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No Face-Down Position for Macular Hole Surgery

No More Face-Down Positioning?

A few years ago, my aunt developed a macular hole and she abruptly lost her central vision. The macula houses the highest concentration of photoreceptors and a hole in the center results central blurry vision, or even worse, a complete break in the middle. She was devastated and scared. Luckily, she had an excellent surgeon and successful surgery that helped her regain a significant portion of her sight. However, my aunt’s one complaint after undergoing this surgery was being asked to stay face down at all times for the extended period of seven days. In her attempts to accommodate this grueling recovery requirement, she rented a massage table to assist with maintaining this position. She allowed herself an occasional 10 minute break. But to this day, she still reminds me of this torture.

The field of retina surgery has progressed since the inception of pars-plana vitrectomy in 1972. There have been many surgical advances that allow for more efficient surgery, quicker recovery, and often better outcomes. Included are:

  • Micro-incisional vitrectomy with small gauge instrumentation
  • New stains for epiretinal membranes and the Internal Limiting Membrane
  • Improved surgical microscopes and lens viewing system advancements

Recovery guidelines after macular hole repair have long been an issue for the patient. There is significant controversy as to why patients need face down positioning after this procedure. It is not unheard of retinal surgeons to ask patients to remain face down at all times for 7 or more days after surgery. Some patients are frightened and decide against undergoing this surgical intervention due to the daunting task of extended prone posturing. Others simply can’t physically tolerate this task. Without surgery, these patients are destined to chronic poor central vision with no chance of visual recovery. In short, face-down positioning is tedious, time consuming, and occasionally physically impossible. But, is it necessary?

The Statistics Show

Macular Hole repair by pars-plana vitrectomy had a success rate of around 60% in some early studies to the mid 80 to 100% in more recent studies. In relation to no face-down positioning, Dr. Paul Tornambe published the first report in 1997 that showed surgical success without prone posturing. Since that time there have been at least five additional papers exhibiting excellent surgical outcomes without any face-down requirement (88-100% success). Even with these documented studies, most retina surgeons still advocate face-down positioning post macular hole repair.

Evidence Based Practices

It is my opinion that macular hole surgery does not require arduous post-operative positioning for the vast majority of patients. However, as a physician that practices evidenced based medicine, I periodically reevaluate my results and make necessary modifications. Together with Petros Carvounis, MD, F.R.C.S.C., a Professor at Baylor College of Medicine, we analyzed our surgical results over the past 5 years. The statistics showed that in 59 eyes of 54 patients, the overall macular hole closure rate was 93.2% without face down positioning. Visual acuity improved from 20/115 preoperatively to 20/42 after surgery. Overall, these results are in agreement with the published literature. Furthermore, they reaffirm our belief that post operative face-down positioning is not necessary for most patients. If you are in need of this surgery, ask your doctor about his/her recommendations for positioning.

For a list of Retina surgeons performing macular hole surgery without face-down positioning in your area, visit this website: