Facedown Positioning After Vitrectomy Will Not Facilitate Macular Hole Closure Based on Swept-Source Optical Coherence Tomography Imaging in Gas-Filled Eyes

Abstract

Purpose: To compare clinical outcomes in eyes with macular hole (MH) managed by either facedown (FD) or no-FD (nFD) postoperative positioning protocols. Methods: This is a prospective randomized cohort study. Eighty eyes of 80 consecutive patients with MH who had undergone vitrectomy surgery with internal limiting membrane peeling and gas tamponade were included in this study. Forty eyes of 40 patients who were kept in FD position for 3 days after surgery were assigned to the FD group, 40 eyes of 40 patients with nFD positioning were assigned to the nFD group. Macular hole was examined with swept-source optical coherence tomography images at 1 day, 2 days, 3 days, 2 weeks, 1 month, and 3 months after surgery. The MH closure rate and change of best-corrected visual acuity were compared. Results: At postoperative Day 1, MH was closed in 24 of 32 eyes (with clear optical coherence tomography images) (75%) in the FD group and 23 of 30 eyes (with clear optical coherence tomography images) (77%) in the nFD group (P = 0.97). At postoperative Day 2, MH closure was confirmed in 32 of 36 eyes (88.9%) in the FD group and in 31 of 33 eyes (94%) in the nFD group (P = 0.84), and the results were unchanged at Day 3. At 2 weeks after surgery, clear optical coherence tomography images were acquired from all eyes in both groups, and MH closure was confirmed in 36 of 40 eyes (90%) in the FD group and in 37 of 40 (92.5%) eyes in the nFD group (P = 0.91). Macular hole closure was not achieved in eyes that were kept open by Day 3 after surgery, and none of the eyes with confirmed MH closure by Day 3 had a reopening of the MH by 3 months. The distribution of macular configuration at 3 months was not significantly different between the two groups (P = 0.96). There was no difference in terms of the improvement in best-corrected visual acuity (Early Treatment Diabetic Retinopathy Study letters gain) between the 2 groups at 1 month (P = 0.22) and 3 months (P = 0.45). Conclusion: The nFD protocol neither delayed the MH closure nor decreased the final closure rate after vitrectomy surgery. Therefore, postoperative prone position seems to be unnecessary for all MH repair procedures.

Macular hole surgery recovery with and without face-down posturing: a meta-analysis of randomized controlled trials

“…Of these 34 reports, 8 were not RCTs, 2 did not apply ILM peeling, and 19 did not include a comparison group, and were excluded from the meta-analysis as they did not meet the inclusion criteria. The remaining 5 RCTs were included in the final meta-analysis [ 14,[18][19][20][21]. The trial selection process is summarized in Fig.…”

Macular hole surgery recovery with and without face-down posturing: a meta-analysis of randomized controlled trials

“…Of these 34 reports, 8 were not RCTs, 2 did not apply ILM peeling, and 19 did not included a comparison group, so they were excluded from the meta-analysis owing to conflict with the inclusion criteria. The remaining 5 RCTs were included in the final meta-analysis [14,[18][19][20][21]. The trial selection process is summarized in Fig.…”

“…Previous studies have reported that the healing of MHs begins within 24 hours after the surgery, and the bridge configuration occurs around 3 days [30,31]. The MHs were basically healed within 3 days after the surgery, and those that were not healed within 3 days were still open during the 3-month follow-up [3,21]. All of the studies included in this meta-analysis were in the prone position for 3 days or more, so the comparison of the closure rate of the MHs with sizes larger than 400 µm in the FDP and nFDP groups after MH surgery is credible.…”

“…Because the distance between the broken ends of the retina is so large, it requires a strict prone position to ensure that the gas bubble, under a sufficient or partial absorption state, keeps the intraocular gas-macula contact extended, drawing the edges of the hole into apposition with each other, providing a scaffold for the migration of glial cells, blocking fluid entry into the hole and moving the subretinal fluid to reattach the retina. This process contributes to successful anatomic healing [8,21,29]. This may explain why, for the patients with large MHs, the successful healing rate of the FDP group was higher than that of the nFDP group.…”

“…On the other hand, the gas will be gradually absorbed with time, and the buoyancy will be weakened after partial gas absorption. Within 3 days, 30% of the gas will be absorbed [21], which does not affect the healing of MHs smaller than 400 µm. This may be due to the removal of the traction force by ILM peeling which is important for hole healing in addition to the top pressure effect of the gas.…”