Impact of Face-Down and Book-Reading Positions on the Success of Macular Hole Surgery

By Suleyman Gokhan Kerci, Berna Sahan

Affiliations

1. Department of Ophthalmology, Medicana International Izmir Hospital, Izmir, Turkiye

doi: 10.29271/jcpsp.2025.10.1279

ABSTRACT
Objective: To evaluate the impact of face-down positioning (FDP) and book reading position (BRP) on the success of full-thickness macular hole (FTMH) surgery and their influence on patients’ quality of life.
Study Design: Descriptive, analytical study.
Place and Duration of the Study: Department of Ophthalmology, Medicana International Izmir Hospital, Izmir, Turkiye, from January 2018 to June 2024.
Methodology: Thirty-six patients adopted the FDP after surgery (Group 1), and another 36 adopted the BRP (Group 2) following FTMH surgery. The two groups were compared in terms of preoperative patient data, postoperative parameters, success rates, and complications. Additionally, patients filled the short form-36 (SF-36) quality of life questionnaire preoperatively and at the first 1-month postoperative check-up. Continuous variables were compared using the independent Student’s t-test or the Mann–Whitney U test, as appropriate. Categorical variables were analysed using the Chi-square test.
Results: Functional success was achieved in 26 (72.2%) patients in Group 1 and 29 (80.6%) patients in Group 2 (p = 0.405). Anatomical success was obtained in 34 (94.4%) patients in both Group 1 and Group 2 (p >0.99). Complications occurred in 5 (13.8%) patients in Group 1, and 4 (11.1%) in Group 2 (p = 0.443). Three subdomains of SF-36, including physical functioning, bodily pain, and general health, significantly improved in Group 2 compared with Group 1 (p <0.05 for all three parameters).
Conclusion: The results of this study indicated that FDP and BRP had similar effects on the anatomical and functional success and complications of FTMH surgery. However, patients in the BRP group had significantly better quality of life following surgery, according to the SF-36 questionnaire.

Key Words: Book reading position, Face-down positioning, Macular hole surgery, Short form-36.

INTRODUCTION

A full-thickness macular hole (FTMH) is defined as a pathological defect in the neurosensorial retina in the foveolar region.¹ Previous reports emphasised the importance of FTMH for public health, and the incidence of FTMH was found to be almost 7.5 individuals and 8.0 eyes per 100,000 population.^2,3 FTMH is strongly associated with central visual field impairment and reduced visual acuity.⁴ Untreated FTMH results in restricted movement, loss of work capacity, and social isolation.⁵ Pars plana vitrectomy combined with internal limiting membrane (ILM) peeling and intraocular tamponade has been estimated as an effective and safe treatment option for FTMH management.⁶ Although the success of the surgical technique has been proven, multiple factors may affect the surgical outcomes, including surgeon experience, whether the case is primary or secondary, and the duration of gas tamponade contact with the macula.^7,8

Face-down positioning (FDP) is recommended to increase the contact for intraocular gas-macula interaction. Analysing the effect of FDP on FTMH surgery outcomes, Lange et al. concluded that it significantly increased surgical success.⁹ Similarly, Chandra et al., in a review of studies on FTMH with and without FDP, reported that FDP had a significant impact on healing in larger FTMH.¹⁰ However, multiple studies have reported that FDP is technically difficult for patients and negatively impacts their quality of life. Therefore, many ophthalmologists focus on alternative strategies that positively contribute to the success of FTMH surgery while maintaining patient comfort.¹¹

Although many studies analysed the impact of FDP on FTMH surgical outcomes, to the best of authors’ knowledge, no research has compared the effect of FDP and book reading position (BRP) after FTMH surgery on patient quality of life. This study aimed to identify the impact of FDP and BRP on the anatomical and functional success of FTMH surgery and their influence on patient’s quality of life.

