Is Face-Down Positioning After Macular Hole Surgery Still Needed?

Among retina surgeons, there is an ongoing debate around the value and necessity of face-down positioning after macular hole surgery. Historically, patients with macular hole surgery would be positioned face down for 2-3 weeks, although the number of days of face-down positioning required by retina surgeons has been decreasing in recent years.

To provide some much-needed data on this subject, investigators in the United Kingdom conducted a randomized clinical trial to determine whether face-down positioning would result in an increased closure rate in patients with large (≥400 μm) macular holes.

This multicenter trial compared face-down positioning with face-forward positioning for 8 consecutive or nonconsecutive hours daily for 5 days, after vitrectomy with internal limiting membrane peeling and 14% C3F8 gas, with or without simultaneous cataract surgery. The primary outcome was macular hole closure on spectral-domain optical coherence tomography within 3 months. The secondary outcome was visual acuity at 3 months.

Baseline characteristics were similar in both groups with regard to lens status, cataract surgery, macular hole size, visual acuity, and the presence of vitreofoveal detachment. More Black participants and fewer Asian participants were in the face-down positioning group.

Macular hole closure was observed in 90 patients (85.6%) in the face-forward group and in 88 patients (95.5%) in the face-down group. This was not statistically significant. The study was powered to detect a 15% difference in macular hole closure rate with 85% power and 95% confidence. However, the face-down group had better visual acuity than the face-forward group (0.34 vs 0.57 logMAR, respectively).

It is important to remember that these results are applicable to a similar surgery with vitrectomy, internal limiting membrane peel (not flaps), and 14% C3F8 gas (not another tamponade). In addition, these results apply to primary macular hole surgeries but not to persistent or recurrent macular holes.

Although this is a well-designed study, it did not uncover a statistically significant difference in macular hole closure rate between the groups, despite the rate being higher in the face-down group. It is also unknown why visual acuity was better in the face-down group despite a similar macular hole closure rate.

The findings did not provide definitive evidence for the face-down position, but they can help further guide us in our discussions of positioning options with patients undergoing macular hole surgery, particularly those with larger macular holes.

Sophie J. Bakri, MD, a longtime contributor to Medscape, specializes in diseases and surgery of the retina and vitreous, including age-related macular degeneration. She also undertakes both clinical and translational research in the pathogenesis and treatment of retinal diseases.

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