Face‐down positioning or posturing after pars plana vitrectomy for macula‐involving rhegmatogenous retinal detachments

Timothy HM Fung; Tsz Wing Yim; Noemi Lois; David M Wright; Su-Hsun Liu; Tom Williamson

doi:10.1002/14651858.CD015514.pub2

. 2024 Mar 15;2024(3):CD015514. doi: 10.1002/14651858.CD015514.pub2

Face‐down positioning or posturing after pars plana vitrectomy for macula‐involving rhegmatogenous retinal detachments

Timothy HM Fung ^1,^✉, Tsz Wing Yim ², Noemi Lois ³, David M Wright ³, Su-Hsun Liu ^2,⁴, Tom Williamson ¹

Editor: Cochrane Eyes and Vision Group

PMCID: PMC10941635 PMID: 38488250

Abstract

Background

A macula‐involving rhegmatogenous retinal detachment (RRD) is one of the most common ophthalmic surgical emergencies and causes significant visual morbidity. Pars plana vitrectomy (PPV) with gas tamponade is often performed to repair primary macula‐involving RRDs with a high rate of anatomical retinal reattachment. It has been advocated by some ophthalmologists that face‐down positioning after PPV and gas tamponade helps reduce postoperative retinal displacement. Retinal displacement can cause metamorphopsia and binocular diplopia.

Objectives

The primary objective of this review is to determine whether face‐down positioning reduces the risk of retinal displacement following PPV and gas tamponade for primary macula‐involving RRDs.

Search methods

We searched the Cochrane Central Register of Controlled Trials (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 11), MEDLINE (January 1946 to 28 November 2022), Embase.com (January 1947 to 28 November 2022), PubMed (1948 to 28 November 2022), Latin American and Caribbean Health Sciences Literature database (1982 to 28 November 2022), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 28 November 2022.

Selection criteria

We included randomized controlled trials (RCTs) in which face‐down positioning was compared with no positioning or another form of positioning following PPV and gas tamponade for primary macula‐involving RRDs.

Data collection and analysis

We used standard Cochrane methodology and assessed the certainty of the body of evidence for the prespecified outcomes using the GRADE approach.

Main results

We identified three RCTs (369 eyes of 368 participants) that met the eligibility criteria. Two RCTs provided data on postoperative retinal displacement, one reported on postoperative distortion and quality of life outcomes, two on postoperative best‐corrected visual acuity (BCVA) in logMAR, and two on postoperative ocular adverse events such as outer retinal folds.

Study characteristics and risk of bias

All the trials involved predominantly male participants (range: 68% to 72%). Only one trial provided race and ethnicity information, was registered on a trial registry, and reported funding sources. Using the RoB 2 tool, we assessed the risk of bias for proportion of eyes with retinal displacement, mean change in visual acuity, objective distortion scores, quality of life assessments, and ocular adverse events, with most domains judged to be at low risk of bias.

Findings

Immediate face‐down positioning may result in a lower proportion of participants with postoperative retinal displacement compared with support‐the‐break positioning at six months (risk ratio [RR] 0.73, 95% confidence interval [CI] 0.54 to 0.99; 1 RCT; 239 eyes of 239 participants; very low certainty evidence).

One study found no evidence of a difference in BCVA at three months when comparing postoperative face‐up with face‐down positioning with or without perfluorocarbon liquid (mean difference [MD] −0.03, 95% CI −0.09 to 0.02; I² = 0; 56 eyes of 56 participants; very low certainty evidence).

Immediate face‐down positioning appears to have little to no effect on postoperative distortion scores at week 26 (MD 1.80, 95% CI −1.92 to 5.52; 1 RCT; 219 eyes of 219 participants; very low certainty evidence) and postoperative quality of life assessment scores at week 26 (MD −1.80, 95% CI −5.52 to 1.92; 1 RCT; 217 eyes of 217 participants; very low certainty evidence).

Adverse events

One study that enrolled 262 participants with macula‐involving RRDs suggested that immediate face‐down positioning after PPV and gas tamponade may reduce the ocular adverse event of postoperative outer retinal folds at six months (RR 0.39, 95% CI 0.17 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) and binocular diplopia (RR 0.20, 95% CI 0.04 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) compared with support‐the‐break positioning. Immediate face‐down positioning may increase the ocular adverse event of elevated intraocular pressure compared with support‐the‐break positioning (RR 1.74, 95% CI 1.11 to 2.73; 1 RCT; 262 eyes of 262 participants; very low certainty evidence). Another study found no evidence of a difference in postoperative outer retinal folds when comparing face‐down versus face‐up positioning at one and three months (RR 1.00, 95% CI 0.50 to 2.02; RR 1.00, 95% CI 0.28 to 3.61; 1 RCT; 56 eyes of 56 participants; very low certainty evidence). No studies reported non‐ocular adverse events.

Authors' conclusions

Very low certainty evidence suggests that immediate face‐down positioning after PPV and gas tamponade may result in a reduction in postoperative retinal displacement, outer retinal folds, and binocular diplopia, but may increase the chance of postoperative raised intraocular pressure compared with support‐the‐break positioning at six months. We identified two ongoing trials that compare face‐down positioning with face‐up positioning following PPV and gas tamponade in participants with primary macula‐involving RRDs, whose results may provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and patient preferences should be examined in addition to clinical and adverse event outcomes.

Keywords: Humans, Bias, Macula Lutea, Patient Positioning, Patient Positioning/methods, Postoperative Complications, Prone Position, Randomized Controlled Trials as Topic, Retinal Detachment, Retinal Detachment/surgery, Visual Acuity, Vitrectomy, Vitrectomy/adverse effects, Vitrectomy/methods

Plain language summary

Is face‐down positioning better than other positioning after vitrectomy and gas tamponade for macula‐involving rhegmatogenous retinal detachments?

Key messages

‐ There is not enough high‐quality information to say whether face‐down positioning should be recommended to people after surgery for retinal detachments affecting the center of the retina (the macula).

‐ Overall, evidence from studies suggests that face‐down positioning after surgery may lead to fewer complications, with less postoperative retinal displacement, outer retinal folds, and binocular diplopia (double vision with both eyes open). These complications can be very bothersome to those affected, but their impact on quality of life was not studied.

‐ Face‐down positioning may increase intraocular pressure (fluid pressure inside the eye) compared with support‐the‐break positioning (head positioning dependent on the location of retinal breaks [holes or tears in the retina]); however, intraocular pressure can most often be treated successfully.

What is a macula‐involving rhegmatogenous retinal detachment?

The retina is a layer at the back of the eye which provides sight. It is normally attached to the wall of the eye. When it separates from the wall of the eye, then this is called a retinal detachment. When a retinal detachment is caused by a tear or break in the retina, then it is termed a rhegmatogenous retinal detachment. The macula is the center of the retina. If the macula also detaches, then this is called a macula‐involving rhegmatogenous retinal detachment.

The visual cells (the cells in the retina that provide sight) get their nourishment through blood vessels in the wall of the eye. If the retina is detached and away from the wall of the eye, then the visual cells do not receive nourishment. As a result, sight is lost.

Retinal detachments are treated with surgery, often with a type of surgery called a vitrectomy. In vitrectomy surgery, the gel that fills the middle of the eye (called vitreous) is removed, and most often gas is put inside the eye to push the retina back in place (gas tamponade). The gas rises, like a balloon. Some surgeons ask their patients to keep their head down (face‐down positioning) right after surgery so that the gas pushes the macula flat into its normal position.

What did we want to find out?

We wanted to find out if keeping the face‐down position after vitrectomy and gas tamponade for macula‐involving rhegmatogenous retinal detachment is better than keeping the head in other positions. Keeping the head face‐down may prevent such complications as large or small folds forming in the macula. These folds can affect sight. We also wanted to find out if face‐down positioning has any harmful effects, such as neck problems.

What did we do?

We searched for studies that compared keeping the head face‐down after surgery with other head positions in people with macula‐involving retinal detachments. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found three studies with a total of 368 people (369 eyes) with macula‐involving retinal detachments. Study follow‐up time varied, with the longest being six months. The results showed that some complications may be less frequent with face‐down positioning, including retinal displacement (the retina 'landing' in a different position than where it was before it detached), retinal folds, and double vision. These complications may be very troublesome for people. Face‐down positioning may increase the chance of high pressure in the eye; however, this can most often be successfully treated with eye drops. Face‐down positioning did not seem to make any difference in the quantity of vision (reading letters in the chart) or quality of vision (how clearly people saw), or in quality of life.

