Pediatric Macular Hole Outcomes with Surgical and Nonsurgical Management: An IRIS® Registry Study.

PURPOSE: To compare visual outcomes, recovery trajectories, and complication rates between surgical and observational management of pediatric macular hole (MH) using a large national registry.

DESIGN

Retrospective cohort study.

SUBJECTS: Children younger than 18 years diagnosed with MH-related pathology between January 2013 and October 2024 in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight), with a minimum of 6 months of follow-up.

METHODS

Eyes were categorized as surgical if they underwent pars plana vitrectomy with or without internal limiting membrane or epiretinal membrane peeling, or observational if managed without surgery. Best-corrected visual acuity (BCVA; logarithm of the minimum angle of resolution) was assessed longitudinally for up to 2 years. Visual acuity trajectories were modeled using generalized estimating equations, and multivariable mixed-effects logistic regression was used to identify predictors of surgical intervention.

MAIN OUTCOME MEASURES: Longitudinal BCVA, time to maximal BCVA, magnitude of visual acuity improvement, postoperative complications, and predictors of surgical management.

RESULTS

A total of 1261 patients (1390 eyes; median age, 14 years; 62% male) were included; 254 patients (20.1%) underwent surgery, and 1007 (79.9%) were observed. Surgical eyes presented with worse baseline BCVA than observed eyes (median, 0.80 vs. 0.40 logarithm of the minimum angle of resolution; P < 0.001). Both cohorts demonstrated significant visual improvement over time (P < 0.001), with parallel improvement trajectories. Surgical eyes achieved greater median improvement from baseline to maximal BCVA (-0.40 vs. -0.12 logarithm of the minimum angle of resolution; P < 0.001) and reached maximal vision sooner (median, 0.75 vs. 1.30 years; P < 0.001). Among surgical eyes, 83.5% experienced no postoperative complications; repeat MH surgery occurred in 10.6%, cataract surgery in 4.3%, retinal detachment repair in 1.6%, and no cases of endophthalmitis were observed. Worse baseline visual acuity was the only independent predictor of surgical intervention.

CONCLUSIONS

In this large registry-based study of pediatric MH management, surgical repair was associated with rapid, sustained, and clinically meaningful visual improvement with low complication rates. Nonsurgical management also yielded spontaneous clinically significant visual improvement. These findings support an individualized approach to pediatric MH management that takes into consideration baseline anatomic and visual severity, recovery trajectory, and surgical risk.

FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.