Retina Surgery Feature Story

SEPTEMBER 2010 I RETINA TODAY I 75 W hen Kelly and Wendel described vitreous surgery for idiopathic macular holes in 1991, they advised face-down postoperative posturing for patients.1 Since that time, most retina specialists have adopted face-down positioning as a cardinal rule after macular hole surgery, although there is a lack of data showing its necessity. At the American Academy of Ophthalmology meeting in Chicago in 1996, I presented the first paper to suggest that macular holes can be closed without face-down posturing. The single-operation success rate that my colleagues and I reported in that series was only 79%; however, 79% of patients in the series had stage 3 or 4 macular holes. At the same meeting we also suggested combining cataract surgery with macular hole repair surgery. The presentation was severely criticized at the meeting, and a resulting paper was rejected by Ophthalmology but subsequently published in Retina in 1997.2 There was little interest in the concept of no facedown positioning for approximately the next decade, but since 2007 at least eight published, peer-reviewed papers have confirmed our finding that face-down posturing for any period of time after macular hole repair is not necessary.3-9 This paper reviews my experience with idiopathic primary macular holes not associated with high myopia, repaired without face-down positioning. The purpose of the review is to determine which techniques made a difference in outcomes. My premise is that the purpose of the postoperative intraocular gas bubble is to isolate liquid vitreous from the macular hole, much like a Band-Aid, to allow the retina to heal. The buoyancy of the bubble plays no role at all. With the patient lying on his or her side, even a 75% fill seals a macular hole in the patient’s uppermost eye (Figure 1). Macular Hole Repair Without Face-down Positioning