What are the limitations of the evidence?

We have very low confidence in the evidence for face‐down positioning after vitrectomy and gas tamponade for macula‐involving rhegmatogenous retinal detachment because of the relatively small sample sizes and flawed study designs.

How up‐to‐date is this evidence?

The evidence is current to November 2022.

Summary of findings

Summary of findings 1. Face‐down positioning compared with other positioning.

Face‐down positioning compared with other positioning after pars plana vitrectomy and gas tamponade for primary macula‐involving rhegmatogenous retinal detachments
Patient or population: people with primary macula‐involving rhegmatogenous retinal detachments Settings: eye hospital, eye clinics, and medical center Intervention: face‐down positioning Comparison: other positioning (support‐the‐break, face‐up positioning)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Other posturing	Face‐down positioning
Proportion of eyes with retinal displacement at 6 months or later (RR < 1 favored)	483 per 1000	353 per 1000 (261 to 479)	RR 0.73 (0.54 to 0.99)	239 (1 study) Casswell 2020	⊕⊝⊝⊝ Very low^a,b
Mean change in logMAR or Snellen visual acuity from baseline to 3 months or later (lower is favored)	Change in BCVA in logMAR in face‐up positioning group was 0.03 lower (95% CI 0.09 lower to 0.02 higher) than in face‐down positioning group at 3 months.		MD −0.03 (−0.09 to 0.02)	56 (1 study) Peiretti 2017	⊕⊝⊝⊝ Very low^a,b
	Change in BCVA in ETDRS in face‐up positioning group was 0.70 lower (95% CI 4.62 lower to 3.22 higher) at week 8.		MD −0.70 (−4.62 to 3.22)	221 (1 study) Casswell 2020		Casswell 2020 reported ETDRS visual acuity in site‐adjusted differences with an MD of 0.10 (95% CI −3.04 to 3.24) at week 26.
Mean objective distortion score at 3 months or later (lower is favored)	Change in objective distortion score in face‐down positioning group was 1.80 higher (95% CI 1.92 lower to 5.52 higher) than in support‐the‐break positioning group at week 26.		MD 1.80 (−1.92 to 5.52)	219 (1 study)	⊕⊝⊝⊝ Very low^a,b	Casswell 2020 reported objective distortion score in site‐adjusted differences.
Quality of life assessments at 3 months or later (higher is favored)	Change in quality of life assessments in support‐the‐break positioning group was 1.80 lower (95% CI 5.52 lower to 1.92 higher) than in face‐down positioning group at week 26.		MD −1.80 (−5.52 to 1.92)	217 (1 study)	⊕⊝⊝⊝ Very low^a,b	Casswell 2020 reported NEI‐VFQ assessment score in site‐adjusted differences.
Frequency of intervention‐related ocular adverse events (follow‐up to 6 months)	Outer retinal folds			262 (1 study)	⊕⊝⊝⊝ Very low^a,b	Peiretti 2017 reported outer retinal folds at 1 month with an RR of 1.00 (95% CI 0.5 to 2.02) and 3 months with an RR of 1.00 (95% CI 0.28 to 3.61).
	137 per 1000	54 per 1000 (23 to 124)	RR 0.39 (0.17 to 0.90)
	Binocular diplopia
	76 per 1000	15 per 1000 (3 to 69)	RR 0.20 (0.04 to 0.90)
	Elevated intraocular pressure
	176 per 1000	305 per 1000 (195 to 479)	RR 1.74 (1.11 to 2.73)
Frequency of intervention‐related non‐ocular adverse events (follow‐up 2 weeks to 6 months)	No studies measured this outcome.
The basis for the assumed risk* is the mean baseline risk from the studies in the meta‐analysis; the total number of events in the control group divided by the total number of participants in the control groups, scaled to 1000. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BCVA: best‐corrected visual acuity; CI: confidence interval; CORDS: Complications of Retinal Detachment Surgery; ETDRS: Early Treatment Diabetic Retinopathy Study; logMAR: logarithm of the Minimum Angle of Resolution; MD: mean difference; NEI‐VFQ: National Eye Institute Visual Function Questionnaire; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Open in a new tab

^aDowngraded two levels for very serious imprecision. ^bDowngraded one level for risk of bias related to missing outcome data.

Background

Description of the condition

The term rhegmatogenous retinal detachment (RRD) refers to separation of the neurosensory retina from the retinal pigment epithelium caused by one or more full‐thickness retinal breaks (Sodhi 2008). Retinal breaks originate from vitreoretinal traction and allow fluid from the vitreous cavity to enter the subretinal space (Ghazi 2002). RRD is one of the most common ophthalmic surgical emergencies (Grey 1989), and usually requires surgical intervention. Worldwide, the reported annual incidence of RRD varies. It was reported to be 14 cases per 100,000 persons per year in Sweden (Algvere 1999), 12.05 cases per 100,000 persons per year in Scotland (Mitry 2010), and 7.98 cases per 100,000 persons per year in Beijing (Li 2003). RRD is more common in men than women (Limeira‐Soares 2007; Mitry 2010; Mowatt 2003), and has the highest incidence rate in people aged 60 to 70 years (Mitry 2010). Major predisposing factors for the development of an RRD include high myopia (Clayman 1981; Ninn‐Pedersen 1996), ocular trauma (Cox 1969; Nagpal 2004), cataract surgery (Lois 2003), ocular infections (Davis 1999; Doft 2000), and lattice degeneration (Ashrafzadeh 1973; Benson 1978). RRD is often preceded by symptoms of flashes of light, floaters, and/or a progressive shadow over the field of vision (Gariano 2004). RRD is diagnosed based on dilated fundus examination. Late presentation in RRD may cause significant visual morbidity from macula involvement. Advanced age is associated with late presentation (Siddiqui 2010). Late presentation may also occur as a result of lack of awareness of the condition or its presenting symptoms (Goezinne 2009; Quintyn 2006). In the Scottish Retinal Detachment epidemiology study of 1202 RRD cases, the macula was affected in more than 50% of cases at presentation (Mitry 2011). Pars plana vitrectomy (PPV) with gas tamponade is a common procedure used to repair macula‐involving RRD with a high rate of anatomic retinal reattachment (Jackson 2014). A critical component of the surgical procedure is to identify all retinal breaks and treat them with either cryotherapy or laser therapy to create a thermal adhesion. The gas tamponade is used to approach the neurosensory retina to the retina pigment epithelium (RPE) and to reduce or eliminate the rate of fluid going through the open retinal break(s) until adhesion around the break occurs, creating a permanent seal. Following surgery, most surgeons advise patients to maintain their heads in a particular head position; this will depend on the characteristics of the retinal detachment, location of retinal breaks and, to a certain extent, the surgeon's preference. Common posturing regimens advocated after surgery include face‐down positioning, face‐up (supine) positioning, and support‐the‐break positioning (positioning upright for detachments with superior retinal breaks and positioning on the contralateral cheek for detachments with nasal, temporal, or inferior retinal breaks). Despite successful retinal reattachment, several studies have shown that 44% to 72% of eyes in people with macula‐involving RRD had unintentional retinal displacement postoperatively (Brosh 2020; Casswell 2020; Lee 2013; Pandya 2012; Shiragami 2010; Shiragami 2015). It has been hypothesized that stretching of the retina from displacement of subretinal fluid induced by the buoyant force of a gas tamponade leads to retinal displacement (Figure 1) (Brosh 2020; Mason 2022). However, the mechanism for its occurrence has yet to be fully elucidated. Retinal displacement can cause metamorphopsia (dell’Omo 2013; Pandya 2012; Shiragami 2015) and lower vision‐related quality of life (Lina 2016).

Proposed mechanism of retinal displacement. Subretinal fluid (blue areas) typically remains at the macula peroperatively and in the immediate postoperative period following PPV and gas tamponade for a macula‐involving RRD. Retinal displacement may occur as a result of subretinal fluid flow under the retina induced by the buoyant force of the gas bubble and gravity in a direction related to postoperative head positioning, leading to stretching of the retina as demonstrated by the stretch of the retinal vessels.

Description of the intervention

PPV, identification and treatment of the retinal break(s), and injection of gas are performed to repair macula‐involving RRDs. In some cases, removal of either the natural crystalline lens or an artificial lens may be performed, as required. After completion of the surgery, face‐down positioning for a variable period, as much as 10 days, has been advocated to reduce the risk of retinal displacement (Casswell 2020; dell’Omo 2013; Schawkat 2019; Shiragami 2015).

