Does Facedown Position Improve Macular Hole Surgery Outcomes?

Facedown positioning following surgery is not more likely to close large (≥400 mcm) macular holes compared with seating faced forward, according to a study published in JAMA Ophthalmology. However, visual acuity outcomes may be superior when patients are placed facedown after surgery.

Idiopathic full-thickness macular holes account for 0.2 to 3.3 of every 1000 individuals affected by sight impairment and have an incidence rate of 8 per 100,000 individuals each year. The condition causes severe sight impairment and most often occurs in older individuals due to age-related degeneration of the vitreous gel.

“The retina at the edges of a full-thickness macular hole typically becomes separated from the underlying pigment epithelium by subretinal fluid and swollen by the accumulation of intraretinal fluid,” the authors wrote.

Surgical removal of the vitreous gel, to relieve persistent traction acting at the macula, in addition to an intraocular injection of a gas bubble to provide a temporary scaffold that promotes hole closure is the most common form of treatment for the condition. Some individuals may be advised to lie facedown after the procedure to maintain consistent close contact of the gas bubble with the macula at the posterior pole.

However, the researchers note, “facedown positioning can be arduous, uncomfortable, and disabling; it is of unproven benefit and presents a risk of harm.”

In a multicenter randomized clinical trial, investigators assessed whether advice to position facedown postoperatively improves the outcome of surgery for large full-thickness macular holes.

Of the 178 participants enrolled in the study, 90 individuals were advised to position face forward after surgery and 88 were advised to position facedown. All participants were to adjust to their position for at least 8 consecutive or nonconsecutive hours daily for 5 days following surgery.

After 3 months, the researchers evaluated anatomical closure of the macular hole, best-corrected visual acuity (BCVA) via a Snellen chart, and participants’ health and quality of life, measured using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25). Surgeons and independent retina specialists were masked to the treatment allocation.

Analyses revealed:

• Successful macular hole closure was observed in 77 (85.6%) of those advised to position face forward and in 84 participants (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08)
• Mean (SD) improvement in BCVA 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; P = .01; equivalent to 2 Snellen lines)
• Median NEI VFQ-25 score was 89 (interquartile range [IQR], 76-94) in the facedown group and 87 (IQR, 73-93) in the face-forward group (mean change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean difference on a logistic scale, 0.02; 95% CI, −0.03 to 0.07; P = .41)

“The relative immobility of the seated position may reduce shear stress associated with intraocular fluid currents otherwise induced by physical activity in gas-filled eyes,” the authors hypothesize.

Limitations present in the study included lack of guidance for sleeping position among participants. Additionally, the researchers were not able to definitively determine whether improved visual acuity was a result of hole closure, because of the limited size of the trial and its design.

Reference

Pasu S, Bell L, Zenasni Z, et al. Facedown positioning following surgery for large full-thickness macular hole. JAMA Ophthalmol. 2020;138(7):725-730. doi:10.1001/jamaophthalmol.2020.0987