Face down postoperative positioning may not be needed for macular hole closure

The difficulty in maintaining postoperative face down positioning (FDP) has stirred debate on mitigating the duration and even eliminating FDP altogether following macular hole surgery. Lacking a consensus, postoperative protocols vary widely. This study attempts to provide answers by synthesizing available evidence from randomized controlled trials (RCT) related to the issue.

Study design

Ovid MEDLINE, EMBASE, CENTRAL, and SCOPUS databases were searched from their inception to October 3, 2021, for RCTs that evaluated FDP vs non-FDP (nFDP) after full-thickness macular hole surgery (FTMH). nFDP included any positioning that was not explicitly asking patients to keep their face down following surgery. Data was collected for 7 clinically important outcomes after macular hole surgery: closure rate, visual acuity (VA) improvement, recurrence of FTMH, visual function, quality of life, patient satisfaction, and complication rates. The researchers used various tools to determine bias risk and the certainty in the evidence across outcomes.


A total of 709 eyes from 8 RCTs were included. Closure rates were similar between FDP and nFDP groups. The relative risk of successful FTMH closure comparing FDP versus nFDP was 1.05. The FDP group achieved significantly greater improvement in VA than patients in the nFDP group, resulting in a mean difference of –0.07. The duration of positioning did not appear to affect closure rates or visual outcomes. However, there was low certainty of evidence for hole closure rate, VA outcomes, and complication rates.


Given the heterogeneity of certain reporting outcomes and bias inherent to the included trials, the closure rate and visual outcome findings were graded as having a low certainty of evidence. Terms used for surgical techniques and the duration of positioning significantly varied, affecting broad extrapolation of the findings.

Clinical significance

Despite showing a low certainty of evidence, the current study did not demonstrate a difference between FDP and nFDP with respect to FTMH closure.

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