How the intervention might work

Face‐down positioning after PPV and gas tamponade for a macula‐involving RRD is believed to reduce the risk of any residual subretinal fluid that remains at the end of surgery from displacing the retina inferiorly as a result of gravity (Figure 2) (Brosh 2020; Codenotti 2013; Mason 2022; Pandya 2012; Shiragami 2015).

Proposed mechanism of face‐down positioning for preventing retinal displacement. By positioning face‐down after PPV and gas tamponade without an intervening elevated head position, any subretinal fluid that remains at the macula peroperatively and in the immediate postoperative period will be encouraged to flow in all directions rather than just inferior, leading to lower rates of inferior retinal displacement.

Why it is important to do this review

Several studies have been conducted to assess the role of face‐down positioning following PPV and gas tamponade on retinal displacement for macula‐involving RRDs (Casswell 2020; dell’Omo 2013; Schawkat 2019; Shiragami 2015). However, there is no consensus as to whether face‐down positioning following PPV and gas tamponade is effective at reducing retinal displacement in order to improve the care and outcomes of people with macula‐involving RRDs.

Although no guidelines exist concerning the duration of face‐down positioning, some vitreoretinal (VR) surgeons typically advocate strict face‐down positioning for a minimum of 50 minutes of every hour and throughout the night for one to two weeks after PPV and gas tamponade (Casswell 2020; Seno 2015; Shiragami 2015). Face‐down positioning is a challenge for many patients. Elderly people and those with cervical spondylosis, obesity, or coronary heart disease have serious difficulties adhering to the face‐down position (Chen 2015). Face‐down positioning may cause people to complain of musculoskeletal pains, and they may suffer mental stress, anxiety, and a sense of psychological isolation (Harker 1996). Face‐down positioning after PPV and gas tamponade also bears the risk of pressure sores, Treister 1996, and ulnar nerve palsies (Brouzas 2011; Ciulla 1996).

In order to evaluate the beneficial and adverse effects of face‐down positioning on retinal displacement after PPV and gas tamponade for macula‐involving RRDs, we sought to undertake a systematic review and meta‐analysis of the literature. The findings of our review are important to inform VR surgeons and patients of the potential benefits and side effects of face‐down positioning following PPV and gas tamponade for the repair of macula‐involving RRDs.

Objectives

The primary objective of this review is to determine whether face‐down positioning reduces the risk of retinal displacement following PPV and gas tamponade for primary macula‐involving RRDs.

Methods

Criteria for considering studies for this review

Types of studies

We included randomized controlled trials (RCTs) that compared face‐down positioning against no positioning or against another form of positioning on retinal displacement following PPV and gas tamponade for the repair of macula‐involving RRDs.

Types of participants

We included RCTs involving adult participants with primary (no previous surgery for RRD) macula‐involving RRDs undergoing PPV and gas tamponade. We employed no restrictions with respect to characteristics of the RRD (e.g. extent of detached retina, location of retinal breaks) or type of gas tamponade used.

Types of interventions

The intervention under investigation is face‐down positioning after PPV and gas tamponade for macula‐involving RRDs. We included studies comparing face‐down positioning against no positioning or against another form of positioning.

Types of outcome measures

We assessed the following outcome measures. For studies that reported outcomes at multiple eligible time points, we collected outcome data reported at the longest follow‐up period (for all outcomes).

Critical outcome

Proportion of eyes with retinal displacement at six months or later following PPV and gas tamponade for primary macula‐involving RRDs.

Important outcomes

Proportion of eyes with retinal displacement within three months following PPV and gas tamponade for primary macula‐involving RRDs.
Mean change in logarithm of the Minimum Angle of Resolution (logMAR) or Snellen visual acuity from baseline to three months or later following PPV and gas tamponade.
Mean objective distortion score (e.g. D chart test score, McGowan 2016) at three months or later following PPV and gas tamponade.
Quality of life assessments (e.g. the National Eye Institute Visual Function Questionnaire [NEI‐VFQ, Potic 2021]) at three months or later following PPV and gas tamponade.
Frequency of intervention‐related ocular adverse events, recorded following the Complications of Retinal Detachment Surgery (CORDS) classification (Xu 2021), including:
- outer retinal folds;
- binocular diplopia;
- elevated intraocular pressure.
Frequency of intervention‐related non‐ocular adverse events, if provided in the included RCTs, including:
- pressure sores;
- ulnar nerve palsies;
- anxiety disorder.

We planned to report each ocular and non‐ocular adverse event as the proportion of participants who experienced the specific adverse event, and grade it.

Search methods for identification of studies

Electronic searches

The Cochrane Eyes and Vision Information Specialist searched the following electronic databases for RCTs. There were no restrictions on language or date of publication. The date of the last database search was 28 November 2022.

Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) in the Cochrane Library (2022, Issue 11) (Appendix 1).
MEDLINE Ovid (January 1946 to 28 November 2022) (Appendix 2).
Embase.com (January 1947 to 28 November 2022) (Appendix 3).
PubMed (1948 to 28 November 2022) (Appendix 4).
LILACS (Latin American and Caribbean Health Sciences Literature database) (1982 to 28 November 2022) (Appendix 5).
US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) (Appendix 6).
World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp) (Appendix 7).

Searching other resources

We searched the reference lists of included studies for other potentially eligible studies. We did not search conference proceedings for the purposes of this review.

Data collection and analysis

Selection of studies

After importing the search results into the web‐based citation management software Covidence (Covidence), two review authors independently screened the titles and abstracts of all records identified. Based on the eligibility criteria, review authors classified each citation as 'No (not relevant),' 'Maybe (relevant),' or 'Yes (relevant)' for full‐text review. We then retrieved the full‐text reports for records classified as 'Yes' or 'Maybe'. Two review authors independently reviewed the full‐text manuscripts according to the eligibility criteria, classifying them as 'exclude' or 'include'. Any discrepancies between the two review authors with regard to the above classification were resolved by discussion. We classified eligible trials in progress as 'ongoing' and trials with missing results as 'awaiting classification'. We also contacted the study investigator to obtain information on potentially eligible ongoing studies and studies awaiting classification. If they did not respond within 14 days, we used the information available from publications or trial registries on the ongoing studies and studies awaiting classification.

Data extraction and management

Two review authors (TF, TWY) independently extracted data using a data extraction form developed by Cochrane Eye and Vision US Project in Covidence. We extracted the following information, if provided by the RCT:

Study methods (single center or multicenter, method of allocation, masking [blinding], exclusions after randomization, losses to follow‐up and compliance).
Study participants (country(ies) where participants were enrolled, number randomized, age, gender, ethnicity, inclusion and exclusion criteria).
Surgeon details (number of surgeons, grade of surgeons [attending, fellow, resident]).
Surgical details (preoperative visual acuity, eye laterality, lens status, location and quadrants of retina detached, number and location of retinal breaks, presence or absence of grades of proliferative vitreoretinopathy, performance of 360 degree laser barrier, use of intraoperative surgical adjuncts such as perfluorocarbon liquid, complete or partial fluid‐gas exchange, type of gas tamponade used [air, sulfur hexafluoride, hexafluoroethane, perfluoropropane]).
Study interventions (test and comparison [control] intervention, duration of intervention, timing of intervention).
Outcomes following surgery (presence or absence of retinal displacement, quantification of retinal displacement, visual acuity, distortion score, quality of life score, adverse events following the intervention), and how they were measured.
Source(s) of funding and potential conflicts of interest.
Details and contact information of the corresponding author.

Any discrepancies between the two review authors regarding extracted data were resolved by discussion. One review author (TWY) entered data into RevMan (RevMan 2023), and a second review author (TF) verified the data entry.

Assessment of risk of bias in included studies

Two review authors independently judged risk of bias in the included studies reporting outcomes listed in the summary of findings table (see Summary of findings and assessment of the certainty of the evidence), using the RoB 2 tool outlined in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2022). This tool incorporates assessment of bias arising from the randomization process (random sequence generation and allocation concealment), bias due to deviations from intended interventions (masking of participants and treatment providers), bias due to missing outcome data (incomplete outcome data), bias in measurement of the outcome (blinding of outcome assessment), and bias in selection of the reported results.

We quantified the effect of assignment to the interventions at baseline, regardless of whether the interventions were received as intended (the 'intention‐to‐treat effect') (Hernán 2017). We judged each risk of bias domain, as well as the overall risk of bias, as 'low risk of bias,' 'some concerns,' or 'high risk of bias'. The assessment of each domain was guided by signaling questions (with 'yes,' 'probably yes,' 'no,' 'probably no,' or 'no information') using the Excel tool available at www.riskofbias.info (Sterne 2019).

