Combined versus Sequential Surgery in Lamellar Macular Holes: A Multicenter Observational Study

Abstract

PURPOSE: To compare 1-year best-corrected visual acuity (BCVA) after pars plana vitrectomy (PPV) for lamellar macular hole (LMH) between combined phacovitrectomy and sequential strategies, and to explore factors associated with postoperative visual outcome. METHODS: Multicenter observational study of adults with optical coherence tomography (OCT)-confirmed LMH undergoing PPV. Surgical sequence was classified as combined surgery or sequential surgery (PPV?phacoemulsification, PPV in pseudophakic eyes, or PPV without subsequent cataract extraction). LMHs were classified as tractional, mixed, or degenerative based on OCT criteria. BCVA (logMAR) was recorded preoperatively and at 1 year. Ceiling effect was defined as achieving 1-year BCVA ?0.22 logMAR. Independent predictors of 1-year BCVA were assessed using a linear mixed-effects model with a random intercept for patient. RESULTS: A total of 175 eyes from 167 patients were included; 1-year BCVA was available for 126 eyes (72.0%), whereas 49 eyes (28.0%) had missing 1-year BCVA. Among eyes with recorded 1-year BCVA, no statistically significant differences were detected between combined and sequential surgery (0.2 [0.1-0.3] vs 0.2 [0.1-0.3]; p = 0.939) or among LMH subtypes. Overall, BCVA improved from 0.4 (IQR 0.3-0.5) to 0.2 (0.1-0.3) at 1 year. In ceiling-effect analysis, baseline BCVA (p = 0.013) and the presence of isolated epiretinal membrane (p = 0.032) were associated with achieving BCVA ?0.22 logMAR. In the mixed-effects model, baseline BCVA was the only independent predictor of 1-year BCVA (? = 0.60; 95% CI 0.32-0.89; p < 0.001). CONCLUSION: PPV for LMH was associated with visual improvement at 1 year, and the study did not detect statistically significant differences in final BCVA between combined and sequential strategies or among LMH subtypes. Baseline BCVA was the main determinant of 1-year outcomes, supporting individualized selection of surgical sequence based on lens status and shared patient-surgeon preferences.