Facedown Positioning in Macular Hole Surgery: A Systematic Review and Individual Participant Data Meta-Analysis

Area of Science:

• Ophthalmology
• Retinal Surgery
• Macular Hole Treatment

Background:

• Idiopathic full-thickness macular holes (FTMHs) are a significant cause of vision loss.
• The role and optimal duration of facedown positioning (FDP) after vitrectomy for FTMHs remain debated.
• Current guidelines lack consensus on FDP necessity and duration.

Purpose of the Study:

• To evaluate the anatomic and visual outcomes associated with FDP in patients undergoing vitrectomy for FTMHs.
• To investigate how macular hole size and FDP duration influence treatment effects.
• To provide evidence-based recommendations for FDP in FTMH surgery.

Main Methods:

• A prospective systematic review and individual patient data (IPD) meta-analysis was conducted.
• Included randomized controlled trials comparing FDP with no FDP (nFDP) from major databases and registries (Jan 2000-Mar 2023).
• Primary outcomes were macular hole closure and visual acuity at 6 months post-surgery.

Main Results:

• FDP showed a modest, though not statistically significant, improvement in primary closure (OR 2.41, P=0.06) and a significant improvement in visual acuity (mean -0.08 logMAR, P=0.006).
• Benefits were more pronounced in patients with larger macular holes (≥400 microm), with significant improvements in closure and visual acuity.
• Each additional day of FDP was associated with improved odds of anatomic success and visual acuity, potentially plateauing at 3 days.

Conclusions:

• Facedown positioning (FDP) offers modest anatomic and visual benefits for FTMH surgery, with greater efficacy in larger macular holes.
• The findings support considering FDP for patients with macular holes exceeding 400 microm.
• Further research is needed to establish definitive guidelines on FDP necessity and duration.