We applied the RoB 2 tool to the critical outcome (proportion of eyes with retinal displacement at six months), important outcomes within or at three months (proportion of eyes with retinal displacement, mean change in visual acuity from baseline, objective distortion scores, and quality of life assessments), as well as frequencies of ocular adverse events.

We considered the overall risk of bias for each trial as follows.

Low risk of bias: the trial was of low risk of bias for all domains for this result.
Some concerns: the trial was judged to raise some concerns in at least one domain for this result, but was not at high risk of bias for any domain.
High risk of bias: the trial was judged to be at high risk of bias in at least one domain, or to have some concerns for multiple domains such that confidence in the result is substantially lowered.

We contacted trial investigators for clarification of trial information or results. When the trial investigators did not respond to our multiple inquiries within 14 days, we assessed the risk of bias based on the available information. We resolved any disagreements through discussion within the review author team.

Measures of treatment effect

We calculated risk ratios (RR) with 95% confidence intervals (CI) when comparing dichotomous outcomes, including proportion of eyes with retinal displacement and proportion of each specified ocular adverse event. We planned to record specified ocular adverse events following the CORDS classification; however, as the included studies did not use the classification, we could not determine the severity of the adverse events. When only a single study reported the outcome, and it did not provide analyzable data for RR, we presented the estimates derived from the original analysis in the study. We calculated mean differences (MDs) when comparing continuous outcomes, such as visual acuity in logMAR or Snellen lines (or letters) or distortion scores (Li 2022).

Unit of analysis issues

We included trials where the unit of analysis for outcomes was the eyes of individuals. Whenever both eyes of all or some individuals were included in an RCT, we documented how many participants contributed data for both eyes to the study.

Dealing with missing data

Lack of information about the characteristics of any data will raise concerns as to whether the missing data may have introduced bias. Where statistical data were missing or unclear, we contacted the primary trial investigators for clarification and further information. When we received no responses within two weeks, we proceeded with complete‐case analysis, assuming that data were missing at random (Bhaskaran 2014). We evaluated our assumption by collecting data on the numbers of participants (or eyes) excluded or lost to follow‐up after randomization and the reasons, when available.

Assessment of heterogeneity

We evaluated the overall characteristics of the included studies, especially characteristics of study participants, types of interventions, and study design, to assess the extent of clinical and methodological heterogeneity before conducting meta‐analysis. We assessed statistical heterogeneity by inspecting the distribution of effect size estimates presented in the forest plots and using the I² statistic to assess the proportion of total variability explained by heterogeneity among studies. As suggested in Chapter 10 of the Cochrane Handbook (Deeks 2022), we used the following thresholds for interpreting I² values:

0% to 40%: may not be important;
30% to 60%: may represent moderate heterogeneity;
50% to 90%: may represent substantial heterogeneity;
75% to 100%: considerable heterogeneity.

Assessment of reporting biases

We assessed selective result reporting of the review outcomes by the associated signaling questions of the RoB 2 tool (Higgins 2022). Because there were only three eligible trials, we did not use funnel plots to assess the presence of small‐study effects as suggested in Chapter 13 of the Cochrane Handbook (Page 2022).

Data synthesis

We provided qualitative synthesis for each review outcome specified for all included trials. We performed quantitative data synthesis according to the guidelines in Chapter 9 of the Cochrane Handbook (McKenzie 2022a). We used random‐effects models when there are three or more trials providing data for a given outcome; otherwise, we used a fixed‐effect model. When the direction of treatment effects was inconsistent across trials, or we noted evidence of substantial or considerable statistical heterogeneity, we did not combine trial results in a meta‐analysis, but presented a narrative synthesis of results instead, according to the guidance in Chapter 12 of the Cochrane Handbook (McKenzie 2022b).

Subgroup analysis and investigation of heterogeneity

We did not plan any subgroup analysis.

Sensitivity analysis

For analyses relevant to the critical outcome, we planned to conduct a sensitivity analysis to determine the impact of exclusion of studies at overall high risk of bias and industry‐funded studies. However, sensitivity analysis was precluded by insufficient data.

Summary of findings and assessment of the certainty of the evidence

We prepared a summary of findings table for the following outcomes that included the assumed absolute risks based on the relative risks estimated across the included studies. Two review authors (TF, TWY) independently rated the certainty of the evidence for each outcome using the GRADE classification (Schünemann 2022):

Proportion of eyes with retinal displacement at six months or later following PPV and gas tamponade for primary macula‐involving RRDs.
Mean change in logMAR or Snellen visual acuity from baseline to three months or later following PPV and gas tamponade.
Mean objective distortion score at three months or later following PPV and gas tamponade.
Quality of life assessments at three months or later following PPV and gas tamponade.
Frequency of intervention‐related ocular adverse events, recorded following the CORDS classification.
Frequency of intervention‐related non‐ocular adverse events.

For each outcome, we graded the certainty of evidence as 'high,' 'moderate,' 'low,' or 'very low' according to the five GRADE considerations (overall risk of bias, unexplained heterogeneity or inconsistency of results, indirectness of evidence, imprecision of results, and publication bias) (Schünemann 2013). We resolved any disagreements by discussion.

Results

Description of studies

Results of the search

Our search of the electronic databases in November 2022 yielded 3935 records. After removal of duplicates, we screened 2966 titles and abstracts (Figure 3). We retrieved 16 full‐text reports for further screening and excluded 6 studies (8 records), with reasons that are reported in Characteristics of excluded studies. We included three studies (five records); identified two ongoing studies (Characteristics of ongoing studies); and listed one study as awaiting classification (Characteristics of studies awaiting classification).

We contacted the study investigators of one study to clarify study eligibility, but did not receive a response (JPRN‐UMIN000023272). One ongoing study started in 2022 and is estimated to be completed in 2024 (NCT04035343); another ongoing study started in 2019 but did not provide the estimated completion time (CTRI/2022/10/046837).

Included studies

Types of studies

All three included studies were parallel‐group RCTs and were published between 2017 and 2020. The trials were conducted in England and Scotland (Casswell 2020), the Netherlands (Peiretti 2017), and Switzerland (Schawkat 2019). Only one trial had a multicenter design (Casswell 2020). Two trials provided power and sample size calculation (Casswell 2020; Schawkat 2019). Only one trial was registered on a trial registry, and reported funding sources from the affiliated institution and the government (Casswell 2020). Two trials randomized the intervention at the participant level, and one trial analyzed findings at the eye level as the trial included two eyes for one of the participants (Schawkat 2019).

Types of participants

The three included trials enrolled a total of 368 randomized participants (369 eyes); the median (interquartile range [IQR]) was 56 (53, 148). The average age of study participants in 2 trials was 61 years (Casswell 2020; Schawkat 2019), and the median age of 1 trial was 63 years, ranging from 43 to 90 years (Peiretti 2017). In three trials, more than 70% of enrolled participants were male (range: 68% to 72%). One trial reported that the majority of the study participants were white (Casswell 2020); the other two trials did not provide any race and ethnicity information.

Types of interventions

All three trials compared face‐down positioning with other positioning. Casswell 2020 compared face‐down positioning with support‐the‐break positioning. Face‐down positioning involved 24 hours of face‐down positioning, started immediately after surgery, for a minimum of 50 minutes in every hour, with compliance assessed through participant diaries. Support‐the‐break positioning involved head positioning dependent on the location of retinal breaks: detachments with nasal, temporal, or inferior breaks were positioned on the contralateral cheek, whereas those with superior breaks were positioned upright. After the initial 24 hours of positioning, all participants were positioned in the support‐the‐break regimen for another 6 days. Schawkat 2019 compared log‐roll postoperative positioning (30 minutes face to temporal followed by 30 minutes face‐down postoperative positioning) with face‐up postoperative positioning. Peiretti 2017 compared five hours of immediate face‐down postoperative positioning with five hours of face‐up postoperative positioning. After five hours, all participants were positioned in the support‐the‐break regimen for a further five days.

All trials reported on the use of perfluorocarbon liquid during surgery. Two trials reported intraoperative use of adjuvant perfluorocarbon liquid in 50% of participants (Peiretti 2017; Schawkat 2019); the third trial reported perfluorocarbon liquid use in 1.3% of participants (Casswell 2020). In two trials (Casswell 2020; Schawkat 2019), more than 82% of participants received sulfur hexafluoride gas tamponade.

