Three-day face-down positioning for macular hole surgery achieves high success rate

Study finds outcomes enhanced by membrane peeling, sulfur hexafluoride gas and concomitant cataract surgery.

Macular hole surgery using short-duration 3-day face-down positioning yielded good anatomical and visual outcomes and minimal complications, a study found.

“There is controversy over how much positioning time patients actually need and the relative effect that face-down posturing provides after macular hole repair,” lead study author David R.P. Almeida, MD, MBA, PhD, said. “When macular hole surgery was initially performed, patients were doing up to 2 weeks of face-down positioning. That was thought to be the best avenue for a successful outcome after surgery.”

However, patients disliked the lengthy recovery time because it constituted a significant strain and affected their quality of life, Dr. Almeida told OSN Retina.

David R.P. Almeida, MD, MBA, PhD 

David R.P. Almeida

Study protocol

In the study, 50 patients with stage 2 or stage 3 idiopathic macular hole were positioned face down for 50 minutes of every hour for 3 days. There was no comparison arm employing a longer duration protocol.

Study participants were recruited from retina clinics at Hotel Dieu Hospital in Kingston, Ontario, by Jeffrey Gale, MD, who began using the shortened face-down protocol for some patients nearly 10 years ago. All surgeries were performed by Dr. Gale.

“We hoped to confirm what we anecdotally saw, that 3 days of prone positioning for your typical routine idiopathic macular hole can be very successful,” Dr. Almeida said.

The study was published in Retina.

Outcomes

Anatomical closure of macular hole was achieved with one surgery in 49 of 50 eyes (98%). The single eye that did not respond developed an epiretinal membrane.

“We thought we would have about a 90% success rate for closure, so we are very happy and excited by this result,” Dr. Almeida said.

Figure 1a. Preoperative color fundus photograph. 
Figure 1b. OCT macular scan displaying an idiopathic macular hole in the right eye. 
Figure 1c. At 3 months follow-up, OCT demonstrates a successfully closed macular hole with a visual acuity of 6/9. 

Preoperative color fundus photograph (top) and OCT macular scan (middle) displaying an idiopathic macular hole in the right eye of a 69-year-old woman with a presenting visual acuity of 6/120. The patient underwent combined cataract extraction and vitrectomy with internal limiting membrane peeling, 20% SF6 intraocular gas tamponade and 3 days of face-down positioning. At 3 months follow-up, OCT demonstrates a successfully closed macular hole (bottom) with a visual acuity of 6/9.

Images: Almeida DRP

Visual acuity improved to various degrees in all eyes. Prior to surgery, 10% of eyes were 6/12 or better; postoperatively, 38% of eyes were 6/12 or better. However, 72% of patients had cataract surgery in the same session as macular hole repair, and visual acuity would be expected to improve with cataract surgery, Dr. Almeida noted.

There were no IOP complications, which can be common with some methods of macular hole surgery, he said. Two patients developed minor complications: persistent cystoid macular edema and IOL pupillary capture.

“This was a lower complication rate than we expected,” Dr. Almeida said.

Surgical technique

The researchers used 20% sulfur hexafluoride as an intraocular agent for macular hole tamponade.

“This is important because the short-acting gas is well tolerated. For a duration of 3 days, I think it is the ideal gas,” Dr. Almeida said.

In contrast, air tamponade has a lower rate of macular hole closure, and silicone oil requires a second surgery to remove the oil, he said.

Successful outcomes for the study may be attributed in part to internal limiting membrane (ILM) peeling to relieve traction.

“We believe that as long as ILM is present, pathological traction will occur on the hole and you will not be as successful in closing,” Dr. Almeida said. “I also think combining cataract surgery actually gives us a better vitrectomy. You end up with a better gas fill if the native lens is removed.”

Cataract surgery was performed before macular hole repair.

A limitation of the study was that postoperative compliance was not monitored.

An effective face-down regimen of even fewer than 3 days is feasible, Dr. Almeida said. A follow-up study of 1-day therapy may be pursued. – by Bob Kronemyer

Reference:
  • Almeida DR, Wong J, Belliveau M, Rayat J, Gale J. Anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning. Retina. 2012;32(3):506-510.
For more information:
  • David R.P. Almeida, MD, MBA, PhD, can be reached at Department of Ophthalmology, Queen’s University, Hotel Dieu Hospital, 166 Brook Street, Kingston, Ontario, Canada K7L 5G2; 613-483-4508; email: dalmeida@evolation-medical.com.
  • Disclosure: Dr. Almeida has no relevant financial disclosures.

