Macular hole surgery without face-down positioning. A pilot study

To investigate whether postoperative face-down positioning is necessary for successful macular hole repair.

Although never proven, face-down positioning is strongly considered an important maneuver to achieve macular hole closure. Face-down posturing is inconvenient, and for patients with physical or mental limitations, weeks of face-down positioning may be an impossible task. A gas bubble that completely fills the vitreous cavity will tamponade a macular hole despite head position and may close a macular hole as effectively as a partial gas fill with face-down positioning. If face-down positioning were not necessary, more patients would be eligible to benefit from this surgery.

Thirty-three consecutive eyes in 31 patients aged 65-79 years with Stage II, III, or IV full-thickness macular holes underwent macular hole surgery with a complete 15% C3F8 vitreous fill. Hole duration varied from 1 month to 10 years; in 21% of eyes, (seven of 33) holes had been present for more than 1 year. All phakic eyes (n = 25) had cataract extraction with intraocular lens insertion when macular hole surgery was done. No patients were positioned face down.

The follow-up period was 6-40 months; 73% of the patients have been observed for more than 1 year. Preoperative hole duration did not affect hole closure rate. The success rate after one surgery was 79% (26 of 33 eyes), and with additional vitrectomy surgery, the total success rate was 85% (28 of 33 eyes). Forty-eight percent of eyes attained visual acuity of 20/50. Eighty percent of eyes with preoperative acuity of > 20/100 attained > 20/50 acuity. Significant complications included iris incarceration into the cataract wound during a postoperative fluid-gas exchange (one eye), posterior synechiae (four eyes), intraocular lens capture (two eyes), elevated intraocular pressure (three eyes), and retinal detachment (three eyes). Most of these problems can be avoided or reduced.

This pilot study suggests that successful macular hole closure is possible without face-down positioning. This technique may be an alternative for patients with macular holes in pseudophakic eyes who are unable to assume face-down posturing. Combining cataract surgery with this technique for macular hole repair is reasonable for phakic patients who cannot maintain prone positioning. Major disadvantages of combined surgery include the morbidity of the second procedure and removal of a visually insignificant cataract. This approach should be considered for those patients unable to tolerate face-down positioning.