From the Guidelines
The current guidelines for facedown positioning after macular hole surgery recommend a shortened duration of 1-3 days of strict facedown positioning, with some studies suggesting that no facedown positioning may be similar to facedown positioning for holes smaller than 400μm. This is based on recent studies, including a meta-analysis of 251 cases by Hu et al. 1, which concluded that no face down positioning was similar to face down positioning for holes smaller than 400μm, but face-down positioning may be beneficial for holes larger than 400μm. The positioning requirements depend on several factors including hole size, duration, patient factors, and surgical technique.
Some key points to consider when determining the optimal facedown positioning duration include:
- Hole size: Larger holes (>400μm) may require longer positioning durations 1
- Patient factors: Patients who cannot maintain facedown positioning may be considered for silicone oil tamponade, although this may not provide the same anatomic and visual results as gas tamponade 1
- Surgical technique: The use of gas tamponade, such as SF6 or C3F8, may require more stringent positioning in the early postoperative period 1
In terms of specific positioning instructions, patients are typically advised to:
- Maintain facedown positioning for 50 minutes of every hour while awake
- Take breaks for meals and personal care
- Avoid supine positioning and maintain a face-parallel or face-down position when possible
- Use special equipment like face-down chairs, mirrors, and positioning pillows to improve compliance and comfort during the recovery period.
From the Research
Current Guidelines for Facedown Positioning after Macular Hole Surgery
The current guidelines for facedown positioning after macular hole surgery are evolving, with various studies suggesting different approaches.
- A study from 1997 2 found that successful macular hole closure is possible without face-down positioning, with a success rate of 79% after one surgery and 85% with additional vitrectomy surgery.
- A 2014 study 3 demonstrated equivalent closure rates among patients who were assigned nonsupine versus face-down positioning postoperatively for macular hole repair, with 96% of final hole closure in the face-down group versus 100% in the nonsupine group.
- Another study from 2012 4 suggested that post-operative face-down positioning may improve the likelihood of macular hole closure, particularly for holes larger than 400 μm, with a closure rate of 93.3% in the posturing group versus 60% in the non-posturing group.
- A 2009 study 5 found that sustained postoperative face-down positioning is unnecessary for successful macular hole surgery, with a hole closure rate of 93% using 1-day postoperative face-down positioning.
- A 2012 study 6 evaluated the anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning, achieving anatomical closure of macular holes in 98% of eyes by 1 surgery.
Key Findings
- The necessity of face-down positioning after macular hole surgery is still debated, with some studies suggesting it may not be necessary for successful closure 2, 3, 5.
- The duration of face-down positioning may also be flexible, with some studies using short-duration positioning of 1-3 days 5, 6.
- Patient preference may also play a role, with a 2014 study finding that most patients prefer to avoid strict face-down positioning if reoperated 3.