Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole

Abstract

for the Positioning In Macular Hole Surgery (PIMS) Study Group IMPORTANCE The value of facedown positioning following surgery for large full-thickness macular holes is unknown.OBJECTIVE To determine whether advice to position facedown postoperatively improves the outcome for large macular holes. DESIGN, SETTING, AND PARTICIPANTSThis randomized, parallel group superiority trial with 1:1 randomization stratified by site with 3 months' follow-up was conducted at 9 sites across the United Kingdom and included participants with an idiopathic full-thickness macular hole of at least 400 μm minimum linear diameter and a duration of fewer than 12 months. All participants had vitrectomy surgery with peeling of the internal limiting membrane and injection of perfluoropropane (14%) gas, with or without simultaneous surgery for cataract.INTERVENTIONS Following surgery, participants were randomly advised to position either facedown or face forward for 8 hours daily for 5 days. MAIN OUTCOMES AND MEASURES The primary outcome was closure of the macular hole determined 3 months following surgery by masked optical coherence tomography evaluation. Secondary outcome measures at 3 months were visual acuity, participantreported experience of positioning, and quality of life measured by the National Eye Institute Visual Function Questionnaire 25. RESULTS A total of 185 participants (45 men [24.3%]; 156 white [84.3%]; 9 black [4.9%]; 10 Asian [5.4%]; median age, 69 years [interquartile range, 64-73 years]) were randomized.Macular hole closure was observed in 90 (85.6%) who were advised to position face forward and 88 (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08). The mean (SD) improvement in best-corrected visual acuity at 3 months was 0.34 (0.69) logMAR (equivalent to 1 Snellen line) in the face-forward group and 0.57 (0.42) logMAR (equivalent to 3 Snellen lines) in the facedown group (adjusted mean difference, 0.22 [95 % CI, 0.05-0.38]; equivalent to 2 Snellen lines); 95% CI, 0.05-0.38; P = .01). The median National Eye Institute Visual Function Questionnaire 25 score was 89 (interquartile range, 76-94) in the facedown group and 87 (interquartile range, 73-93) in the face-forward group (mean [SD] change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean [SD] difference on a logistic scale, 0.02; 95% CI, −0.03 to 0.07; P = .41). CONCLUSIONS AND RELEVANCEThe results do not prove that facedown positioning following surgery is more likely to close large macular holes compared with facing forward but do support the possibility that visual acuity outcomes may be superior.

Face-Down Posture versus Non-Face-Down Posture following Large Idiopathic Macular Hole Surgery: A Systemic Review and Meta-Analysis

“…A total of 371 participants with large IMH (FDP, 183; nFDP, 188) were included in our study. Six studies [ 11 , 12 , 13 , 28 , 30 , 31 , 32 ] were conducted in Europe, and one was conducted [ 9 ] in Asia. The FDP protocols included 3 [ 13 , 31 , 32 ], 5 [ 11 , 28 ], and 10 [ 12 , 30 ] days of FDP.…”

“…Six studies [ 11 , 12 , 13 , 28 , 30 , 31 , 32 ] were conducted in Europe, and one was conducted [ 9 ] in Asia. The FDP protocols included 3 [ 13 , 31 , 32 ], 5 [ 11 , 28 ], and 10 [ 12 , 30 ] days of FDP. The mean age of the patients ranged from 62.35 to 72.4 years.…”

“…According to the O’Brien–Fleming alpha-spending function, we constructed TSA boundaries to determine whether the p value was sufficiently statistically significant to show the anticipated effect, or whether the analysis should be terminated early [ 27 ]. We adjusted the relevant parameters according to the RCT of Pasu et al [ 28 ]. A 5% (α = 0.05; two-sided) total risk of type-1 error and 85% statistical power were set, and a relative risk difference of 15% was set for defining improved large IMH closure rate.…”

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

“… 55 Facedown positioning provides a better visual outcome despite no apparent beneficial effect on anatomical success. 57 ILM peeling with autologous platelet-rich plasma on FTMH was superior to ILM peeling alone, with a hole closure rate of 100% in a total of 62 eyes. 58 Initially, inverted ILM flap technique was proposed to improve the surgical outcomes for large FTMHs.…”

Review: Ophthalmic Surgery as a cause of Pulmonary Emboli

“…In terms of the VR post-operative conundrum, there is a growing interest in research and emerging evidence to reduce the need for strict posturing post-operatively [13,14]. The need for post-operative posturing and the ability to comply is usually discussed pre-operatively and should there be concerns, the surgeon may opt to use a medium that does not require posturing -e.g.…”