Types of outcomes

Critical outcome

Proportion of eyes with retinal displacement at six months or later

Casswell 2020 was the only trial to report the proportion of study eyes with retinal displacement at six months or later. Investigators of Casswell 2020 recruited participants from two study sites (London and Glasgow), and consistently reported study outcomes based on invariant regression models with adjustment for study site.

Important outcomes

Proportion of eyes with retinal displacement within three months

Two trials reported the proportion of study participants whose eyes had retinal displacement within three months, reporting this outcome at eight weeks, Casswell 2020, and six weeks, Schawkat 2019.

Mean change in logMAR or Snellen visual acuity

Peiretti 2017 reported best‐corrected visual acuity (BCVA) in logMAR at baseline and three months after surgery. Casswell 2020 reported the corrected Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity in median and IQR at week 8 and week 26, as well as differences between the two comparison groups, adjusted for differences between sites using linear regression models.

Mean objective distortion score

Casswell 2020 was the only trial that reported median distortion score and its IQR at week 8 and week 26, as well as differences between the two comparison groups, adjusted for differences between sites using linear regression models.

Quality of life assessments

Casswell 2020 was the only trial that reported this outcome using the National Eye Institute Visual Function Questionnaire (NEI‐VFQ 25) in median and IQR at week 26, and differences between the two comparison groups adjusted for differences between sites using linear regression models.

Frequency of intervention‐related ocular adverse events

Two trials reported the frequency of the intervention‐related ocular adverse event outer retinal folds at one, three, and six months (Casswell 2020; Peiretti 2017). Only one trial reported on binocular diplopia and elevated intraocular pressure at six months (Casswell 2020). No classification systems were used to grade ocular adverse events in any of the included trials.

Frequency of intervention‐related non‐ocular adverse events

None of the included trials reported this outcome.

Excluded studies

We excluded six studies at the full‐text stage. We excluded three studies because they were not RCTs, and the other three studies because the intervention or comparator was irrelevant (Characteristics of excluded studies).

Risk of bias in included studies

We applied the RoB 2 tool to assess risk of bias for the following five outcomes presented in Table 1:

proportion of eyes with retinal displacement (Casswell 2020; Schawkat 2019);
mean change in visual acuity from baseline to three months or later (Casswell 2020; Peiretti 2017);
objective distortion scores (Casswell 2020);
quality of life assessments (Casswell 2020); and
frequency of intervention‐related ocular adverse events (Casswell 2020; Peiretti 2017).

We did not apply the RoB 2 tool to non‐ocular adverse events because no studies measured or reported this outcome. We summarized assessment results and supporting statements for each signaling question in the corresponding risk of bias tables. Detailed risk of bias assessments are also available upon request.

For proportion of eyes with retinal displacement, we judged the overall risk of bias for one study as at low risk of bias (Casswell 2020), and one study as at high risk of bias (Schawkat 2019). For mean change in visual acuity from baseline to three months or later and ocular adverse events, we judged one study to have an overall low risk of bias (Casswell 2020), and the other study to have some concerns (Peiretti 2017). For objection distortion scores, we judged Casswell 2020 as having an overall low risk of bias. For quality of life assessments, we judged Casswell 2020 to have an overall high risk of bias due to this being a patient‐reported outcome.

Domain 1: Bias arising from the randomization process

We judged Casswell 2020 as at low risk of bias for this domain. Peiretti 2017 and Schawkat 2019 did not provide sufficient information on the method of allocation concealment and were judged as having some concerns.

Domain 2: Bias due to deviations from intended interventions

We judged all three trials as at low risk of bias for this domain.

Domain 3: Bias due to missing outcome data

We judged all three trials as at low risk of bias for all five outcomes assessed.

Domain 4: Bias in measurement of the outcome

For proportion of eyes with retinal displacement, we judged Casswell 2020 to be at a low risk of bias. We judged Schawkat 2019 to be at high risk of bias because it was unclear whether outcome assessors were aware of the intervention received by the study participants (Table 8; Table 9).

Risk of bias for analysis 1.1 Proportion of eyes with retinal displacement at 6 months.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Casswell 2020

Low risk of bias

"Patients were randomized 1:1 using random permutated blocks of varying sizes, stratified by site." According to the protocol (supplement 1), centrally administered method was used to conceal allocation.

Low risk of bias

"Because of the nature of the intervention, participants and researchers could not be masked to group allocation."
"Analysis was conducted following a modified intention to‐ treat principle, with patients experiencing a redetachmentor failure toattach themacula being excluded fromanalysis."

Low risk of bias

Of the 119 participants in the face‐down group, 19 (16%) had missing or ungradable images. Of the 120 participants in the support‐the‐break group, 17 (14.2%) had missing or ungradable images.

Low risk of bias

"Retinal displacement was defined by the presence of hyper autofluorescent lines running approximately parallel to first‐ or second‐order retinal blood vessels, with a similar contour and caliber but distinct from the vessel and of at least 0.25 disc diameters in length. Ghost vessels had to be identified by 2 independent graders on the Topcon FAF image to be judged as present." (Bilateral FAF and optical coherence tomographic macular imaging)
Image graders, data manager, and statistician were masked to treatment allocation and clinical details.

Low risk of bias

All the prespecified outcomes in the protocol were reported in the paper.

Low risk of bias

See above.

Open in a new tab

Risk of bias for analysis 1.2 Proportion of eyes with retinal displacement within 3 months.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Casswell 2020

Low risk of bias

Of the 119 participants in the face‐down group, 19 (16%) had missing or ungradable images. Of the 120 participants in the support‐the‐break group, 17 (14.2%) had missing or ungradable images.

Low risk of bias

All the prespecified outcomes in the protocol were reported in the paper.

Low risk of bias

See above.

Schawkat 2019

Some concerns

Patients were randomly assigned to one of two cohorts using numbered containers in sequence.

Low risk of bias

Because of the nature of the intervention, participants and researchers could not be masked to group allocation.
It was not reported if the analysis was followed by intention‐to‐treat, but all randomized participants were included in the analysis.

Low risk of bias

There was no missing outcome data.

High risk of bias

Evidence of retinal displacement was based on increased autofluorescence lines parallel to retinal vessels by the autofluorescene imaging (FAF). No information about if outcome assessor aware of the intervention.

Some concerns

No statistical analysis plan and protocol are publicly available.

High risk of bias

See above.

Open in a new tab

For mean change in visual acuity at three months (Table 10; Table 11) and ocular adverse events (Table 14; Table 15), we judged Peiretti 2017 to have some concerns due to lack of detail about allocation concealment. We judged Casswell 2020 as at low risk of bias for this domain.

Risk of bias for analysis 1.3 Mean change in visual acuity (logMAR) at 3 months.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Subgroup 1.3.1 Without perfluoron

Peiretti 2017

Some concerns

This is a 4‐arm randomized trial, in which patients were randomized to use PFCO or not as well as prone or supine position after surgery for 5 hours. However, it was unclear whether allocation of interventions was properly concealed. There was no evidence of imbalance in baseline characteristics across the comparison groups.

Low risk of bias

The trial was "single‐blind" yet it was unclear who was masked to the intervention received. Based on the nature of the intervention, patients and researchers were unlikedly masked.

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

BCVA was measured using logMAR. It was unclear whether assessors were aware of the intervention received yet it was unlikely that measurement of the outcome have differed among intervention groups.

Low risk of bias

No study protocol was available for evaluation, yet the data were analyzed in a typical manner.

Some concerns

This trial was judged to have some concerns due to potential risk due to the randomization process.

Subgroup 1.3.2 With perfluoron

Peiretti 2017

Some concerns

Low risk of bias

The trial was "single‐blind" yet it was unclear who was masked to the intervention received. Based on the nature of the intervention, patients and researchers were unlikedly masked.

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

BCVA was measured using logMAR. It was unclear whether assessors were aware of the intervention received yet it was unlikely that measurement of the outcome have differed among intervention groups.

Low risk of bias

No study protocol was available for evaluation, yet the data were analyzed in a typical manner.

Some concerns

This trial was judged to have some concerns due to potential risk due to the randomization process.

Open in a new tab

Risk of bias for analysis 1.4 Mean change in visual acuity (ETDRS).

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Subgroup 1.4.1 Week 8

Casswell 2020

Low risk of bias

Patients and researchers were not masked due to the nature of the intervention. There was unlikely deviations from the interventions in the trial context.

Low risk of bias

Data for this outcome was available for nearly all participants randomized (221/262, 84.4%).

