Clinical presentation, diagnostic approaches, pathophysiology, and management of retinal pseudo-holes: a comprehensive synthesis of 35 peer-reviewed studies

Background: Retinal pseudo-hole (RPH) is a macular configuration defined on optical coherence tomography (OCT) by foveal depression without a full-thickness retinal defect, and may clinically resemble true/full-thickness macular hole (MH). Misclassification has therapeutic consequences. Objective: To synthesize evidence on the clinical presentation, diagnostic yield of imaging, pathophysiology, and management of RPH, with prespecified quantitative pooling where valid. Methods: A PRISMA-aligned systematic review identified 35 peer-reviewed studies (1990–2024). Two reviewers independently screened/extracted data (κ = 0.86) and appraised risk of bias (Cochrane RoB, Newcastle–Ottawa, adapted tools). Quantitative meta-analysis was performed only when outcomes, time-points, and variance were compatible. Results: Patients most commonly reported metamorphopsia, central scotoma, and blurred vision; many had preserved or mildly reduced BCVA. OCT consistently demonstrated the defining RPH signature and frequently revealed epiretinal membrane (ERM) and/or vitreomacular traction (VMT) that informed management; fluorescein angiography and fundus photography were adjunctive rather than discriminatory. Eleven of the 35 studies (11 studies) met pooling criteria for visual outcomes after pars plana vitrectomy (PPV) ± ERM peeling: the pooled mean BCVA improvement was + 2.1 Snellen lines (95% CI + 1.7 to + 2.5, p < 0.001; I 2 = 46%), and 70.3% (95% CI 63.9%–75.9%) achieved a ≥2-line gain (I 2 = 38%). Sensitivity analyses excluding high-risk studies produced similar effects (+2.0 to + 2.2 lines) with modestly reduced heterogeneity. Few studies reported extractable 2 × 2 data; therefore, pooled sensitivity/specificity for OCT was not estimated. Conclusions: Evidence supports an OCT-first, traction- and symptom-guided pathway: observation with serial OCT for minimally symptomatic RPH, and PPV ± ERM peeling for traction-positive, function-limiting presentations, with clinically meaningful average visual gains and low complication rates in experienced settings. Conclusions should be tempered by the heterogeneity and the fact that only 11 of 35 studies were quantitatively combinable; standardized outcomes and rigorous diagnostic-accuracy studies are priorities. Abstract Retinal pseudo-holes (RPH) are macular abnormalities that mimic accurate macular holes (MH) but lack full-thickness retinal disruption. This systematic review synthesizes findings from 35 peer-reviewed studies on the clinical presentation, diagnostic methods, pathophysiology, and management strategies for retinal pseudo-holes. The review highlights the challenges of diagnosing RPH due to its clinical similarity to MH, emphasizing the critical role of optical coherence tomography (OCT) in distinguishing between the two conditions. The pathophysiology of RPH is primarily attributed to vitreomacular traction (VMT) and epiretinal membranes (ERM), which exert mechanical forces on the macula, leading to a foveal depression. Management approaches range from conservative observation to surgical intervention, depending on the severity of symptoms. Surgical treatments, particularly pars plana vitrectomy with membrane peeling, have shown promising results in improving visual acuity, particularly in symptomatic patients. The review also discusses the need for further research into the long-term outcomes of RPH and the potential for newer imaging technologies to improve diagnostic accuracy and monitoring.