Lindtjorn B, Krohn J Austeng D et al. Nonsupine positioning after macular hole surgery: a prospective multicenter study. Ophthalmol Retina. 2019 May;3(5):388-92.
Macular hole (MH) surgical repair typically involves the release of tangential traction on the retina by lifting the hyaloid, removal of the internal limiting membrane, epiretinal membrane, or both followed by a gas fill. The purpose of the gas is to isolate the hole from intraocular fluid and allow for anatomic closure. Although closure rates after primary MH surgery are high, adherence to postoperative facedown positioning is challenging and there is increasing evidence that it may not be necessary. Recently, Lindtjorn et al evaluated the postoperative closure rate of full thickness MH after nonsupine positioning, as monitored by a positioning measuring device attached to their forehead.
This was a prospective multicenter study that enrolled and analyzed 203 patients (average age of 69.8 years) with primary MH. Patients underwent pars plana vitrectomy with induction of posterior hyaloid separation, dye-assisted internal limiting membrane peeling and SF6 gas tamponade (26%-30%). In phakic patients, the decision to perform a combined phacovitrectomy was made by the surgeon. This was followed by 3 to 5 days of nonsupine positioning, defined as avoiding upward gaze and a supine sleeping position. A positioning measuring device was attached to patients’ forehead after surgery for 24 hours and recorded the time spent in the supine position. Based on the surgeon preference, the tennis ball technique (attaching tennis ball to the back of the nightshirt during sleep to prevent the patient from sleeping in a supine position) could also be applied.
The primary endpoint was anatomic closure of the MH at two weeks or more after surgery. 202 of 203 MHs closed after a single surgery, giving a closure rate of 99.5%. The median time of supine positioning during the first 24 hours was 28 seconds. In patients who used the tennis ball technique, the median supine time was on 19 seconds compared to 1 minute and 21 seconds in those who did not (p=0.02). The authors had intended to correlate position compliance with closure rate but could not due to the high closure rate. Median VA improved significantly, with 3.8 ETDRS letters from 0.7 logMAR to 0.3 logMAR (p<0.001) or approximately equivalent to Snellen VA from 20/100 to 20/40.
The results of this study suggest that face-down positioning may not be necessary to achieve high closure rates after pars plana vitrectomy with internal limiting membrane peeling and gas tamponade for MH. Short-term nonsupine positioning may be sufficient. It is not clear, though, if any patients positioned face down despite instructions or had postoperative IOP spikes in the setting of the high gas concentration. Further studies correlating time spent in the supine/non-supine position and macular hole closure rate would be helpful.
Katherine E. Talcott, MD
Cole Eye Institute