Macular hole surgery using short-duration 3-day face-down positioning yielded good anatomical and visual outcomes and minimal complications, a study found.

“There is controversy over how much positioning time patients actually need and the relative effect that face-down posturing provides after macular hole repair,” lead study author David R.P. Almeida, MD, MBA, PhD, said. “When macular hole surgery was initially performed, patients were doing up to 2 weeks of face-down positioning. That was thought to be the best avenue for a successful outcome after surgery.”

However, patients disliked the lengthy recovery time because it constituted a significant strain and affected their quality of life, Dr. Almeida told OSN Retina.

David R.P. Almeida, MD, MBA, PhD 

David R.P. Almeida

Study protocol

In the study, 50 patients with stage 2 or stage 3 idiopathic macular hole were positioned face down for 50 minutes of every hour for 3 days. There was no comparison arm employing a longer duration protocol.

Study participants were recruited from retina clinics at Hotel Dieu Hospital in Kingston, Ontario, by Jeffrey Gale, MD, who began using the shortened face-down protocol for some patients nearly 10 years ago. All surgeries were performed by Dr. Gale.

“We hoped to confirm what we anecdotally saw, that 3 days of prone positioning for your typical routine idiopathic macular hole can be very successful,” Dr. Almeida said.

The study was published in Retina.

Outcomes

Anatomical closure of macular hole was achieved with one surgery in 49 of 50 eyes (98%). The single eye that did not respond developed an epiretinal membrane.

“We thought we would have about a 90% success rate for closure, so we are very happy and excited by this result,” Dr. Almeida said.

Figure 1a. Preoperative color fundus photograph. 
Figure 1b. OCT macular scan displaying an idiopathic macular hole in the right eye. 
Figure 1c. At 3 months follow-up, OCT demonstrates a successfully closed macular hole with a visual acuity of 6/9. 

Preoperative color fundus photograph (top) and OCT macular scan (middle) displaying an idiopathic macular hole in the right eye of a 69-year-old woman with a presenting visual acuity of 6/120. The patient underwent combined cataract extraction and vitrectomy with internal limiting membrane peeling, 20% SF6 intraocular gas tamponade and 3 days of face-down positioning. At 3 months follow-up, OCT demonstrates a successfully closed macular hole (bottom) with a visual acuity of 6/9.

Images: Almeida DRP

Visual acuity improved to various degrees in all eyes. Prior to surgery, 10% of eyes were 6/12 or better; postoperatively, 38% of eyes were 6/12 or better. However, 72% of patients had cataract surgery in the same session as macular hole repair, and visual acuity would be expected to improve with cataract surgery, Dr. Almeida noted.

There were no IOP complications, which can be common with some methods of macular hole surgery, he said. Two patients developed minor complications: persistent cystoid macular edema and IOL pupillary capture.

“This was a lower complication rate than we expected,” Dr. Almeida said.

Surgical technique

The researchers used 20% sulfur hexafluoride as an intraocular agent for macular hole tamponade.

“This is important because the short-acting gas is well tolerated. For a duration of 3 days, I think it is the ideal gas,” Dr. Almeida said.

In contrast, air tamponade has a lower rate of macular hole closure, and silicone oil requires a second surgery to remove the oil, he said.

Successful outcomes for the study may be attributed in part to internal limiting membrane (ILM) peeling to relieve traction.

“We believe that as long as ILM is present, pathological traction will occur on the hole and you will not be as successful in closing,” Dr. Almeida said. “I also think combining cataract surgery actually gives us a better vitrectomy. You end up with a better gas fill if the native lens is removed.”

Cataract surgery was performed before macular hole repair.

A limitation of the study was that postoperative compliance was not monitored.

An effective face-down regimen of even fewer than 3 days is feasible, Dr. Almeida said. A follow-up study of 1-day therapy may be pursued. – by Bob Kronemyer

Reference:
  • Almeida DR, Wong J, Belliveau M, Rayat J, Gale J. Anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning. Retina. 2012;32(3):506-510.
For more information:
  • David R.P. Almeida, MD, MBA, PhD, can be reached at Department of Ophthalmology, Queen’s University, Hotel Dieu Hospital, 166 Brook Street, Kingston, Ontario, Canada K7L 5G2; 613-483-4508; email: dalmeida@evolation-medical.com.
  • Disclosure: Dr. Almeida has no relevant financial disclosures.