METHODOLOGY

This study was conducted in the Department of Ophthalmology, Medicana International Izmir Hospital, Izmir, Turkiye, from January 2018 to June 2024. The study received approval from the Ethics Committee of the University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkiye (Decision No. 202442), in accordance with the Declaration of Helsinki. All patients who underwent pars plana vitrectomy combined with ILM peeling (with additional epiretinal membrane (ERM) peeling if present) and intraocular tamponade for primary FTMH were evaluated for inclusion in the study. FTMH size was evaluated using optical coherence tomography (OCT) and categorised according to Gass’ classical staging system. All operations were performed by a single ophthalmologist with 20 years of surgical experience. A detailed anamnesis was obtained, and all patients underwent a detailed ophthalmological examination. In addition, detailed information was given to patients about the surgical success rate, possible complications, and the postoperative recovery process. Patients with secondary or refractory FTMH, previous vitrectomy, coexisting cataracts, diabetic retinopathy, or age-related macular degeneration were excluded from the study. Moreover, the presence of foveoschisis, retinal detachment, glaucoma, and coagulopathy were additional exclusion criteria.

Demographic data and preoperative findings, including age (years), gender, side of pathological eye, diameter of hole (µm), stage of FTMH, presence of concomitant ERM, lens status (phakic or PC-IOL), macular hole index (MHI), hole form factor (HFF), and tractional hole index (THI), were recorded. In addition, preoperative best-corrected visual acuity (BCVA) and postoperative BCVA at the 1-month, 3-month, and 6-month follow-up were recorded. Moreover, preoperative intraocular pressure (IOP) and postoperative IOP at the 1^-month were recorded. Lastly, functional and anatomical success and complications of the procedure (increased IOP, persistent hole, presence of ERM) were recorded. Complete anatomical closure of FTMH was accepted as the primary outcome of the procedure and evaluated by OCT. The secondary outcome of the procedure was analysed with the evaluation of visual acuity at 6-month follow-up. Additionally, patients completed the SF-36 quality of life questionnaire preoperatively and at 1-month check-up.

A 3-port, 23 G transconjunctival pars plana vitrectomy was performed by the same surgeon (SGK) in all cases using an HI-R 900 surgical microscope and an EIBOS imaging system (Moller-Wedel, Germany), along with a Constellation posterior segment vitrectomy device (Alcon, Fort Worth, TX). Transconjunctival scleral trocar incisions were made using the two-step approach (an initial oblique incision at 5°, followed by 30°. The incisions were placed 3 mm from the limbus in pseudophakics and 3.5 mm in phakics (clear lens). The posterior hyaloid was then peeled, and the peripheral vitreous was cleaned. The ILM was dyed with ILM blue (DORC International) and peeled using ILM forceps. The ERM, if present, was peeled with microforceps before ILM. After this procedure, intraocular gas tamponade (20% SF₆) was applied to all patients. Patients maintained in the prone position (FDP) for three days (including night-time) postoperatively were assigned to Group 1, whereas those who maintained the BRP for three days and slept on their non-operated eye were assigned to Group 2.

The SF-36 questionnaire was developed and externally validated to assess the health status in particular populations. It evaluated eight domains: physical functioning (10 items), physical limitations (four items), bodily pain (two items), general health status (five items), energy/vitality (four items), social functioning (two items), emotional role (three items), and mental health status (five items). Scores for each domain ranged from 0 to 100, with higher scores indicating battle health status.¹²

To identify the impact of FDP and BRP on the outcomes of FTMH surgery, the groups were compared in items of preoperative patient data, postoperative parameters, success rates, complications, and change in patient quality of life, according to the SF-36.

Statistical analysis was conducted using the Statistical Package for the Social Sciences version 27 (SPSS, IBM Corp., Armonk, NY, USA). Normality of variable distribution was assessed by the Shapiro-Wilk test. The independent Student’s t-test was used for the comparison of normally distributed parameters, and the Mann-Whitney U test was used for non-normally distributed parameters. Quantitative data were expressed as mean ± standard deviation or median (IQR). Categorical variables were compared using the χ² test or Fisher’s exact test. The data were evaluated at a 95% confidence level, and a p-value of <0.05 was considered  statistically  significant.  

Table I: Comparison of demographic data and preoperative findings between the groups.
 

