Objective: To compare anatomic outcomes of primary scleral buckle (SB) vs. lens sparing pars plana vitrectomy (LSV) in treating retinopathy of prematurity (ROP) associated Stage 4A retinal detachment (RD). Conclusions: ROP is the leading cause of blindness in childhood in industrialized countries worldwide. ROP eyes with Type 1 disease can progress into tractional retinal detachment with or without a rhegmatogenous component despite early medical management with retinal ablation and/or intravitreal anti-VEGF injections, necessitating surgical management.

Methods: This systematic review and meta-analysis was registered with the Open Science Framework. A PubMed literature search was performed, and ROP-associated Stage 4A RD studies were selected based on preset inclusion criteria. Information on gestational age, age at surgery, type of surgery, and surgical outcomes were collected. Snellen visual acuity (VA) was collected when available. Postoperative anatomic success was defined as complete retinal reattachment, in which both the fovea and retinal periphery were attached. Overall, 231 eyes with confirmed ROP Stage 4A RD were collected from 24 studies. Cross-sectional analyses were used to study the rates of anatomic success and need for re-operation between eyes repaired with primary SB vs. primary LSV.

Results: The mean gestational age was 26.0 weeks old (range 21 to 31). 152 eyes (66%) had primary LSV, 73 eyes (32%) had primary SB, and 6 eyes (8%) had combined SB & LSV. The rate of single surgery anatomic success was 84% for primary LSV, 62% for primary SB (p < 0.05), and 83% for SB & LSV. The final anatomic success rate was 91% for primary LSV, 66% for primary SB (p < 0.05), and 100% for SB & LSV. The mean logMAR VA for eyes with final anatomic success was 0.9 (Snellen equivalent of ~20/159) after primary LSV, and 1.1 (Snellen ~20/250) after primary SB.

Conclusions: Our study suggests that primary LSV for patients with ROP-associated Stage 4A RD offers superior anatomic results compared to primary SB. Our study provides important tools for counselling parents regarding anatomic success, and visual prognosis following surgery for ROP-associated RD.