Casswell EJ, Yorston D, Lee E, et al. Effect of Face-Down Positioning vs Support-the-Break Positioning After Macula-Involving Retinal Detachment Repair: The PostRD Randomized Clinical Trial. JAMA Ophthalmol. Published online April 16, 2020.
There is a lack of consensus among vitreoretinal surgeons in regard to the optimal positioning for patients after surgery for a macula-off retinal detachment. Face-down positioning can be onerous for patients. Some studies show anatomic success may be achieved without face-down positioning; however, imaging studies and case series indicate there may be reduced retinal displacement and decreased postoperative distortion with face-down positioning.
This was a prospective 6-month single-masked randomized controlled trial to evaluate the effect of face-down vs. support-the-break positioning on retinal displacement and distortion after surgery for macula-off retinal detachment. Patients were randomized in a 1:1 fashion to position face-down or position to support-the-break for 24 hours postoperatively. After 24 hours, patients were positioned to support the break for 6 additional days. All of the patients were adults with fovea-involving rhegmatogenous retinal detachments with central vision loss within 14 days from surgery. All patients underwent surgical repair with primary vitrectomy and gas. Subretinal fluid was drained via a retinotomy or through the break at the surgeon’s discretion. Those patients with redetachment or failure to attach the macula were excluded from the analysis.
Data from 239 patients was included in the analysis with a mean age of 60.8 years. While visual acuity was similar in the face-down and support-the-break positioning groups, there was significantly more retinal displacement in the support-the-break positioning group. At 6 months, retinal displacement was detected in 42 of 100 (42%) in the face-down positioning group vs. 58 of 103 (56%) in the support-the-break positioning group (p = .04). The authors also analyzed the degree of displacement, which was lower in the face-down positioning group (at 6 months: 0.3 degree, face-down vs. 0.9 degree, support-the-break). Additionally, retinal folds were significantly less common in the face-down group compared to the support-the-break positioning group (5.3% vs 13.5%, respectively; OR=2.8; 95% CI, 1.2-7.4; P = .03), as was binocular diplopia (7.6% vs 1.5%, respectively; OR=5.3; 95% CI, 1.3-24.6; P = .03). Interestingly, distortion scores and quality of life scores were similar among the two groups.
The major conclusion supported by this randomized prospective study is that face-down positioning is associated with a reduction in the frequency and amplitude of postoperative retinal displacement after a macula-off retinal detachment repair with PPV. Face-down positioning also results in a decreased rate of retinal fold formation and reduction in binocular diplopia. This study confirms anecdotal surgical evidence, prior uncontrolled studies, and case series that have reported increased rates of macular folds or retinal displacement when patients are not positioned face-down due to residual subretinal fluid. Other factors that are also important to control are the use of heavy liquid intraoperatively and the amount of posterior fluid remaining at the end of the surgery. In this study, PFCL was only used in 3 eyes and in the majority of eyes in both groups subretinal fluid was drained through the break (77% of eyes in the face-down group and 71% of eyes in the support-the-break group). This presumably leaves some posterior subretinal fluid at the end of the case, affecting retinal displacement and the formation of folds. In future studies, it may be interesting to study the effect of temporal side down positioning compared to face-down positioning as many suggest this also decreases retinal displacement and may afford greater patient comfort.
Avni P. Finn, MD
Northern California Retina Vitreous Associates
Mountain View, CA