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    Review of: Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole

    Pasu S, Bell L, Zenasni Z, et al. JAMA Ophthalmology, in press

    This study assessed whether postoperative facedown positioning improves outcomes for large macular holes.

    Study design

    This randomized, parallel-group, multicenter, superiority trial included 185 patients with idiopathic full-thickness macular holes (minimum linear diameter ≥ 400 μm). All participants underwent vitrectomy, internal limiting membrane (ILM) peeling without flaps and 14% C3F8 gas tamponade. Following surgery, participants were randomly directed to either facedown or face forward positions for 8 hours daily for 5 days.


    Successful macular hole closure was observed in 85.6% (77/90) of the face-forward group and 95.5% (84/88) of the facedown group (P=0.08). At 3 months, mean improvement in BCVA was approximately 1 Snellen line in the face-forward group and 3 Snellen lines in the facedown group (P=0.01).


    This trial does not clarify why vision outcomes were better in the facedown group. It was assessed at 3 months which may not be adequate time for full visual recovery, especially with large macular holes. In addition, some eyes were phakic and it is not clear how the authors controlled for lens status and cataract development in these eyes. The face-forward and facedown groups had a similar number of phakic eyes at baseline (78 vs. 72 eyes) and eyes that underwent combined phacovitrectomy (44 vs. 45 eyes). The median baseline macular hole diameter was also slightly larger in the face-forward group (517 μm vs. 480 μm).

    Clinical significance

    Facedown positioning does not appear to improve the chance of closing large macular holes following vitrectomy but it may be associated with superior visual outcomes. This randomized trial provides higher quality evidence that positioning after macular hole surgery may not be as critical as once believed even for larger holes. Maintaining facedown positioning is one of the more arduous and uncomfortable postoperative demands we place on patients. It's helpful to know that such positioning may not be crucial, even for large macular holes.