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Postoperative positioning in macular hole surgery: an objective evaluation of non-supine positioning and the effect of the “tennis ball technique”

Session Details

Session Title: Vitreoretinal Surgery II

Session Date/Time: Friday 18/09/2015 | 08:00-10:00

Paper Time: 08:32

Venue: Calliope

First Author: : V.Forsaa NORWAY

Co Author(s): :    J. Krohn              

Abstract Details

PURPOSE:One aim of this study was to objectively evaluate patients’ compliance with a recommended non-supine positioning (NSP) regimen after macular hole (MH) surgery. A second aim was to investigate if the time in supine position during the first postoperative nights was reduced with the tennis ball technique (TBT).


This prospective, randomized, controlled, crossover study was conducted at the Departments of Ophthalmology at Stavanger University Hospital and Haukeland University Hospital, Norway between October 2013 and November 2014.


A head-mounted position monitoring device (PMD) with a sensor of the rolling ball type was specifically developed for the purpose of this study. The PMD records the accumulated time the patient has kept the head in supine or near-supine position. A postoperative NSP regimen was applied, which means that the patients were instructed to maintain their daily activities, but to avoid upward gaze and supine sleeping position at any time. Each study participant had to wear the PMD on the ward for 12 hours, from 9.00 p.m. until 9.00 a.m. for two consecutive nights following surgery. One night the patients were assigned to the TBT, i.e. they had to wear a nightshirt with a tennis ball fastened to the back, whereas no specific arrangements were made for the other night. The TBT was randomised to either the first or the second postoperative night. Patients with maculopathies treated with pars plana vitrectomy followed by intraocular gas tamponade, i.e. full thickness MH and conditions such as vitreomacular traction and lamellar MH were included.


Fourty of 43 included participants completed follow up. A mean supine time of 14 minutes and 47 seconds (SD=27:02) was registered, showing compliance to the NSP regimen in 97.9% of the time. When adding the TBT, the mean supine time was reduced to 4 minutes and 24 seconds (SD=09:28), which means that the patients remained compliant to the NSP regimen in 99.4% of the time. The mean reduction in supine positioning time by the TBT regimen of 10 minutes and 23 seconds (SD=28:33) was statistical significant (p=0.01). In a subgroup of the seven less compliant patients, the mean supine time was reduced statistically significant from 63 minutes and 2 seconds (SD=34:33) to 3 minutes and 46 seconds (SD=06:34) (p=0.02). Twenty-seven participants had a diagnosis of primary MH with duration less than 36 months. In this group 25 patients achieved MH closure, corresponding to a closure rate of 92.6%. Questionnaires revealed that as much as 37 (92.5%) of the patients preferred to sleep in a side position, while only 2 (5%) and 1 (2.5%) preferred the supine and face down position, respectively.


The early avoidance of the supine position is important to allow for undisturbed absorption of the perimacular intraretinal oedema by the pigment epithelium. It will also protect bridging membranes in the MH from the residual intravitreal fluid. In a NSP regimen, the patients in general maintain a high level of compliance. Even though, the TBT additionally improves the compliance significantly to 99.4% of the nighttime. This high compliance is reasonable, as 92.5% of the participants prefer to sleep in a side position. The less compliant patients benefit the most of the TBT. NSP together with TBT should be recommended if a supine position is considered potentially harmful to the patient.

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