To posture or not to posture after macular hole surgery

Objective: To evaluate the anatomic and functional success of phacovitrectomy and intraocular gas tamponade for macular hole surgery with only first night face down posturing. Methods: This was a nonrandomized observational prospective trial over 9 months, with data collection on 28 eyes of 26 consecutive patients who underwent phacovitrectomy, internal limiting membrane peel, and intraocular gas tamponade (C2F6) for stage 2, 3, and 4 macular holes. Data included sex, age, hole latency and Gass stage, preoperative and postoperative visual acuity and ocular coherence tomography, refractive outcome, ocular comorbidity, first postoperative day gas fill, and intraocular pressure. Postoperatively, all patients were postured face down overnight. Thereafter, patients with more than 70% gas fill (beyond the inferior retinal vascular arcade) were asked to stop posturing, although they were advised not to lie flat on their backs at night for 10 days. Results: The sample was divided into patients who did and did not need to posture postoperatively, depending on first day gas fill. Twenty patients did not need posturing and 8 patients needed postoperative posturing for 10 days. The mean macular hole duration was 10.5 months. A total of 87.5% compared to 100% achieved hole closure in the posture and nonposture group, respectively. The mean postoperative visual acuity was 0.5 ± 0.25 LogMAR. Statistical analysis revealed no significant difference in age, hole duration, preoperative and postoperative visual acuities, intraocular pressure measured 24 hours postoperatively, or refractive error between the two samples. Conclusion: Phacovitrectomy for macular hole surgery without postoperative face down posture is a reasonable approach, as long as the eye has more than 70% gas fill (beyond the inferior retinal vascular arcade) on the first postoperative day. This study showed no statistically significant difference between patients who postured and those who did not posture. The combination of phacoemulsification, pars plana vitrectomy, internal limiting membrane, and gas tamponade in macular hole surgery reduces the difficulty of posturing in elderly patients. This technique saves the patient from exposure to a second intraocular intervention to remove a cataract which will commonly develop after vitrectomy and gas tamponade alone.