Abstract：
OBJECTIVE: This systematic review and meta-analysis investigates the efficacy and safety of anti-VEGF injections compared with surgical intervention in improving visual acuity (VA) and reducing complications for patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (AMD).
CONCLUSIONS: Determining the optimal intervention for SMH in AMD is crucial for patient care.
METHODS: We included studies on anti-VEGF injections or surgical interventions for SMH in AMD from 7 databases, searched up to May 2024. Data extraction and quality assessment were done by 2 independent reviewers. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis employed random-effects models. Primary outcomes were pooled mean logarithm of the minimum angle of resolution VA difference (initial examination minus last follow-up VA) and adverse events rates.
RESULTS: A total of 43 observational studies were included: 21 (960 eyes) on anti-VEGF and 22 (455 eyes) on surgery. Comparisons were made across separate studies due to lack of head-to-head studies. Meta-analysis included 11 anti-VEGF studies (444 eyes) and 12 surgical studies (195 eyes) for VA outcomes. The mean difference in VA was -0.16 (95% confidence interval (CI), -0.24 to -0.08) for anti-VEGF and -0.36 (95% CI, -0.68 to -0.04) for surgery, with no significant difference between groups (chi-square = 1.70, df = 1, P = 0.19). Heterogeneity was high in surgical studies (I2 = 96.2%, τ2 = 0.23, P < 0.01) and negligible in anti-VEGF studies (I2 = 7%, τ2 = 0.003, P = 0.38). The GRADE certainty was moderate for anti-VEGF and low for surgery. Anti-VEGF had lower rates of cataract (0% vs. 4.6%), proliferative vitreoretinopathy (0.1% vs. 2.0%), and retinal detachment (0.1% vs. 10.6%), but similar rates of recurrent hemorrhage (5.4% vs. 5.3%). Complications were summarized descriptively due to zero-cell problem.
CONCLUSIONS: Both anti-VEGF and surgery treat SMH in AMD with similar VA outcomes but different safety profiles. Anti-VEGF is preferred for less severe hemorrhage, whereas surgery is suited for extensive hemorrhage. Despite uncertain comparative VA outcomes, treatment should be guided by clinical judgment and patient factors.
BACKGROUND: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
CONCLUSIONS: Determining the optimal intervention for SMH in AMD is crucial for patient care.
METHODS: We included studies on anti-VEGF injections or surgical interventions for SMH in AMD from 7 databases, searched up to May 2024. Data extraction and quality assessment were done by 2 independent reviewers. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis employed random-effects models. Primary outcomes were pooled mean logarithm of the minimum angle of resolution VA difference (initial examination minus last follow-up VA) and adverse events rates.
RESULTS: A total of 43 observational studies were included: 21 (960 eyes) on anti-VEGF and 22 (455 eyes) on surgery. Comparisons were made across separate studies due to lack of head-to-head studies. Meta-analysis included 11 anti-VEGF studies (444 eyes) and 12 surgical studies (195 eyes) for VA outcomes. The mean difference in VA was -0.16 (95% confidence interval (CI), -0.24 to -0.08) for anti-VEGF and -0.36 (95% CI, -0.68 to -0.04) for surgery, with no significant difference between groups (chi-square = 1.70, df = 1, P = 0.19). Heterogeneity was high in surgical studies (I2 = 96.2%, τ2 = 0.23, P < 0.01) and negligible in anti-VEGF studies (I2 = 7%, τ2 = 0.003, P = 0.38). The GRADE certainty was moderate for anti-VEGF and low for surgery. Anti-VEGF had lower rates of cataract (0% vs. 4.6%), proliferative vitreoretinopathy (0.1% vs. 2.0%), and retinal detachment (0.1% vs. 10.6%), but similar rates of recurrent hemorrhage (5.4% vs. 5.3%). Complications were summarized descriptively due to zero-cell problem.
