PIMS (Positioning In Macular hole Surgery) trial - a multicentre interventional comparative randomised controlled clinical trial comparing face-down positioning, with an inactive face-forward position on the outcome of surgery for large macular holes: study protocol for a randomised controlled trial

Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole: A Multicenter Randomized Clinical Trial

Importance

The value of facedown positioning following surgery for large full-thickness macular holes is unknown.

Objective

To determine whether advice to position facedown postoperatively improves the outcome for large macular holes.

Design, Setting, and Participants

This randomized, parallel group superiority trial with 1:1 randomization stratified by site with 3 months' follow-up was conducted at 9 sites across the United Kingdom and included participants with an idiopathic full-thickness macular hole of at least 400 μm minimum linear diameter and a duration of fewer than 12 months. All participants had vitrectomy surgery with peeling of the internal limiting membrane and injection of perfluoropropane (14%) gas, with or without simultaneous surgery for cataract.

Interventions

Following surgery, participants were randomly advised to position either facedown or face forward for 8 hours daily for 5 days.

Main Outcomes and Measures

The primary outcome was closure of the macular hole determined 3 months following surgery by masked optical coherence tomography evaluation. Secondary outcome measures at 3 months were visual acuity, participant-reported experience of positioning, and quality of life measured by the National Eye Institute Visual Function Questionnaire 25.

Results

A total of 185 participants (45 men [24.3%]; 156 white [84.3%]; 9 black [4.9%]; 10 Asian [5.4%]; median age, 69 years [interquartile range, 64-73 years]) were randomized. Macular hole closure was observed in 90 (85.6%) who were advised to position face forward and 88 (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08). The mean (SD) improvement in best-corrected visual acuity at 3 months was 0.34 (0.69) logMAR (equivalent to 1 Snellen line) in the face-forward group and 0.57 (0.42) logMAR (equivalent to 3 Snellen lines) in the facedown group (adjusted mean difference, 0.22 [95 % CI, 0.05-0.38]; equivalent to 2 Snellen lines); 95% CI, 0.05-0.38; P = .01). The median National Eye Institute Visual Function Questionnaire 25 score was 89 (interquartile range, 76-94) in the facedown group and 87 (interquartile range, 73-93) in the face-forward group (mean [SD] change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean [SD] difference on a logistic scale, 0.02; 95% CI, -0.03 to 0.07; P = .41).

Conclusions and Relevance

The results do not prove that facedown positioning following surgery is more likely to close large macular holes compared with facing forward but do support the possibility that visual acuity outcomes may be superior.

Trial Registration

Isrctn.org Identifier: 12410596.

Adherence to face-down and non-supine positioning after macular hole surgery

BACKGROUND

This study aimed to investigate patient adherence to face-down positioning (FDP) and non-supine positioning (NSP) following vitrectomy with gas tamponade for treating macular holes (MHs).

METHODS

Nursing records of 92 patients who underwent vitrectomy with gas tamponade for small-diameter (diameter < 400 μm) MHs during April 2016-June 2017 were examined. Forty-seven and 45 patients were instructed to maintain FDP and NSP (FDP and NSP groups), respectively. Patient adherence was evaluated seven times a day for 3 days, and the adherence rate was calculated.

RESULTS

The mean adherence rate was significantly higher in the NSP group (99.3% ± 2.7%) than in the FDP group (93.7% ± 13.3%; P < 0.001, Mann-Whitney U test). Forty-one patients (91.1%) in the NSP group had an adherence rate of 100%, which was significantly higher than that in the 24 patients in the FDP group (51.1%; P < 0.001, chi-squared test). No statistically significant difference was observed between the patients in the two groups regarding sex, age, MH diameter, and pre- and postoperative visual acuities. MH closure was achieved in all patients.

CONCLUSIONS

Almost half of the patients in the FDP group did not obtain 100% adherence rate, suggesting that patient adherence was largely compromised. Patient adherence was better in the NSP group as patient compliance to NSP was better, however, 8.9% of patients were found in face-up positioning at least once. Incompleteness of patient adherence was common, although to differing degrees.

Best surgical technique and outcomes for large macular holes: retrospective multicentre study in Japan

The purpose of this study was to compare the surgical outcomes of vitrectomy with conventional internal limiting membrane (C-ILM) peeling to that with the inverted ILM (I-ILM) flap technique for large macular holes (MHs). This was a retrospective chart review of consecutive cases with a large MH at nine hospitals in Japan. Among the 1342 eyes, 165 eyes of 165 cases met the inclusion criteria. The results for medium-large MHs with a diameter 400-550 μm were compared to that of eyes with an extra-large MH with a diameter >550 μm. In addition, the results of C-ILM peeling were compared to that of the I-ILM technique. In medium-large MHs, the closure rate was 95.2% (59/62) by C-ILM peeling and 100% (19/19) by the I-ILM technique. In extra-large MHs, the closure rate was 88.4% (38/43) by C-ILM peeling and 100% (41/41) by I-ILM. Although the difference between the two methods was not significant, the I-ILM technique was successful in 100% of the cases. Multiple logistic regression analysis showed the best-corrected visual acuity (BCVA) at 6 months was significantly associated with the preoperative BCVA, MH size, age and sex of the patient. Analyses of the eyes with extra-large MHs show that the surgical success is high, and the I-ILM technique is more effective for closure in eyes with extra-large MHs.

