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Sustained postoperative face-down positioning may not be necessary for all cases of macular hole closure
MEDICAL ABSTRACTS Marc D. Myers, O.D. Sustained postoperative face-down positioning may not be necessary for all cases of macular hole closure Mittra RA, Kim JE, Han DP, et al. Sustained postoperative face-down positioning is unnecessary for successful macular hole surgery. Br J Ophthalmol 2009;93(5):664-6. Two factors aid in determining if the repair of a full-thickness (stage III or IV) macular hole is indicated: visual acuity that is symptomatic and less than 20/70 and its discovery within a time period of 2 years or less. The preferred method for repair involves a 3-port pars plana vitrectomy with internal limiting membrane (ILM) or epiretinal membrane (ERM) peeling with a gas tamponade. Traditionally, postoperatively, patients are instructed to position their head in a face-down position for up to 90% of the time over a 2-week period. This typically is followed by a re-evaluation visit in which successful cases undergo gas bubble reinsertion with face down positioning for up to 50% of the time for an additional 2 weeks. This procedure, although intimidating and inconvenient for patients, has stable and consistent success. This study was a retrospective multicenter review of all consecutive cases of stage III and IV macular hole surgeries performed during a 15month period. The authors set out to determine their ability to achieve successful macular hole closure with 1day postoperative prone positioning followed by instructions to avoid the supine position for 2 weeks with side sleeping at night. The primary outcome assessment was the rate of hole closure. Fifty-six eyes of 53 patients
were identified, with 79% of the eyes having stage III macular holes and 70% of the eyes being phakic at the time of surgery. Mean preoperative visual acuity was approximately 20/ 100, and mean postoperative acuity was approximately 20/50 (measured by Snellen method) over a mean follow-up period of 5.2 months. Using the modality of 1-day postoperative prone positioning followed by instructions to avoid the supine position for 2 weeks with side sleeping at night, macular hole closure was achieved in 52 eyes (93%) with one operation. Recent investigations into the mechanism by which the gas tamponade aides hole closure have found that surface tension rather than buoyancy is the critical factor. In a related study by Berger and Brucker, it was argued that sufficient buoyant pressure with maintenance of adequate surface tension could be achieved by an intraocular gas bubble (0.08 mmHg for a bubble 1 mm in height), without affect by the position of the head, so long as the gas bubble was made large enough to allow for contact with the hole for a sustained period. Although sustained contact is easier to achieve with prolonged prone positioning, these authors believe their data show that reasonable contact between the hole and the gas bubble can be consistently achieved by appropriate 1-day postoperative face-down positioning and the strict avoidance of the supine position alone. Because a larger gas bubble appears to be necessary to provide the compensatory sustained contact in the absence of prone positioning, the procedural adaptations of performing as complete a vitrectomy as possible and taking the time to achieve as complete an air–fluid exchange as possible were advised. The authors conclude that sustained postoperative face-down positioning may not be necessary for all
1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
Marc D. Myers, O.D. cases of macular hole closure. With the combined attractiveness of a 93% success rate and a significantly lessrestrictive postoperative expectation, perhaps more individuals will elect to make the attempt rather than accept the limitations of the deficit. Andrew S. Gurwood, O.D. doi:10.1016/j.optm.2009.09.008
Pretreatment with intravitreal steroid injection should be considered with caution Unoki N, Nishijima K, Kita M, et al. Randomised controlled trial of posterior sub-Tenon triamcinolone as adjunct to panretinal photocoagulation for treatment of diabetic retinopathy. Br J Ophthalmol 2009;93(6):765-70. The National Eye Institute of The National Institutes of Health’s Diabetic
were identified, with 79% of the eyes having stage III macular holes and 70% of the eyes being phakic at the time of surgery. Mean preoperative visual acuity was approximately 20/ 100, and mean postoperative acuity was approximately 20/50 (measured by Snellen method) over a mean follow-up period of 5.2 months. Using the modality of 1-day postoperative prone positioning followed by instructions to avoid the supine position for 2 weeks with side sleeping at night, macular hole closure was achieved in 52 eyes (93%) with one operation. Recent investigations into the mechanism by which the gas tamponade aides hole closure have found that surface tension rather than buoyancy is the critical factor. In a related study by Berger and Brucker, it was argued that sufficient buoyant pressure with maintenance of adequate surface tension could be achieved by an intraocular gas bubble (0.08 mmHg for a bubble 1 mm in height), without affect by the position of the head, so long as the gas bubble was made large enough to allow for contact with the hole for a sustained period. Although sustained contact is easier to achieve with prolonged prone positioning, these authors believe their data show that reasonable contact between the hole and the gas bubble can be consistently achieved by appropriate 1-day postoperative face-down positioning and the strict avoidance of the supine position alone. Because a larger gas bubble appears to be necessary to provide the compensatory sustained contact in the absence of prone positioning, the procedural adaptations of performing as complete a vitrectomy as possible and taking the time to achieve as complete an air–fluid exchange as possible were advised. The authors conclude that sustained postoperative face-down positioning may not be necessary for all
1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
Marc D. Myers, O.D. cases of macular hole closure. With the combined attractiveness of a 93% success rate and a significantly lessrestrictive postoperative expectation, perhaps more individuals will elect to make the attempt rather than accept the limitations of the deficit. Andrew S. Gurwood, O.D. doi:10.1016/j.optm.2009.09.008
Pretreatment with intravitreal steroid injection should be considered with caution Unoki N, Nishijima K, Kita M, et al. Randomised controlled trial of posterior sub-Tenon triamcinolone as adjunct to panretinal photocoagulation for treatment of diabetic retinopathy. Br J Ophthalmol 2009;93(6):765-70. The National Eye Institute of The National Institutes of Health’s Diabetic