Low risk of bias

BCVA was measured using standardized ETDRS charts at 4m. Patients and researchers were not masked due to the nature of the the intervention, however, the surgical team, data manager, image graders, and statisticians were masked.

Low risk of bias

Outcomes pre‐specified in the study protocol were analyzed and reported accordingly. Results reported also matched with the analytic approaches described in the Methods section.

Low risk of bias

The trial was judged to have an overall low risk of bias.

Subgroup 1.4.2 Week 26

Casswell 2020

Low risk of bias

Patients and researchers were not masked due to the nature of the intervention. There was unlikely deviations from the interventions in the trial context.

Low risk of bias

Data for this outcome was available for nearly all participants randomized (221/262, 84.4%).

Low risk of bias

Outcomes pre‐specified in the study protocol were analyzed and reported accordingly. Results reported also matched with the analytic approaches described in the Methods section.

Low risk of bias

The trial was judged to have an overall low risk of bias.

Open in a new tab

Risk of bias for analysis 1.7 Adverse events ‐ outer retinal folds.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Subgroup 1.7.1 1 month

Peiretti 2017

Some concerns

Low risk of bias

The trial was "single‐blind" yet it was unclear who was masked to the intervention received. Based on the nature of the intervention, patients and researchers were unlikedly masked. However, there was no evidence of deviations from the intended interventions under the trial context.

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

Proportions of pariticipants with outer retinal folds were reported at multiple timepoints accordingly.

Low risk of bias

Proportions of pariticipants with outer retinal folds were analyzed accordingly.

Some concerns

The trial was judged to have some concerns in risk of bias due to the randomization process.

Subgroup 1.7.2 3 months

Peiretti 2017

Some concerns

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

Proportions of pariticipants with outer retinal folds were reported at multiple timepoints accordingly.

Low risk of bias

Proportions of pariticipants with outer retinal folds were analyzed accordingly.

Some concerns

The trial was judged to have some concerns in risk of bias due to the randomization process.

Subgroup 1.7.3 6 months

Casswell 2020

Low risk of bias

Patients and researchers were not masked due to the nature of the intervention. There was unlikely deviations from the interventions in the trial context. The authors used modified ITT analysis, i.e., complete case analysis with sensitiity analysis to assess potential risks of "missingness not at random."

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

Proportions of patients with selected ocular adverse events were measured and reported.

Low risk of bias

Proportions of patients with selected ocular adverse events were analyzed and reported.

Low risk of bias

The trial was judged to have an overall low risk of bias.

Open in a new tab

Risk of bias for analysis 1.8 Adverse events ‐ binocular diplopia and elevated intraocular pressure at 6 months.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Subgroup 1.8.1 Binocular diplopia

Casswell 2020

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

Proportions of patients with selected ocular adverse events were measured and reported.

Low risk of bias

Proportions of patients with selected ocular adverse events were analyzed and reported.

Low risk of bias

The trial was judged to have an overall low risk of bias.

Subgroup 1.8.2 Elevated intraocular pressure

Casswell 2020

Low risk of bias

Data for this outcome was available for all participants randomized.

Low risk of bias

Proportions of patients with selected ocular adverse events were measured and reported.

Low risk of bias

Proportions of patients with selected ocular adverse events were analyzed and reported.

Low risk of bias

The trial was judged to have an overall low risk of bias.

Open in a new tab

For objective distortion scores, we judged Casswell 2020 as at low risk of bias for this domain (Table 12).

Risk of bias for analysis 1.5 Objective distortion score.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Subgroup 1.5.1 Week 8

Casswell 2020

Low risk of bias

Of the 119 participants in the face‐down group, 19 (16%) had missing or ungradable images. Of the 120 participants in the support‐the‐break group, 17 (14.2%) had missing or ungradable images.

Low risk of bias

Grading distortion score by bilateral FAF and optical coherence tomographic macular imaging. Image graders, data manager, and statistician were masked to treatment allocation and clinical details.

Low risk of bias

All the prespecified outcomes in the protocol were reported in the paper.

Low risk of bias

See above.

Subgroup 1.5.2 Week 26

Casswell 2020

Low risk of bias

Of the 119 participants in the face‐down group, 19 (16%) had missing or ungradable images. Of the 120 participants in the support‐the‐break group, 17 (14.2%) had missing or ungradable images.

Low risk of bias

Grading distortion score by bilateral FAF and optical coherence tomographic macular imaging. Image graders, data manager, and statistician were masked to treatment allocation and clinical details.

Low risk of bias

All the prespecified outcomes in the protocol were reported in the paper.

Low risk of bias

See above.

Open in a new tab

For quality of life assessments, we judged Casswell 2020 to have high risk of bias, as this patient‐reported outcome could potentially have been influenced by participants knowing what intervention they received (Table 13).

Risk of bias for analysis 1.6 Quality of life score ‐ NEI‐VFQ.

Study

Bias

Randomisation process

Deviations from intended interventions

Missing outcome data

Measurement of the outcome

Selection of the reported results

Overall

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Authors' judgement

Support for judgement

Casswell 2020

Low risk of bias

Of the 119 participants in the face‐down group, 19 (16%) had missing or ungradable images. Of the 120 participants in the support‐the‐break group, 17 (14.2%) had missing or ungradable images.

High risk of bias

It is a patient‐reported outcome could potentially be influenced by knowing what intervention they have received.

Low risk of bias

All the prespecified outcomes in the protocol were reported in the paper.

High risk of bias

See above.

Open in a new tab

Domain 5: Bias in selection of the reported result

For proportion of eyes with retinal displacement, we judged Casswell 2020 to be at a low risk of bias. The statistical analysis plan and protocol were not available for Schawkat 2019, therefore we had some concerns for this domain (Table 8; Table 9).

For the other four outcomes, we judged Casswell 2020 and Peiretti 2017 to have a low risk of bias (Table 10; Table 11; Table 12; Table 13; Table 14; Table 15).

Effects of interventions

See: Table 1

Absolute and relative effects for all prespecified outcomes in the Methods are summarized with their respective GRADE ratings in Table 1.

Critical outcome

Proportion of eyes with retinal displacement at six months or later

Only one trial reported this outcome at six months (Casswell 2020). The single study estimate suggested that immediate face‐down positioning after PPV and gas tamponade for a macula‐involving RRD may reduce the incidence of retinal displacement compared with support‐the‐break positioning at six months (risk ratio [RR] 0.73, 95% confidence interval [CI] 0.54 to 0.99; 239 participants; Figure 4). We assessed the certainty of evidence for this outcome as very low, downgraded for imprecision of the estimate (−2) and risk of bias (−1).

Forest plot of face‐down positioning versus support‐the‐break positioning, outcome 1.1 Proportion of eyes with retinal displacement at 6 months.

Other important outcomes

Proportion of eyes with retinal displacement within three months

Two trials reported this outcome within three months. The sample sizes of two studies were substantially different: one was 239 participants (Casswell 2020), and the other was 50 eyes (Schawkat 2019). The combined estimate suggested no evidence of differences in retinal displacement when comparing face‐down positioning with face‐up or support‐the‐break positioning three months after PPV and gas tamponade (RR 0.79, 95% CI 0.61 to 1.03; I² = 84%; 289 eyes; Figure 5). The substantial heterogeneity between the two studies may be attributed to Schawkat 2019 having a high risk of bias in measurement of the outcome and some concerns for bias arising from the randomization process. The single study estimate suggested that immediate face‐down positioning after PPV and gas tamponade for a macula‐involving RRD may reduce the incidence of retinal displacement compared with support‐the‐break positioning at three months (RR 0.68, 95% CI 0.51 to 0.90; 239 participants; Figure 5) (Casswell 2020). We assessed the certainty of evidence for this outcome as very low because of potential risk of bias (−1), inconsistency (−1), and imprecision (−1).

Forest plot of face‐down positioning versus other positioning, outcome 1.2: Proportion of eyes with retinal displacement at 3 months.

Mean change in logMAR or Snellen visual acuity

Only one trial reported BCVA in logMAR at three months after surgery (Peiretti 2017). The single study estimate indicated no evidence of a difference in visual acuity comparing postoperative face‐up with face‐down positioning with or without perfluorocarbon liquid (mean difference [MD] −0.03, 95% CI −0.09 to 0.02; I² = 0%; 56 participants; Analysis 1.3). The single study estimate also indicated no evidence of a difference in visual acuity comparing face‐up with face‐down positioning with (MD −0.01, 95% CI −0.09 to 0.07; 28 participants) or without perfluorocarbon liquid (MD −0.06, 95% CI −0.15 to 0.03; 28 participants) (Analysis 1.3).

