Role of Positioning After Full-Thickness Macular Hole Surgery Explored in Meta-Analysis

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A meta-analysis and systematic review of RCTs saw no difference between face-down positioning and non-face-down positioning with regard to full-thickness macular hole closure.

A recent systematic review and meta-analysis of randomized controlled trials explored the importance of postoperative face-down positioning in achieving anatomic and functional success after full-thickness macular hole surgery.1

Based on the findings, the current review did not indicate a difference between face-down positioning and non-face-down positioning in regard to full-thickness macular hole closure, although they noted the observed confidence intervals (CIs) were wide.

“There was a visual benefit to face-down positioning; however, the CIs included values of trivial clinical significance,” wrote investigators.1 “Subgroup analyses demonstrated that the visual acuity benefit observed was driven by large holes.”

Substantial variability in clinical practice on the need and length of face-down positioning recommended to patients after full-thickness macular hole surgery lead the way for this analysis. A lack of robust clinical guidelines on the topic also indicated the need for an updated estimate of the effect size of face-down positioning on clinically importance outcomes to inform practice.

Investigators led by Varun Chaudhary, MD, Chief of Ophthalmology, Hamilton Regional Eye Institute, McMaster University, searched Ovid MEDLINE, EMBASE, CENTRAL, and SCOPUS databases from inception to October 2021 for randomized controlled trials evaluating face-down positioning versus non-face-down positioning. They collected data for 7 clinically importance outcomes after macular hole surgery, including closure rate, visual acuity (VA) improvement, recurrence of full-thickness macular hole, visual function, quality of life, patient satisfaction, and complication rates.

The team used the Cochrane risk-of-bias tool for randomized trials to assess the risk of bias, using the Grade of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty in the evidence across the outcomes. Meta-analyses were performed using random-effects modeling and subgroup analyses were conducted based on hole size, type of gas, and duration of face-down positioning.

Overall, investigators included eight randomized controlled trials of 709 eyes in the study. The findings suggest the relative risk (RR) of full-thickness macular hole closure rate comparing face-down positioning versus non-face-down positioning was 1.05 (95% CI, 0.99 - 1.12; P = .09; I2 = 44%; GRADE rating: LOW).

Data show the mean difference for visual acuity improvement comparing face-down positioning and non-face-down positioning was –0.07 (95% CI, –0.12 to 0.01; P = .02; I2 = 16%; GRADE rating: LOW).

Investigators noted the limited data in the study prevented analysis on the recurrence rate of full-thickness macular hole, as well as measures of visual function, quality of life measures, and patient satisfaction metrics, and indicated the need for further trials.

“Further prospective trials are required to assess the gaps in the literature and improve the certainty of evidence for the outcomes examined,” they wrote.1


  1. Chaudhary V, Sarohia GS, Phillips MR, et al. Role of positioning after full-thickness macular hole surgery. Ophthalmology Retina. 2023;7(1):33-43. doi:10.1016/j.oret.2022.06.015