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

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 (β = 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. Plain Language Summary: Lamellar macular hole is a condition that affects the center of the retina. It can make vision blurred, distorted, or less clear for everyday tasks such as reading. Many people who need surgery for lamellar macular hole also have cataract. Surgeons can treat both problems during the same operation, or they can do cataract surgery later. In daily practice, patients and surgeons often need to decide which approach to choose. In this study, we looked at people treated in four Spanish hospitals. We compared vision at 1 year after vitrectomy in those who had combined surgery and those who had sequential surgery. We also studied which factors were linked to better vision after surgery. Overall, vision improved at 1 year after surgery. We did not detect clear differences in vision at 1 year between combined and sequential surgery. People who had better vision before surgery were more likely to have better vision after surgery. Patients with an isolated epiretinal membrane on OCT were also more likely to achieve better visual outcomes. These findings suggest that both surgical approaches can be reasonable. The best choice may depend on the person’s lens status, symptoms, and discussion with the surgeon.