Author’s Name(s): Yosra Er-reguyeg, El Yazid Rhalem, Eunice Linh You, Anas Abu-Dieh, Mélanie Hébert, Huixin Zhang, Serge Bourgault, Mathieu Caissie, Éric Tourville, Ali Dirani

Author’s Disclosure Block: Yosra Er-reguyeg: none; El Yazid Rhalem: none; Eunice Linh You: none; Anas Abu-Dieh: none; Mélanie Hébert: none; Huixin Zhang: none; Serge Bourgault: none; Mathieu Caissie: none; Éric Tourville: Department of Ophthalmology, Hospital Saint-Sacrement, Laval University, Quebec, QC; Ali Dirani: none

Abstract Body
Purpose: Lamellar macular hole (LMH) surgery consists of pars plana vitrectomy with membrane peeling. Alternative membrane peeling techniques have emerged to improve outcomes and minimize complications of standard peeling surgery. To date, no systematic review has compared the outcomes of both techniques in the surgical treatment of LMH. The purpose of this study is to review the literature on the peeling techniques used in LMH surgery and compare their outcomes. Study Design: Systematic Review and Meta-Analysis Methods: This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and registered on PROSPERO (CRD42024547022).MEDLINE and Embasedatabases were queried. Pairwise meta-analyses comparedmean differencesin best-corrected visual acuity (BCVA) inlogMAR,LMH closure rates, and postoperative full-thickness macular hole (FTMH)rates between the flap embedding peeling technique (FE) andthe standard peeling technique (ST). Proportional meta-analyses were used to assess the prevalence of secondary outcomes such aspostoperative full-thickness macular hole (FTMH). Results: Three peeling techniques were identified: ST (29 studies, 886 eyes), fovea sparing (3 studies, 64 eyes) and FE (8 studies, 196 eyes).FE was superior to ST for improving BCVA (MD -0.20; 95% CI: -0.31 to -0.09),for LMH closure rate (RR 1.53; 95% CI: 1.23 to 1.90; I2=0%), and for postoperative FTMH occurence(RR 0.08; 95% CI: 0.01 to 0.58; I2=0%).The prevalence of postoperative FTMH was higher in the ST group (proportion: 0.04; 95% CI: 0.02 to 0.07) whereas no postoperative FTMH cases were observed for alternative techniques. Conclusion: Alternative surgical approaches appear to yield better outcomes for LMH management compared to the conventional peeling. The paucity of comparative studies and low confidence of evidence preclude definitive conclusions.