EURETINA 2023: Varun Chaudhary, MD, discusses posturing after macular hole surgery

The 23rd annual EURETINA Congress is finally underway in Amsterdam, the Netherlands. We spoke with Varun Chaudhary, MD, who provided an overview of his presentation, "Systematic Review and Metanalysis in Macular Hole RCTs – Posturing after Macular Hole Surgery." Here's what he had to say about the meeting and his research.

Editor's note: The following transcript has been lightly edited for clarity.

David Hutton: I'm David Hutton of Ophthalmology Times. I'm joined today by Dr Varun Chaudhary, who at EURETINA 2023 in Amsterdam presented "Systematic Review and Metanalysis in Macular Hole RCTs Posturing after Macular Hole Surgery." Thank you for joining us today. Tell us about your presentation.

Varun Chaudhary, MD: Thank you very much, my pleasure to be here. And for this topic, what me and my co-authors decided to do was look at the question about the importance of face-down positioning, which we know majority of retinal surgeons recommend for patients in terms of what impact it has on macular hole closure rate.

As you know, David, historically, face down positioning has been a very important part of success. or what we thought were successful outcomes after macula-off surgery. But there have been more recent RCTs that are raising raising questions about the importance of face-down positioning. So we carried out a large, systematic review and metanalysis, looking at only RCT. So this was the most unbiased estimate of the treatment effect of positioning after macular hole surgery.

The outcome we were looking at were 7 different outcomes. In specific, we were looking at macular closure rate, visual acuity outcomes, as well as outcomes such as complication risk and patient reported outcome measures after surgery. We carried out a systematic review, pre registered protocol in prospero and we identified 8 RCTs that looked at positioning after macular hole surgery. And we were looking at two groups, patients who did face-down positioning versus patients who did not do face-down positioning.

And what our results essentially demonstrated was that there was no definitive treatment benefit of face-down positioning compared to no face-down positioning after macular hole surgery in terms of looking at the outcome for macular hole closure rate. So essentially, our findings are 95 confidence intervals for the relative risks showed that face-down positioning could either be 1% worse, are up to 12% better in terms of hole closure rate compared to no face-down positioning. But because it crossed the threshold of a relative risk of 1, we cannot make any conclusion that it's beneficial for our patients.

Now, we looked at some subgroup analysis as well. One question that often comes up is what about larger macular holes? So we did a subgroup analysis looking at closure rates in patients with macular hole less than 400 microns and compare those with patients who had macular holes greater than 400 microns. And our results once again demonstrated no treatment effect, either for small holes or for large holes in terms of macular hole closure closure rate. We, of course wanted to look at visual acuity outcome that's what our patients care most about. And as clinicians, we are obviously most focused on visual acuity outcomes. What we found with a visual acuity analysis was that there was a small potential benefit of face-down positioning compared to no face-down positioning after macular hole surgery. But this this benefit included clinically insignificant improvement or benefit as well as potentially clinically meaningful benefit.

So it was, the results were essentially imprecise in terms of giving us a definite answer whether face and positioning actually leads to better visual acuity. But the confidence intervals did suggest some statistical benefit of face-down positioning compared to no face-down positioning. And once again, when we looked at the subgroups here in terms of macular hole size, the predominant benefit we saw in terms of better vision with face-down positioning was in patients with larger macular holes. Again, this was a subgroup analysis, and the credibility of the analysis was low based on Iceman credibility scores that we carried out to look at the validity of these conclusions.

We also wanted to look at macula oral gas well. We know surgeons have preferences in terms of different gases they would use and essentially our results showed no benefit of one gas versus another in terms of improving success rate of macular hole surgery, in terms of anatomic outcomes and closure rates. We looked at adverse events, once again, there was no difference between face-down positioning and no face-down positioning.

What was also very interesting, David, was there's a definitely an area of evidence gap in this field when it comes to patient reported outcome measures. Very few RCTs measure that. When we talk about evidence-based medicine, it's vital that we look at clinical expertise, the evidence in the field. But the third item we need to look at is patient preferences. And I think in conclusion, what the data is showing is that the benefit of face-down positioning in terms of anatomic closure after macular hole surgery is not clear. Our data, in fact, suggests that there is no definitive benefit of face-down positioning compared to no face-down positioning. So I think it's important that we have these discussions and bring this data forward as part of the informed consent so patients can be part of that informed consent process and make a decision that's most in keeping with what they would like to do in collaboration with their clinician and surgeon input as well. Thank you.