CONCLUSIONS: Both anti-VEGF and surgery treat SMH in AMD with similar VA outcomes but different safety profiles. Anti-VEGF is preferred for less severe hemorrhage, whereas surgery is suited for extensive hemorrhage. Despite uncertain comparative VA outcomes, treatment should be guided by clinical judgment and patient factors.
BACKGROUND: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
摘要：
目的：本系统综述和荟萃分析研究了抗血管内皮生长因子（抗VEGF）注射与手术干预相比在改善患者视力（VA）和减少因新生血管性年龄相关性黄斑变性（AMD）引起的黄斑下出血（SMH）并发症方面的疗效和安全性。
结论：确定AMD中SMH的最佳干预措施对于患者护理至关重要。
方法：我们从7个数据库中纳入了抗VEGF注射或SMH手术干预AMD的研究，搜索到2024年5月。数据提取和质量评估由两名独立的审阅者完成。证据的确定性被评估为等级方法。Meta分析采用随机效应模型。主要结果是汇总平均logMARVA差异（初始检查减去最后一次随访VA）和不良事件发生率。
结果：共纳入43项观察性研究：21项（960只眼）抗VEGF治疗，22项（455只眼）手术治疗。由于缺乏头对头研究，在不同的研究中进行了比较。Meta分析包括11项抗VEGF研究（444只眼）和12项手术研究（195只眼）。VA的平均差异（MD）是-0.16（95CI：-0.26，-0.07）的抗VEGF和-0.36（95CI：-0.68，-0.04）的手术，组间无显著差异(X2=1.70,df=1,p=0.19)。手术研究的异质性很高(I2=96.2%，tau2=0.23，p<0.01），在抗VEGF研究中可忽略不计（I2=7%，tau2=0.003，p=0.38）。抗VEGF的等级确定性中等，手术的等级确定性较低。抗VEGF的白内障发生率较低（0％vs4.6％），增生性玻璃体视网膜病变（PVR，0.1%对2.0%)，和视网膜脱离（RD，0.1%对10.6%)，但复发性出血的发生率相似(5.4%vs5.3%)。由于零细胞问题，对并发症进行了描述性总结。
结论：抗VEGF和手术治疗SMH在AMD中具有相似的VA结果，但安全性不同。抗VEGF优选用于不太严重的出血，而手术适合大面积出血。尽管VA的比较结果不确定，治疗应以临床判断和患者因素为指导。
结论：确定AMD中SMH的最佳干预措施对于患者护理至关重要。
方法：我们从7个数据库中纳入了抗VEGF注射或SMH手术干预AMD的研究，搜索到2024年5月。数据提取和质量评估由两名独立的审阅者完成。证据的确定性被评估为等级方法。Meta分析采用随机效应模型。主要结果是汇总平均logMARVA差异（初始检查减去最后一次随访VA）和不良事件发生率。
结果：共纳入43项观察性研究：21项（960只眼）抗VEGF治疗，22项（455只眼）手术治疗。由于缺乏头对头研究，在不同的研究中进行了比较。Meta分析包括11项抗VEGF研究（444只眼）和12项手术研究（195只眼）。VA的平均差异（MD）是-0.16（95CI：-0.26，-0.07）的抗VEGF和-0.36（95CI：-0.68，-0.04）的手术，组间无显著差异(X2=1.70,df=1,p=0.19)。手术研究的异质性很高(I2=96.2%，tau2=0.23，p<0.01），在抗VEGF研究中可忽略不计（I2=7%，tau2=0.003，p=0.38）。抗VEGF的等级确定性中等，手术的等级确定性较低。抗VEGF的白内障发生率较低（0％vs4.6％），增生性玻璃体视网膜病变（PVR，0.1%对2.0%)，和视网膜脱离（RD，0.1%对10.6%)，但复发性出血的发生率相似(5.4%vs5.3%)。由于零细胞问题，对并发症进行了描述性总结。
结论：抗VEGF和手术治疗SMH在AMD中具有相似的VA结果，但安全性不同。抗VEGF优选用于不太严重的出血，而手术适合大面积出血。尽管VA的比较结果不确定，治疗应以临床判断和患者因素为指导。