Variables	Group 1 (FDP) (n = 36)	Group 2 (BRP) (n = 36)	p-values
Age (years)*	69.1 ± 7.4	66.6 ± 7.0	0.145a
Gender, n (%)       Male       Female	- 14 (38.9%) 22 (61.1%)	- 11 (30.6%) 25 (69.4%)	0.458b
Side, n (%)       Right       Left	- 24 (66.7%) 12 (33.3%)	- 17 (47.2%) 19 (52.8%)	0.096b
Diameter of hole (µm)**	401.0 (240.0-602.0)	389.0 (250.0-590.0)	0.173c
Stage, n (%)       2       3       4	- 14 (38.9%) 9 (25.0%) 13 (36.1%)	- 15 (41.7%) 11 (30.6%) 10 (27.8%)	0.731b
Concomitant ERM, n(%)	11 (30.5%)	8 (22.2%)	0.195b
Lens Status, n (%)       Phakic       PC-IOL	- 27 (75.0%) 9 (25.0%)	- 26 (72.2%) 10 (27.8%)	0.789b
MHI**	0.39 (0.35-0.42)	0.33 (0.30-0.56)	0.145c
HFF**	0.74 (0.72-0.83)	0.71 (0.61-0.86)	0.149c
THI**	0.90 (0.66-1.33)	0.97 (0.70-1.21)	0.693c
*Mean ± standard deviation, **Median (IQR). aIndependent Student’s t-test, bChi-square test, cMann-Whitney U test. ERM: Epiretinal membrane, MHI: Macular hole index, HFF: Hole form factor, THI: Tractional hole index.

Table II: Comparison of BCVA and IOP values in preoperative and postoperative periods.

Parameters	Group 1(FDP)  (n = 36)	Group 2 (BRP) (n = 36)	p-values
Preoperative BCVA*	1.3 (0.8-1.5)	0.9 (0.7-1.3)	0.080a
Postoperative BCVA*       1st month       3rd month       6th month	- 1.2 (0.7-1.5) (0.6-1.2) 1.1 (0.5-1.2)	- 0.9 (0.7-1.3) 0.7 (0.4-1.2) 0.6 (0.4-1.2)	- 0.218a 0.092a 0.115a
Change in BCVA*       3rd month       6th month	(0-0.2) 0.1 (0-0.3) 0.3 (0.1-0.3)	0 (-0.2-0.1) 0.1 (0-0.2) 0.2 (0.1-0.3)	0.093a 0.409a 0.405a
Preoperative IOP*	16.0 (14.0-18.0)	14.0 (12.0-16.0)	0.158a
Postoperative IOP* 1st month	15.0 (13.0-34.0)	15.0 (10.0- 31.0)	0.235a
*Median (IQR). aMann-Whitney U test. BCVA: Best-corrected visual acuity; IOP: Intraocular pressure.

Table III: Comparison of success and complication rates between the groups.

Parameters	Group 1 (FDP)  (n = 36)	Group 2 (BRP)  (n = 36)	p-values
Functional Success, n (%)	26 (72.2%)	29 (80.6%)	0.405a
Anatomical Success, n (%)	34 (94.4%)	34 (94.4%)	>0.99a
Complications, n (%)       Increased IOP       Persistent hole	5 (13.8%) 3 (8.3%) 2 (5.6%)	4 (11.1%) 2 (5.5%) 2 (5.6%)	0.443a
IOP: Intraocular pressure. aChi-square test

Figure 1: Comparison of pre-procedure and post-procedure SF-36 scores between the groups.

Figure 2: Comparison of the changes in SF-36 scores after the procedure between the groups.

RESULTS

In total, 72 patients were included in the study. According to the study design, 36 patients adopted FDP, and 36 patients adopted BRP following the procedure. Age, gender ratio, side of procedure, diameter of macular hole, stage of pathology, and concomitant ERM were comparable between the groups (p = 0.145, p = 0.458, p = 0.096, p = 0.173, p = 0.731, and p = 0.195, respectively). In addition, lens status, MHI, HFF, and THI were also similar between the groups (p = 0.789, p = 0.145, p = 0.149, p = 0.693, respectively; Table I).

Preoperative BCVA was 1.3 in Group 1 and 0.9 in Group 2 (p = 0.080). Calculated postoperative BCVA at 1-month, 3-month, and 6-month were not significantly different between the groups (p = 0.218, p = 0.092, and p = 0.115, respectively). Moreover, preoperative IOP was 16.0 in Group 1, and 14.0 in Group 2. Postoperative IOP was 15.0 in both groups (p = 0.158 and p = 0.235). Comparison of preoperative and postoperative BCVA and IOP values is summarised in Table II.

Functional success was achieved in 26 (72.2%) patients in Group 1 and in 29 (80.6%) patients in Group 2 (p = 0.405). Anatomical success was achieved in 34 (94.4%) patients in both groups (p >0.99). Complications occurred in 5 (13.8%) patients in Group 1, and 4 (11.1 %) in Group 2 (p = 0.443). Increased IOP was the most common complication in 3 (8.3%) patients in Group 1 and 2 (5.5%) patients in Group 2 (Table III).

