Positioning after macular hole surgery

“The primary reason we currently position patients after macular hole surgery seems to be that we’ve always done it and it gives good results,” said Dr. Alistair Laidlaw, MD, of St. Thomas’ Hospital in London. “But is it necessary, and do patients actually comply with our advice to position following surgery?”

Presenting to the Club Jules Gonin Symposium at the 14th  EURETINA Congress, Dr Laidlaw reviewed the evidence supporting the practice of patient positioning and found it lacking. He also pointed out several misconceptions regarding the effect of bubble bouyancy on the closure of the macular hole. 

“Retina-bubble interaction is due to surface tension, not bouyancy,” said Dr Laidlaw. “And a 60% gas fill will tamponade a 1.5mm macular hole in an upright position,” he continued, citing CT studies that have proven this.

“I am of course aware that most studies report high rates of hole closure with positioning, but subgroup analysis shows that this effect is primarily relevant for large macular holes >500 microns in diameter,” Dr Laidlaw indicated. “Thenumber needed to treat for small holes <400 microns is 40, while the NNT for these larger holes is only 5.” 

Dr. Laidlaw suggested that positioning might simply be a surrogate for decreasing eye and head motion, which can lead to shear forces on the hole. “The evidence seems to show that positioning is unnecessary for successful macular hole surgery,” concluded Dr. Laidlaw. “and I do not recommend it to my patients.”