THE CURRENT SURGICAL MANAGEMENT OF LARGE, RECURRENT, OR PERSISTENT MACULAR HOLES

PURPOSE

To evaluate the current surgical options available for the management of large (>400 μm), recurrent, or persistent macular holes (MHs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and surgical treatments of large, recurrent, or persistent MHs. Based on this review, a comprehensive overview was provided regarding the topic of large, recurrent, or persistent MHs and focused on recent surgical management updates.

RESULTS

For large MHs, variations of the inverted internal limiting membrane flap technique demonstrated promising rates of primary hole closure and significant visual acuity improvements. For recurrent or recalcitrant MHs, early repeat vitrectomy with extension of the internal limiting membrane peel remains the most straightforward and optimal surgical technique to achieve secondary closure. Regardless of the surgical approach, the goal of each technique described is to induce or aid in stimulating gliosis within the MH to maximize closure.

CONCLUSION

Despite the high success rate of modern MH surgery, large, recurrent, or persistent MHs remain a challenge for retinal surgeons. This review provides a detailed summary on the rationality and efficacy of current surgical options.

Adherence to the face-down positioning after vitrectomy and gas tamponade: a time series analysis

Objective

To determine the adherence to the face-down positioning (FDP) in 296 patients who had undergone vitrectomy and gas tamponade.

Results

We studied 119 female and 177 male patients who had undergone primary vitrectomy and gas tamponade for a macular hole (MH) or for rhegmatogenous retinal detachments (RRDs). Adherence was assessed and recorded four times per day for 3 days postsurgery. The mean ± standard deviation adherence rate was 88.3 ± 11.7 (range 50.0–100.0). Female patients (90.8 ± 10.0) had significantly better adherence than male patients (86.7 ± 13.3; P < 0.02, U test). The adherence was significantly better after MH surgery (90.8 ± 11.7) than after RRD surgery (87.5 ± 12.5; P < 0.02). There were diurnal variations in adherence, being highest in the evening and significantly lower at midnight, and we evidenced a decline in adherence over time, with it being significantly low on the last follow-up day. Adherence to the FDP varied considerably among patients. Adherence was higher in female than in male patients, and higher in patients with MH than in those with RRD. We found patients age had no effect on adherence. Adherence also varied with time, being worst at midnight and declining over time.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3257-1) contains supplementary material, which is available to authorized users.

PROSPECTIVE RANDOMIZED TRIAL ASSESSING THE IMPACT OF FEEDBACK MECHANISMS ON PATIENT POSITIONING

PURPOSE

To investigate the use of a head-fixed feedback sensor to improve good positioning times after macular hole or retinal detachment surgery. The instructional methods, macular hole closure rates, and questionnaire responses were also evaluated.

METHODS

After randomization, sensor devices with different feedback types (none/acoustic/vibration) were fixed on the patients' heads. Two positioning recommendations (verbal/illustrated) were used. The posturing data were logged every 500 ms for 24 hours.

RESULTS

Forty-eight data sets (24 per group) were evaluated. Using sensory feedback, the median time for face-down positioning after macular hole surgery (Group 1) was significantly boosted from 463 minutes (range: 61-1,168) to 1,257 minutes (range: 1,024-1,327). The side positioning time after retinal detachment surgery (Group 2) increased from a median of 1,032 minutes (range: 520-1,165) to 1,284 minutes (range: 1,231-1,437). The night-time alarm records were reduced; however, the instructional methods exhibited no noteworthy effects. The questionnaires indicated positive acceptance of the sensors.

CONCLUSION

Sensory feedback may help in cases where face-down or side positioning is recommended. These constant reminders were superior to verbal or written reminders; however, further studies are required to assess the clinical impact of sensory feedback on patient positioning.

Instrumental variable methods for a binary outcome were used to informatively address noncompliance in a randomized trial in surgery

Objectives

Randomization can be used as an instrumental variable (IV) to account for unmeasured confounding when seeking to assess the impact of noncompliance with treatment allocation in a randomized trial. We present and compare different methods to calculate the treatment effect on a binary outcome as a rate ratio in a randomized surgical trial.

