Is postoperative face-down positioning necessary after pars plana vitrectomy for repair of full-thickness macular hole?

Perspective

Face-down positioning is never necessary, regardless of hole size, and is extremely difficult for many patients in this age group. Our practice has not required any patients to perform face-down positioning for decades, and a recent analysis of our data that we presented at this year’s American Ophthalmological Society meeting revealed a 97% success rate over the past 70 cases by a single surgeon (Paul Tornambe, MD). The two failures had residual internal limiting membrane (ILM) at the edge of each hole and both closed with repeat surgery, removal of the residual ILM, and again no face-down positioning. Patients visit us from all over the country simply to avoid face down posturing, although we have set up a website listing surgeons with a similar philosophy around the world (www.macularholesurgeons.com).

Nikolas London

Our technique does not likely differ greatly from most others out there. We perform 23-gauge vitrectomy, stain and peel the ILM at least  1 disc diameters from the edge of the hole, followed by fluid-gas exchange with 25% SF6 gas. We have never had an issue with postoperative IOP despite use of 25% SF6. For large or chronic holes, we use 16% C3F8. Most of our patients are pseudophakic, which avoids lens opacification and enables a larger bubble. Newly pseudophakic patients are placed on pilocarpine to prevent pupil capture. Postoperatively, we ask patients to only avoid supine positioning. The bubble simply needs to cover the hole for 1 week to prevent liquid vitreous from entering the subretinal space, and a 25% SF6 bubble routinely accomplishes this.

We are not alone in our philosophy, and the literature is replete with evidence to support the notion that face-down positioning is unnecessary. Raymond Iezzi, MD, presented a 100% success rate with holes less than 400 µm at last year’s American Society of Retina Specialists meeting; Rubinstein and colleagues reported a 92% closure rate; Tadayoni and colleagues reported a 91% closure rate, and Lange and colleagues reported a 100% closure rate for nine macular holes less than 400 µm with no face-down positioning.

Nikolas London, MD
Disclosure: London has no relevant financial disclosures.

Perspective

Jennifer I. Lim

Yes. I recommend 1 week to 10 days of face down. When a patient cannot position, one can use silicone oil, but this necessitates another procedure be performed. Oil is also needed for those who need to travel at altitude, such as over mountains or by airplane. Recent work has shown shorter durations of positioning can be effective; however, a few more days of face-down positioning may help and prevents lens feathering or other reaction to large bubbles.

Jennifer I. Lim, MD
Disclosure: Lim has no relevant financial disclosures.

Perspective

Judy E. Kim

Sometimes. If a (near) complete vitrectomy was performed on an eye with pseudophakia and full-gas fill was achieved, no positioning or very limited positioning is needed. This is due to the effect of buoyancy, and the same amount of force would be exerted to the macular hole whether the head is upright or in a prone position. With full vitrectomy and ILM peeling in phakic and pseudophakic eyes, my colleagues and I have published that a high rate of hole closure was achieved with 1 day of prone positioning. If full vitrectomy is not done, if there is a significant reaccumulation of fluid in the eye, or if there is a leak through the sclerotomy in a transconjunctival small incision vitrectomy, a large gas fill cannot be guaranteed. In most cases, I am currently recommending 3 to 4 days of positioning, with the help of a head positioning chair as needed, in order to make sure that the gas bubble is tamponading the hole.

Judy E. Kim, MD
Disclosure: Kim has no relevant financial disclosures.

Perspective

Jay S. Duker

I am not convinced that face-down position makes a difference in closure rate for small (less than 250 µm) or medium sized holes. I generally ask my patients to do 24 hours of face-down positioning immediately following surgery. On postop day 1, I attempt to image the macular hole with OCT. If the hole is closed, face-down positioning ends. For large holes, I generally recommend face-down position for a week, even if the hole appears closed on postop day 1.

Jay S. Duker, MD
Disclosure: Duker receives research support from OptoVue and Carl Zeiss Meditec, is a consultant for Alcon, EMD Serono, Novartis, Optos, QLT, Regeneron and ThromboGenics, and is a stockholder in Hemera Biosciences, EyeNetra, Ophthotech and Paloma Pharmaceuticals.

References:

Iezzi R. Outcomes of macular hole surgery with broad ILM peeling and no face-down positioning. American Association of Retina Specialists annual meeting, Las Vegas, Nev., Aug. 25-29, 2012.
Lange CA, et al. Eye (Lond). 2012;26(2):272-277. doi: 10.1038/eye.2011.221.
Rubinstein A, et al. Clin Exp Ophthalmol. 2007;35(5):458-461.
Tadayoni R, et al. Ophthalmology. 2011;118(1):150-155. doi: 10.1016/j.ophtha. 2010.04.040.