1.3 — Comparison 1: Face‐down positioning versus other positioning, Outcome 3: Mean change in visual acuity (logMAR) at 3 months

One trial reported ETDRS visual acuity in site‐adjusted differences at week 8 and week 26, although the data were not normally distributed (Casswell 2020). The single study estimate from the trial suggested no evidence of difference in visual acuity when comparing immediate face‐down with support‐the‐break positioning at week 8 (MD −0.70, 95% CI −4.62 to 3.22; 221 participants; Analysis 1.4) and week 26 (MD 0.10, 95% CI −3.04 to 3.24; 220 participants; Analysis 1.4). We assessed the certainty of evidence for this outcome as very low because of imprecision (−2) and risk of bias (−1).

1.4 — Comparison 1: Face‐down positioning versus other positioning, Outcome 4: Mean change in visual acuity (ETDRS)

Mean objective distortion score

Casswell 2020 only reported distortion scores in site‐adjusted differences at week 8 and week 26. The single study estimate from the trial suggested no evidence of difference in distortion score when comparing immediate face‐down with support‐the‐break positioning at week 8 (MD 2.70, 95% CI −0.83 to 6.23; 220 participants; Analysis 1.5) and week 26 (MD 1.80, 95% CI −1.92 to 5.52; 219 participants; Analysis 1.5). We assessed the certainty of evidence for this outcome as very low because of risk of bias (−1) and imprecision (−2).

1.5 — Comparison 1: Face‐down positioning versus other positioning, Outcome 5: Objective distortion score

Quality of life assessments

Casswell 2020 only reported NEI‐VFQ 25 assessment score in site‐adjusted differences at week 26. The single study estimate suggested no evidence of difference in quality of life when comparing immediate face‐down positioning with support‐the‐break positioning at week 26 (MD −1.80, 95% CI −5.52 to 1.92; 217 participants; Analysis 1.6). We assessed the certainty of evidence for this outcome as very low because of risk of bias (−1) and imprecision (−2).

1.6 — Comparison 1: Face‐down positioning versus other positioning, Outcome 6: Quality of life score ‐ NEI‐VFQ

Frequency of intervention‐related ocular adverse events

Peiretti 2017 reported the intervention‐related ocular adverse event of outer retinal folds. The estimates suggested no evidence of a difference in the adverse event of outer retinal folds when comparing face‐down with face‐up positioning at one month (RR 1.00, 95% CI 0.50 to 2.02; 56 participants) or three months (RR 1.00, 95% CI 0.28 to 3.61; 56 participants; Figure 6). Casswell 2020 reported proportions of participants with outer retinal folds at six months. The estimate suggested that immediate face‐down positioning may reduce the adverse event of outer retinal folds compared with support‐the‐break positioning (RR 0.39, 95% CI 0.17 to 0.90; 262 participants; Figure 6).

Forest plot of face‐down positioning versus other positioning, outcome 1.7: Adverse events ‐ outer retinal folds.

Only Casswell 2020 reported the intervention‐related ocular adverse events of binocular diplopia and elevated intraocular pressure at six months. The single study estimate suggested that immediate face‐down positioning may reduce the adverse event of binocular diplopia compared with support‐the‐break positioning (RR 0.20, 95% CI 0.04 to 0.90; 262 participants; Figure 7). The single study estimate also suggested that immediate face‐down positioning may increase the risk of elevated intraocular pressure compared with support‐the‐break positioning (RR 1.74, 95% CI 1.11 to 2.73; 262 participants; Figure 7). We assessed the certainty of evidence for intervention‐related ocular adverse events as very low because of imprecision (−2) and risk of bias (−1).

Forest plot of face‐down positioning versus support‐the‐break positioning, outcome 1.8: Adverse events ‐ binocular diplopia and elevated intraocular pressure at 6 months.

Frequency of intervention‐related non‐ocular adverse events

None of the included trials reported this outcome.

Discussion

Summary of main results

We identified three RCTs (369 eyes of 368 participants) that addressed our critical and important outcomes. Participants were recruited from four European countries and followed up for a maximum of six months. All studies examined face‐down positioning versus other positioning regimens after PPV and gas tamponade in the management of macula‐involving RRDs.

Very low certainty evidence from one RCT suggested that immediate face‐down positioning after surgery may result in reduced postoperative retinal displacement, outer retinal folds, and binocular diplopia, but may increase the chance of postoperative raised intraocular pressure compared with support‐the‐break positioning at six months (Casswell 2020). There was little to no effect on postoperative distortion and quality of life assessment scores. Very low certainty evidence from two RCTs (239 eyes of 239 participants in Casswell 2020 and 56 eyes of 56 participants in Peiretti 2017) found no evidence of a difference in postoperative BCVA when comparing face‐down positioning versus face‐up or support‐the‐break positioning at three to six months.

Overall completeness and applicability of evidence

Despite conducting a highly sensitive search strategy for published RCTs, we identified only three eligible trials. All participants were recruited from a European population (England, Scotland, the Netherlands, and Switzerland) (Casswell 2020; Peiretti 2017; Schawkat 2019). Only Casswell 2020 included eyes from a black (3%) or Asian (11%) population. Black patients have been shown to have worse visual outcomes compared to white patients undergoing surgery for RRDs (Xu 2023). Differences in ethnic group representation could therefore potentially hinder the applicability of the results found in this review to non‐white populations.

Of the three included trials, only Casswell 2020 examined our critical outcome. Some important outcomes, such as postoperative distortion (reported in one RCT) and quality of life (reported in one RCT) assessment scores were largely neglected, and evidence regarding these outcomes is incomplete. Of the few important outcomes reported across RCTs, variation in findings was evident, which may be due in part to the small sample sizes of two of the three included RCTs. Findings may also differ as a result of the differing methods of study design (both regarding the positioning or posturing comparators and the duration and timing of intervention used), as well as the short follow‐up period of some of the studies (only six weeks in one RCT). Although most patients who undergo macula‐involving retinal detachment surgery have stable vision three to six months after surgery, vision continues to improve in a subgroup of patients up to five years after surgery (Kusaka 1998). Metamorphopsia also continues to improve over the long‐term after surgery for macula‐involving retinal detachments (Okuda 2018). More studies with longer follow‐up are therefore needed to fully appraise the long‐term effects of the interventions evaluated in this review. Patient preferences were not assessed in any of the included RCTs, and future studies may wish to consider exploring this.

We identified two ongoing RCTs. However, we have not incorporated the data from these ongoing trials in this review because no interim or final results were as yet available. This topic should be revisited in the future once additional RCTs have been published to collate and critique evidence and guide practice.

Certainty of the evidence

We assessed the certainty of the evidence across the outcomes examined in this review as very low (Table 1). In accordance with the GRADE classification (Schünemann 2022), we downgraded the certainty of the evidence for all reported outcomes primarily due to potential risk of bias and imprecision. There was a lack of clarity on sequence generation and allocation concealment, as well as an inability to mask (blind) participants and personnel to the intervention received and to mask assessors to some of the outcomes measured. Our confidence in the evidence was further reduced by its reliance on single study estimates, relatively small sample sizes, or both.

Potential biases in the review process

We followed Cochrane methodology in conducting this review and adhered to the Methodological Expectations of Cochrane Intervention Reviews (MECIR) standards for the reporting of Cochrane Intervention Reviews in order to minimize any bias in the review process (Higgins 2022). An Information Specialist performed highly sensitive searches to identify all relevant studies, thus ensuring a comprehensive search. In addition, we reached out to the authors to seek clarification on study eligibility and outcomes of interest. No authors had any conflicts of interest in the review topic.

Agreements and disagreements with other studies or reviews

There have been no reviews evaluating the value of face‐down positioning in terms of retinal displacement, visual acuity, distortion, and quality of life following PPV and gas tamponade for a macula‐involving RRD. One comparative study of 86 eyes that underwent PPV and gas tamponade showed a lower rate of postoperative retinal displacement with face‐down positioning immediately after surgery compared with face‐down positioning at least 10 minutes after the end of the surgery (Shiragami 2015). This study was a retrospective study performed at a single institution. The presence of selection bias and the low number of participants enrolled in the study may have affected the accuracy of the results and reliability of the conclusions.

Authors' conclusions

Implications for practice.

Three randomized controlled trials (RCTs) addressed the value of face‐down positioning following pars plana vitrectomy (PPV) and gas tamponade for macula‐involving rhegmatogenous retinal detachments (RRDs). Heterogeneity in the timing and durations of positioning and outcomes reported at different time points meant that the studies were not directly comparable.