Study Design and Setting

The effectiveness of peeling versus not peeling the internal limiting membrane of the retina as part of the surgery for a full thickness macular hole. We compared the IV-based estimates (nonparametric causal bound and two-stage residual inclusion approach [2SRI]) with standard treatment effect measures (intention to treat, per protocol and treatment received [TR]). Compliance was defined in two ways (initial and up to the time point of interest). Poisson regression was used for the model-based approaches with robust standard errors to calculate the risk ratio (RR) with 95% confidence intervals.

Results

Results were similar for 1-month macular hole status across methods. For 3- and 6-month macular hole status, nonparametric causal bounds provided a narrower range of uncertainty than other methods, though still had substantial imprecision. For 3-month macular hole status, the TR estimate was substantially different from the other point estimates.

Conclusion

Nonparametric causal bound approaches are a useful addition to an IV estimation approach, which tend to have large levels of uncertainty. Methods which allow RRs to be calculated when addressing noncompliance in randomized trials exist and may be superior to standard estimates. Further research is needed to explore the properties of different IV methods in a broad range of randomized controlled trial scenarios.

Patient adherence to the face-down positioning after macular hole surgery

Purpose

To determine adherence to face-down positioning (FDP) among patients who underwent vitrectomy and gas tamponade for macular hole (MH) repair.

Method

A total of 69 patients (37 females and 32 males) who underwent primary vitrectomy for MH repair were studied. Nurses recorded whether the patient complied with FDP each time they examined the patient. FDP score was obtained from the nursing records; patients were given a score of 1 if they complied with the FDP and 0 if they did not. The score was recorded four times per day for the first 3 postoperative days. A perfect FDP score was 12.

Results

The mean ± standard deviation of the FDP scores was 10.6±1.8 (range: 4–12). Overall, 32 (46.4%) patients scored a perfect 12, and 7 (10.1%) patients scored <8. Failure of the MH closure was observed in only one patient (1.4%), who showed the poorest adherence to FDP (score =4). Consequently, the closure rate in patients with FDP score <7 (2/3, 66.7%) was significantly lower than in patients with an FDP score ≥7 (66/66, 100%) (P<0.05, Fisher’s exact probability test).

Conclusion

While adherence to FDP after MH surgery was better than that observed after vitrectomy for rhegmatogenous retinal detachments in our previous study, the percentage of patients with FDP scores <8 did not differ. Statistically, the poor adherence to FDP can negatively impact the effectiveness of the surgery for MH repair.

Positioning In Macular hole Surgery (PIMS): statistical analysis plan for a randomised controlled trial

Background

The treatment of idiopathic full-thickness macular holes involves surgery to close the hole. Some surgeons advise patients to adopt a face-down position to increase the likelihood of successful macular hole closure. However, patients often find the face-down positioning arduous. There is a lack of conclusive evidence that face-down positioning improves the outcome. The ‘Positioning In Macular hole Surgery’ (PIMS) trial will assess whether advice to position face-down after surgery improves the surgical success rate for the closure of large (≥400 μm) macular holes.

Methods/design

The PIMS trial is a multicentre, parallel-group, superiority clinical trial with 1:1 randomisation. Patients (n = 192) with macular holes (≥400 μm) will be randomised after surgery to either face-down positioning or face-forward positioning for at least 8 h (which can be either consecutive or nonconsecutive) a day, for 5 days following surgery. Inclusion criteria are: presence of an idiopathic full-thickness macular hole ≥400 μm in diameter, as measured by optical coherence tomography (OCT) scans, on either or both eyes; patients electing to have surgery for a macular hole, with or without simultaneous phacoemulsification and intraocular lens implant; ability and willingness to position face-down or in an inactive face-forward position; a history of visual loss suggesting a macular hole of 12 months’ or less duration. The primary outcome is successful macular hole closure at 3 months post surgery. The treatment effect will be reported as an odds ratio with 95% confidence interval, adjusted for size of macular hole and phakic lens status at baseline. Secondary outcome measures at 3 months are: further surgery for macular holes performed or planned (of those with unsuccessful closure); patient-reported experience of positioning; whether patients report they would still have elected to have the operation given what they know at follow-up; best-corrected visual acuity (BCVA) measured using Snellen charts at a standard distance of 6 m; patient-reported health and quality of life assessed using the National Eye Institute Visual Function Questionnaire (VFQ-25).

Discussion

The PIMS trial is the first multicentre randomised control trial to investigate the value of face-down positioning following macular hole standardised surgery.

Trial registration

International Standard Randomised Controlled Trials Number registry, ID: ISRCTN12410596. Registered on 11 February 2015.

United Kingdom Clinical Research Network, ID: UKCRN17966. Registered on 26 November 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2020-6) contains supplementary material, which is available to authorized users.