Short-time prone posturing is well-tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment
© dell'Omo et al.; licensee BioMed Central Ltd. 2013
Published: 8 October 2013
To evaluate the feasibility, efficacy and safety of strict prone posturing taken for 2 hours after operation in preventing the occurrence of unintentional retinal displacement in elderly patients operated on for retinal detachment (RD).
Twenty patients aged 60 or more with diagnosis of macula-off RD were asked to keep a strict face-down posturing for 2 hours after vitrectomy and 20% sulfur hexafluoride tamponade. IOP was measured immediately before and after surgery and after the 2-hour posturing. A questionnaire was administered to each patient to evaluate the rate of discomfort experienced because of the face-down posturing. Unintentional displacement of the retina was assessed by evaluating the presence of retinal vessel printings on fundus autofluorescence images taken 4 weeks after operation.
The 2-hour posturing was generally well-tolerated. A mild neck pain was the most common reported symptom. Only a few patients experienced moderate breath shortness while posturing and none had to break the posturing because of respiratory problems. Intraocular pressure (IOP) measured before operation (11.7 ± 2.6 mmHg) was significantly different from IOP recorded at the end of surgery (18.9 ± 4.9 mmHg) and from IOP measured 2 hours after surgery (16.8 ± 4.7 mmHg, P<0.05, Friedman test). IOPs measured immediately and 2 hours after surgery did not differ significantly. Fundus autofluorescence imaging showed RVPs in 7 eyes.
This study shows that a 2-hour face-down posturing is effective in reducing the rate of retinal displacement in patients operated on for rhegmatogenous retinal detachment using vitrectomy and SF6 20%. A 2-hour face-down posturing is feasible for elderly patients and does not appear to cause unwanted, post-operative IOP raises.
Characteristics of the sample
Age (mean ± SD) years
64.3 (± 3.5)
Pre-op logMAR VA (mean ± SD)
1.15 ± 0.88
Post-op logMAR VA (mean ± SD)
0.55 ± 0.30
Duration of detachment (mean ± SD) days
6.25 ± 3.44
2.95 (± 0.75)
Location of the main break
11.7 ± 2.6
18.9 ± 4.9
IOP 2-hour post-op
16.8 ± 4.7
Statistical analyses (Wilcoxon signed rank test and Friedman test) were performed using MedCalc version 11.5.1 (Med-Calc software, Mariakerke, Belgium). A P value < 0.05 was considered statistically significant.
Score of the discomfort secondary to face down position
How much difficulty did you have keeping the prone position?
2.3 ± 1.67
Did you have breath shortness while posturing face-down?
1.6 ± 1.2
Did you suffer any neck or back pain while posturing face-down?
2.0 ± 1.5
Did you feel dizziness after the face-down posturing?
1.3 ± 0.6
Ageing of the human vitreous is held to play a crucial role in the development of retinal tears subsequently leading to RD. Ageing of the human vitreous is characterized by gel liquefaction and the development of fluid-filled pockets which involves approximately one fifth of the total vitreous volume by the middle to late teenage years and at least 50% of the gel in most individuals older than 70 years. Factors that accelerate vitreous liquefaction and posterior vitreous detachment include inflammation, retinal vascular diseases, and cataract extraction. Rhegmatogenous retinal detachment occurs when liquefied vitreous fluid enters the subretinal space through a full-thickness retinal break. Population-based studies show that the annual incidence is about 10-15 in 100,000 with a prevalence of about 0.3% of the general population and a lifetime risk of 3% by the age of 85 . The incidence increases to 17.9 per 100,000 if detachments after cataract extraction (a common risk factor) are included . Outcomes after RD repair depend upon the length of time that the retina has been detached and whether the macula is involved: prognosis is related inversely to the degree of macular involvement and the length of time the retina has been off. In general, a patient presenting late with a 'macula-off' RD has a very bleak outlook and several weeks may be needed for the vision to improve after surgery (particularly if there is a gas bubble in situ). Even in cases in which retinal reattachment is achieved after a single operation, patients with macula-off detachment may complain of visual disurbances including poor visual acuity and metamorphopsia. RD cannot be addressed by utilizing endothelial progenitor cells-based therapy, which has otherwise been suggested to treat other forms of eye disease [15–17]. In particular metamorphopsia may result from unintentional retinal displacement which may be eleganty disclosed by fundus autofluorescence [6, 7]. Since metamorphopsia may severely affect the performance of daily tasks, which can be already limited in elderly people, any effort should be done in order to limit its occurrence. In the present study we investigated if a strict 2-hour long face-down posturing was able to limit the occurrence of retinal displacement in patients undergone vitrectomy and gas to repair macula-off RD. In addition we wanted to evaluate the feasibility and safety of the posturing for elderly people. We noted that the rate of unintentional displacement as showed by FAF was much lower than that reported previously . It suggests that a 2-hour posturing taken immediately after operation is effective in reducing the rate of unintentional displacement of the retina. It also appeared that a 2-hour posturing was generally well-tolerated by our sample of elderly patients and therefore feasible in the daily practice. A mild neck pain was the most common reported symptom. Only a few patients experienced moderate breath shortness while posturing and none had to break the posturing because of respiratory problems. In order to examine the safety of the procedure and its repercussions on IOP we took measurements of the ocular pressure three times (i.e. immediately before and immediately after operation and immediately after the face-down posturing). There was no significant difference between the IOPs recorded immediately after surgery and after the face-down posturing suggesting that the no-expansible mixture of SF6 20% and air is safe and does not induce IOP raise after short prone posturing. In conclusion, our results show that a 2-hour face-down posturing is effective in reducing the rate of retinal displacement in patients operated on for rhegmatogenous retinal detachment using vitrectomy and SF6 20%. A 2-hour face-down posturing is feasible for elderly patients and does not appear to cause unwanted, post-operative IOP raises.
RDOM: Assistant Professor of Ophthalmology at University of Molise. FS: Associate Professor of Ophthalmology at University of Brescia. GG: Assistant Professor of Anatomy at University of Molise. MV: Chief Staff Physician of Ophthalmology at Boscotrecase Hospital. MPC: Assistant Professor of Anatomy at University of Naples "Federico II". SM: Full Professor of Anatomy at University of Naples "Federico II". CC: Associate Professor of Ophthalmology at University of Molise.
Publication charges for this article were covered by research funds of the project Bando Faro 2012 - Finanziamenti per l'Avvio di Ricerche Originali, cofounded by the Compagnia di San Paolo and by the Polo per le Scienze e le Tecnologie per la Vita of the University Federico II in Naples.
This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/13/S2
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