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    Prone Positioning After Macular Hole Surgery

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    The need for face-down posi­tioning following macular hole (MH) surgery has been a focus of debate among retina specialists for a number of years. In a recent meta-analysis of randomized controlled trials comparing the treatment effect of prone position­ing with that of seated or other posi­tions, researchers found no significant differences between the two protocols.1

    “Our study challenges the notion that all patients must do face-down positioning after surgery to optimize the success of macular hole closure,” said lead author Varun Chaudhary, MD, MSc, at McMaster University in Hamilton, Ontario, Canada.

    Retinal detachment with giant retinal tear and macular hole.

    MACULAR HOLE. Retinal detachment, giant retinal tear, and macular hole in a 61-year-old patient. This image was originally published in the ASRS Retina Image Bank. Matteo M. Forlini, MD, Alessandro Romani, MD, and Purva Date, MD. Retinal Detachment With Giant Retinal Tear and Macular Hole. Retina Image Bank. 2020; Image Number 45626. © The American Society of Retina Specialists.

    Assessing magnitude of effect. To determine the effect of face-down posi­tioning on both anatomic and func­tional outcomes, the researchers pooled data from eight clinical trials involving 709 eyes randomized to face-down positioning (n = 358) or to no prone positioning (n = 351). Outcomes, in order of importance, were closure rate, improvement in VA, recurrence rates, visual function, patient satisfaction, patient-reported quality of life, and complication rates.

    Results. Overall, results of the analy­sis did not show a difference in closure rates between the two approaches. The relative risk of full-thickness MH closure rate was 1.05 (95% CI, .99 to 1.12; p = .09; GRADE rating = low). This was true for holes both smaller and larger than 400 μm. With regard to VA, the results showed that the mean difference between the two approaches was –.07 (95% CI, –.12 to –.01; p = .03; GRADE rating = low).

    There was also a lack of robust evidence to demonstrate significant differences between the two approaches for adverse events/complication rates, as well as for other outcomes important to patients (e.g., visual function, quality of life, and patient satisfaction).

    Similarly, a subgroup analysis showed that hole size (<400 μm vs. >400 μm), type of gas tamponade, and duration of positioning did not signifi­cantly affect outcomes.

    Consider patient preferences. Because this study could not establish the benefit of face-down positioning with any certainty, surgeons who want to continue the practice might con­sider reducing its duration, said Dr. Chaudhary. He noted that, because of the study results, he has shortened the length of time he asks patients to lie face down by half.

    Dr. Chaudhary stressed that patients who are unable to lie face down should still be considered as surgical candidates and can be expected to achieve high closure rates. And, he said that while there is “a small possibility” that face-down positioning could increase the chance of closure, it comes at a cost to patient comfort.

    “We propose that, given the likeli­hood that face-down positioning has a very small benefit, this lack of evidence should be shared with patients as part of the informed consent process, and a decision should be made that is in keeping with patient preferences and values.”

    Need for additional research. Look­ing ahead, Dr. Chaudhary and his co-authors emphasized the need for ongo­ing research on the topic. As they wrote, “The lack of precision in determining the true effect of face-down positioning is a topic that would benefit from a large, well-conducted investigation that thoroughly evaluates important out­comes for macular hole surgery.” This would help inform clinical practice and support the development of related practice guidelines, they concluded.

    —Miriam Karmel


    1 Chaudhary V et al. Ophthalmol Retina. 2023;7(1):33-43.


    Relevant financial disclosures: Dr. Chaudhary—None.

    For full disclosures and the disclosure key, see below.

    Full Financial Disclosures

    Dr. Chaudhary Bayer: C,L,S; Boehringer Ingelheim: C; Novartis: C,S; Roche: L,S.

    Dr. Santhiago Alcon: C; Ziemer: C.

    Dr. Skowronska-Krawczyk Visgenx: C.

    Disclosure Category



    Consultant/Advisor C Consultant fee, paid advisory boards, or fees for attending a meeting.
    Employee E Hired to work for compensation or received a W2 from a company.
    Employee, executive role EE Hired to work in an executive role for compensation or received a W2 from a company.
    Owner of company EO Ownership or controlling interest in a company, other than stock.
    Independent contractor I Contracted work, including contracted research.
    Lecture fees/Speakers bureau L Lecture fees or honoraria, travel fees or reimbursements when speaking at the invitation of a commercial company.
    Patents/Royalty P Beneficiary of patents and/or royalties for intellectual property.
    Equity/Stock/Stock options holder, private corporation PS Equity ownership, stock and/or stock options in privately owned firms, excluding mutual funds.
    Grant support S Grant support or other financial support from all sources, including research support from government agencies (e.g., NIH), foundations, device manufacturers, and\or pharmaceutical companies. Research funding should be disclosed by the principal or named investigator even if your institution receives the grant and manages the funds.
    Stock options, public or private corporation SO Stock options in a public or private company.
    Equity/Stock holder, public corporation US Equity ownership or stock in publicly traded firms, excluding mutual funds (listed on the stock exchange).


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