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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The end of submacular surgery for age-related macular degeneration: a meta-analysis

CI Falkner, H Leitich, F Frommlet, P Bauer, and S Binder.

Review published: 2007.

CRD summary

This review concluded that, compared with trials, case series showed more favourable changes in visual acuity after surgical procedures to treat age-related macular degeneration, but that this may be due to selection bias. However, given the limitations of the included evidence and the poor reporting of the review process, the results should be treated with caution.

Authors' objectives

To evaluate the results associated with submacular surgical procedures for age-related macular degeneration (AMD) across different study designs. The authors also compared the findings with the results of the Submacular Surgery Trials Research Group.

Searching

MEDLINE was searched from 1992 to 2004; the search terms were reported. The reference lists of retrieved articles were also screened. Only studies written in full, in English or German, were included.

Study selection

Study designs of evaluations included in the review

Prospective or retrospective studies with at least 5 cases and a minimum of 1 month follow-up were eligible for inclusion.

Specific interventions included in the review

Studies of the four main submacular surgical treatments were included: removal of subfoveal choroidal neovascularisation, macular translocation, pigment epithelium transplantation and removal of subretinal haemorrhage.

Participants included in the review

Studies of patients diagnosed with AMD were eligible for inclusion. Pre-operative visual acuity ranged from 0.01 to 0.31, with patients undergoing removal of subretinal haemorrhage appearing to have poorer pre-operative visual acuity than those undergoing the other surgical procedures.

Outcomes assessed in the review

Studies reporting a detailed visual outcome, defined as at least two or more lines or 0.2 logMAR unit changes, were eligible for inclusion. The outcomes reported were the proportion improved or worsened by surgery, the proportion with a final visual acuity of at least 20/200, recurrence and the proportion of complications.

How were decisions on the relevance of primary studies made?

The authors did not state how the studies were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

The authors did not state that they assessed study quality; the studies were classified using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. The proportion of patients with two or more lines of improvement or deterioration in visual acuity after surgery and complications were extracted from each study using a standardised extraction sheet.

Methods of synthesis

How were the studies combined?

Improvement and deterioration were analysed separately using logistic regression with study design as the random variable. Clopper-Pearson values were used to calculate confidence intervals (CIs). Complication rates were analysed using logistic regression with study as the random variable and treatment as the fixed variable.

How were differences between studies investigated?

Differences between the studies were discussed in the text, and study details were tabulated. Subgroup analyses were conducted on the basis of duration of minimum follow-up, study type, sample size and level of evidence.

Results of the review

Eighty-eight studies were included (1,915 cases); three were level 1 randomised controlled trials, three were level 2 cohort studies, and the remainder were lower level cohort studies or case series.

Subfoveal choroidal neovascularisation (765 cases): overall, 28% showed improved, and 25% worsened, visual acuity. The complication rate was 50% (CI: 12, 100) and the recurrence rate was 22%.

Macular translocation (792 cases): overall, 31% showed improved, and 27% worsened, visual acuity. The complication rate was 71% (CI: 8, 100) and the recurrence rate was 16%.

Pigment epithelium transplantation (94 cases): overall, 22% showed improved, and 21% worsened, visual acuity. The complication rate was 61% (CI: 29, 100) and the recurrence rate was 4%.

Removal of subretinal haemorrhage (264 cases): overall, 62% showed improved, and 13% worsened, visual acuity. The complication rate was 39% (CI: 0, 100) and the recurrence rate was 16%.

Logistic regression showed that the surgical intervention was the only significant predictor of improvement (p<0.0004), but not of deterioration (p=0.0568), in visual acuity. Study design was a significant predictor of improvement (p<0.0001) and deterioration (p<0.0001).

Authors' conclusions

Case series showed superior results of visual acuity in comparison with trials; this may be due to selection bias in the study design.

CRD commentary

The authors addressed a clear review question with defined inclusion criteria. Only one database was searched and only full publications in English and German were included, thus leading to the potential for publication and language bias. There was no report of attempts to reduce error and bias during the review process. The authors graded studies on level of evidence, but individual study quality was not assessed. Lower levels of evidence were included in the review, but this, along with other variables, was taken into account in the analysis. Given the limitations of the included evidence and the lack of reporting of the review process, the results should be treated with caution.

Implications of the review for practice and research

Practice: The authors stated that, in the absence of long-term results, there are still indications for submacular surgery, for example in patients with AMD with low pre-operative visual acuity due to large haemorrhagic or fibrotic membranes or for patients refractory to photodynamic therapy.

Research: The authors stated that future trials of alternative surgical techniques and combinations of existing techniques with pharmacological therapy or photodynamic therapy are required.

Funding

Not stated.

Bibliographic details

Falkner C I, Leitich H, Frommlet F, Bauer P, Binder S. The end of submacular surgery for age-related macular degeneration: a meta-analysis. Graefe's Archive for Clinical and Experimental Ophthalmology 2007; 245(4): 490-501. [PubMed: 16673139]

Indexing Status

Subject indexing assigned by NLM

MeSH

Humans; Macular Degeneration /physiopathology /surgery; Ophthalmologic Surgical Procedures; Visual Acuity /physiology

AccessionNumber

12007001406

Database entry date

30/09/2008

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 16673139