The comparison of preoperative SF-36 values between the two groups is detailed in Figure 1. The eight domains of SF-36 were similar between the groups (p >0.005 for each parameter). However, three subdomains of SF-36, including physical functioning, bodily pain, and general health, significantly improved in Group 2 compared to Group 1 (p <0.005 for all three parameters, Figure 2). The preoperative and postoperative SF-36 scores and the changes in SF-36 are summarised in Figure 1 and 2.

DISCUSSION

Untreated FTMH often results in serious visual impairments and loss, and surgery is the gold standard for the management of FTMH.¹³ Although techniques for FTMH surgery are well-defined, the impacts of postoperative position on the anatomical and functional success of FTMH surgery remain under investigation.^14,15 Recently, almost nine out of ten vitreoretinal surgeons have suggested FDP for some period after surgery; however, this remains a challenge for most patients.¹⁶ Therefore, this study was conducted to evaluate the effects of postoperative positioning on FTMH surgical outcomes and patients’ quality of life by comparing FDP and BRP. This study revealed that BRP achieved similar success and complication rates to FDP, while offering a superior quality of life for patients.

The primary goal of FTMH surgery is to achieve the highest success rate with minimal complication rate.¹⁷ Alberti and Cour retrospectively analysed the data of 122 patients who underwent pars plana vitrectomy. The authors achieved anatomical closure of FTMH in almost 95% of patients, and visual improvement was found in 70.0% of patients with FDP and 75.0% in patients without FDP, with similar rates.¹⁸ In another retrospective study by Gao et al., which analysed 53 patients who underwent FTMH surgery, FDP or adjustable positioning did not significantly affect the success and complication rates.¹⁹ Consistent with the aforementioned studies, no significant impact of FDP or BRP on the success and complication rates of FTMH surgery was observed.

Recently, surgeons have aimed not only to achieve technical success without complications but also to improve patients’ quality of life following surgery. The SF-36 form is a validated and frequently used questionnaire for assessing quality of life before and after treatment.¹² Although numerous studies have focused on the success and complications of FTMH surgery, relatively few have focused on patients’ quality of life. Alberti and Cour analysed the impact of positioning after FTMH surgery; however, the authors asked a question with three options (no discomfort, uncomfortable or very uncomfortable) and did not use a validated questionnaire.¹⁸ Tadayoni et al. used a pain scale to analyse the impact of positioning following FTMH and concluded that postoperative pain was significantly lower in non-FDP positions compared with FDP. However, they did not analyse the effect of positioning on quality of life.²⁰ In the present study, for the first time, the SF-36 form was used to analyse the impact of positioning on patient quality of life following FTMH surgery. This study showed that BRP significantly improved physical functioning, bodily pain, and general health compared with FDP.

This study has some limitations. First of all, only the short-term outcomes of surgery were identified, and long-term results are lacking. Secondly, this study reflected the experience of a single surgeon about positioning following FTMH surgery. However, multicentre studies involving different surgeons and institutions may affect the study results due to variations in surgeon experience and surgical technique. Lastly, it is unclear whether patients strictly followed the recommendations and provided accurate answers on the SF-36 questionnaire. To minimise this limitation, the importance of the position and the currect method to get into the position were explained to each patient in detail, and patients were provided with a quiet, unrestricted environment when filling out the SF-36 forms.

CONCLUSION

The present study revealed that FDP and BRP following FTMH surgery had similar effects on the success and complications of FTMH surgery. However, patients with BRP had significantly better quality of life following surgery, according to the SF-36 questionnaire. However, these results must be supported by further prospective randomised studies with larger sample size.

ETHICAL APPROVAL:
Ethical approval was obtained from the Ethics Committee of the University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkiye (Decision No. 202442). This study followed the principles of the Declaration of Helsinki.

PATIENTS’ CONSENT:
Informed consent was not obtained due to the retrospective nature of the study design.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
SGK: Conception, study design, acquisition of the data, writing, and critical revision of the manuscript.
BS: Conception, design study, interpretation of the data, critical and statistical analysis, and writing.
Both authors approved the final version of the manuscript to be published.
 

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