicability / external validity:

Generalisability is curtailed by the predominance of retrospective designs, varied surgical techniques and inconsistent outcome reporting. Further high-quality randomised trials with standardised protocols and extended follow-up are required.

Geographic focus:

Studies originated from North America, South America, Europe and Asia; none were excluded on geographical grounds.

Summary of quality assessment:

Medium confidence in the review’s conclusion. Searches were comprehensive, inclusion criteria clear, and dual-reviewer processes employed. Study characteristics and statistical methods were reported transparently, and heterogeneity was investigated. Limitations are the English-language restriction, absence of a list of excluded studies and the low quality of several included reports.