Face-down post-op positioning may not be necessary for many macular hole repairs


Face-down orientation does not appear to significantly influence clinical outcomes in most cases of macular hole repair. Larger holes are one possible exception.

Study design

This meta-analysis sought to compare results after macular hole surgery based on postoperative positioning. Eight randomized controlled trials (RCTs) with a total of 709 eyes were included. Data were collected for 7 clinically important outcomes of macular hole repair, including closure rate, visual acuity (VA) improvement, recurrence of full-thickness macular hole (FTMH), visual function, quality of life, patient satisfaction, and complication rates.


A total of 358 eyes were randomized to the face-down positioning (FDP) group and 351 to the non-face-down positioning (nFDP) group. There was no significant difference in hole closure rate between the two groups, but VA gain was greater in the FDP group for holes >400 microns as compared to the nFDP group. For smaller holes, there was no difference noted between the two groups.


There are several limitations to this study, including the inability to truly measure compliance with FDP instructions and significant study-to-study variability in the duration of FDP after surgery. There was also a wide range of surgical techniques used, which may have affected outcomes. Finally, the issue of complex macular holes was not addressed.

Clinical significance

This meta-analysis suggests that FDP may not be as important to macular hole closure as previously thought, especially for macular holes smaller than 400 microns. For larger holes, a visual acuity benefit was noted for the FDP group. Future large-scale RCTs may help define which holes require FDP so that patients with smaller holes could avoid the inconvenience of FDP.

Financial Disclosures: Dr. Lisa Schocket discloses no financial relationships.

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