Pilot randomised controlled trial of face-down posturing following phacovitrectomy for macular hole

Abstract

Background To gather information on the effect of postoperative face-down posturing following combined phacoemulsification and vitrectomy for macular hole surgery in order to assist in the design of a larger definitive study. Methods Thirty phakic patients with stage II-IV full-thickness macular hole had combined phacoemulsification and pars plana vitrectomy with internal limiting membrane peel and 14% perfluoropropane (C 3 F 8 ) gas. At the conclusion of surgery, patients were randomised either to face-down posture or to no posture, for 10 days. The primary outcome was macular hole closure. Results The macular hole was successfully closed in 93.8% of the face-down posture group and in all of the no-posture group. Mean visual improvement was 0.63 (SD ¼ 0.21) logMAR units in the face-down group and 0.53 (SD ¼ 0.22) in the no posture patients. Conclusion Following combined phacoemulsification and vitrectomy, postoperative face-down posturing appears to make little difference to the final anatomical or visual outcome. If we assume a success rate of 95% in the posturing arm, and that there is no difference between posturing and non-posturing, then 798 patients would be required to be 90% sure that the 95% confidence interval will exclude a difference of more than 5%.

Pilot randomised controlled trial of face-down positioning following macular hole surgery

“…11 The visual acuity outcomes in this study are less good than those in our companion study. 18 This difference may reflect the effect of lens opacities in subjects in this study and the earlier assessment of outcome (6 weeks vs 6 months).…”

“…Simultaneous cataract surgery may facilitate a more complete vitrectomy enabling injection of a larger volume of gas than in phakic eyes, which could reduce the need for face-down positioning in this group of subjects. This has been investigated in a companion study 18 that suggests no benefit from posturing when vitrectomy is combined with cataract surgery. Furthermore, Guillaubey et al arbitrarily used a range of tamponade gases according to the size of the macular hole and acknowledged that this could also be a source of potential bias.…”

The Case Mix of Patients Presenting with Full-Thickness Macular Holes and Progression before Surgery: Implications for Optimum Management

“…The need for posturing is debated with many studies showing successful non-posturing surgery in holes <400 μm and often with the use of short-acting gases [5,15,16,17,18]. Large holes are still usually treated with longer-acting gases and posturing [5,6,7,19,20] although the requirement for posturing is debated and a further study is needed [21]. For about 3/4 (72%) of our patients' vitrectomy surgery would currently be the only available treatment option but in only approximately a 1/3 of the cases (28.5%), would vitrectomy, ILM peeling, long-acting gas and post-operative face-down posturing be recommended by the majority of surgeons.…”

Individualized, Spectral Domain-Optical Coherence Tomography–guided Facedown Posturing After Macular Hole Surgery

“…4,11,12,[24][25][26][27][28] The results of recent comparative studies 12,[26][27][28] suggested no statistically significant difference in the closure rates between no posturing or short-term posturing and standard posturing. However, there was a tendency for the closure rate to be better with standard posturing than with no or short-term posturing, for example, posturing versus no posturing was 97.4% versus 87.5% in a study by Guillaubey et al 26 27 Nonetheless, these results must be questioned because 800 cases are theoretically required to achieve a 95% confidence interval.…”