Although the number of studies reporting on our critical and important outcomes is insufficient, very low certainty evidence suggests that immediate face‐down positioning after PPV and gas tamponade may result in reduced postoperative retinal displacement, outer retinal folds, and binocular diplopia compared to support‐the‐break positioning. Given its possibility for reducing troublesome postoperative complications, immediate face‐down positioning after PPV and gas tamponade may be considered in people with macula‐involving RRDs. Because of imprecision with wide estimate and a small sample size, clinical decisions should be tailored to each individual following comprehensive consultations with patients and their families.

Implications for research.

In addition to the three included RCTs, we also identified two ongoing trials that aim to compare face‐down positioning with face‐up positioning following PPV and gas tamponade in participants with primary macula‐involving RRDs. Once available, the findings of these ongoing trials may help improve the overall certainty of evidence in this review. Future RCTs should be designed with standardized comparisons and outcomes. Study investigators should analyze outcome data appropriately and report adequate information by following the CONSORT statement for RCTs to provide evidence of high certainty (Moher 2010). In particular, future trials may follow a recently published international consensus on reporting the severity as well as the frequency of complications of RRD surgery (Xu 2021). In addition to clinically important outcomes and adverse event outcomes, patient‐important outcomes such as quality of life and patient acceptability and satisfaction should be considered by future trials. It is also essential for future research to have a strong patient and public involvement in the trial design and conductance.

History

Protocol first published: Issue 12, 2022

Risk of bias

Acknowledgements

Acknowledgements from the authors

We would like to acknowledge the contributions of Raphael Killian (University of Verona), Henry Jampel (Johns Hopkins University), and Andrew Eller (University of Pittsburgh) for their comments on the protocol.

Editorial and peer‐reviewer contributions

The Cochrane Eyes and Vision US Project (CEV@US) supported the authors in the development of this review.

The following people conducted the editorial process for this review:

Sign‐off Editors (final editorial decision via the Central Editorial Service): Dr Gianni Virgilli (Queen's University Belfast, Ireland; University of Florence, Italy); (final editorial decision at CEV@US): Dr Tianjing Li (University of Colorado Anschutz Medical Campus), Dr Roberta W Scherer (Johns Hopkins University);
Managing Editors (selected peer reviewers, provided editorial guidance to authors, edited the article): Anupa Shah, Cochrane Central Editorial Service;
Editorial Assistant (conducted editorial policy checks, collated peer‐reviewer comments, and supported the editorial team): Sara Hales‐Brittain, Cochrane Central Editorial Service;
Methodologist (provided methodological and editorial guidance to authors, edited the article): Sueko Ng (University of Colorado Anschutz Medical Campus);
Information Specialist: Lori Rosman (Johns Hopkins University);
Copy Editor (copy‐editing and production): Lisa Winer, Cochrane Central Production Service;
Peer reviewers (provided comments and recommended an editorial decision): Peter J Kertes, MD CM, FRCSC, Department of Ophthalmology and Vision Sciences Temerty Faculty of Medicine, The University of Toronto (clinical/content review), Amin Nabavi, MD, FICO, Department of Ophthalmology, Guilan University of Medical Sciences, Rasht, Iran (clinical/content review), Jennifer Hilgart, Cochrane (methods review), Jo Platt, Central Editorial Information Specialist (search review). One additional peer reviewer provided clinical/content peer review but chose not to be publicly acknowledged.

Appendices

Appendix 1. CENTRAL search strategy

#1 MeSH descriptor: [Retinal Detachment] explode all trees #2 MeSH descriptor: [Retinal Perforations] explode all trees #3 MeSH descriptor: [Vitreous Detachment] explode all trees #4 rhegmatogenous OR RRD #5 (retina*) NEAR/3 (break* OR tear* OR hole* OR detach* OR perforat*) #6 (macula* NEXT/1 (off OR on OR involv*)) #7 {OR #1‐#6} #8 MeSH descriptor: [Vitrectomy] explode all trees #9 Vitrectom* OR PPV #10 {OR #8‐#9} #11 MeSH descriptor: [Postoperative Care] explode all trees #12 MeSH descriptor: [Postoperative Period] explode all trees #13 MeSH descriptor: [Postoperative Complications] explode all trees #14 MeSH descriptor: [Patient Positioning] explode all trees #15 MeSH descriptor: [Posture] explode all trees #16 (postur* OR position* OR prone OR supine) #17 "face down" OR "facing down" OR "faced down" #18 postoperativ* OR "post operative" OR postsurgical* OR "post surgical" OR "post surgery" #19 (retina* NEAR/3 displace*) #20 shift* OR stretch* OR slippage* OR folds #21 {OR #11‐#20} #22 #7 AND #10 AND #21 in Trials

Appendix 2. MEDLINE (Ovid) search strategy

1. Randomized Controlled Trial.pt. 2. Controlled Clinical Trial.pt. 3. (randomized or randomised).ab,ti. 4. placebo.ab,ti. 5. drug therapy.fs. 6. randomly.ab,ti. 7. trial.ab,ti. 8. groups.ab,ti. 9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 10. exp animals/ not humans.sh. 11. 9 not 10 12. exp Retinal Detachment/ 13. exp Retinal Perforations/ 14. exp Vitreous Detachment/ 15. (rhegmatogenous or RRD).tw. 16. (retina* adj3 (break* or tear* or hole* or detach* or perforat*)).tw. 17. (macula* adj1 (off OR on OR involv*)).tw. 18. or/12‐17 19. exp Vitrectomy/ 20. (Vitrectom* or PPV).tw. 21. 19 or 20 22. exp Postoperative Care/ 23. exp Postoperative Period/ 24. exp Postoperative Complications/ 25. exp Patient Positioning/ 26. exp Posture/ 27. (postoperative* or "post operative*" or postsurgical* or "post surgi*" or "post surger*").tw. 28. (postur* or position* or prone or supine).tw. 29. ("face down" or "facing down" or "faced down").tw. 30. (retina* adj3 displace*).tw. 31. (shift* or stretch* or slippage* or folds).tw. 32. or/22‐31 33. 18 and 21 and 32 34. 11 and 33

The search filter for trials at the beginning of the MEDLINE strategy is from the published paper by Glanville 2006.

Appendix 3. Embase.com search strategy

#1 'randomized controlled trial'/exp #2 'randomization'/exp #3 'double blind procedure'/exp #4 'single blind procedure'/exp #5 random*:ab,ti #6 #1 OR #2 OR #3 OR #4 OR #5 #7 'animal'/exp OR 'animal experiment'/exp #8 'human'/exp #9 #7 AND #8 #10 #7 NOT #9 #11 #6 NOT #10 #12 'clinical trial'/exp #13 (clin* NEAR/3 trial*):ab,ti #14 ((singl* OR doubl* OR trebl* OR tripl*) NEAR/3 (blind* OR mask*)):ab,ti #15 'placebo'/exp #16 placebo*:ab,ti #17 random*:ab,ti #18 'experimental design'/exp #19 'crossover procedure'/exp #20 'control group'/exp #21 'latin square design'/exp #22 #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 #23 #22 NOT #10 #24 #23 NOT #11 #25 'comparative study'/exp #26 'evaluation'/exp #27 'prospective study'/exp #28 control*:ab,ti OR prospectiv*:ab,ti OR volunteer*:ab,ti #29 #25 OR #26 OR #27 OR #28 #30 #29 NOT #10 #31 #30 NOT (#11 OR #23) #32 #11 OR #24 OR #31 #33 'retina detachment'/exp #34 'retina tear'/exp #35 'vitreous body detachment'/exp #36 'retinal detachment surgery'/exp #37 'retinal detachment complications'/exp #38 rhegmatogenous:ab,ti,kw OR RRD:ab,ti,kw #39 (retina* NEAR/3 (break* OR tear* OR hole* OR detach* OR perforat*)):ab,ti,kw #40 (macula* NEXT/1 (off OR on OR involv*)):ab,ti,kw #41 #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 #42 'vitrectomy'/exp #43 vitrectom*:ab,ti,kw OR ppv:ab,ti,kw #44 #42 OR #43 #45 'postoperative care'/exp #46 'postoperative period'/exp #47 'postoperative complication'/exp #48 'patient positioning'/exp #49 'body position'/exp #50 'prone positioning'/exp #51 'prone position'/exp #52 'face down positioning'/exp #53 postur*:ab,ti,kw OR position*:ab,ti,kw OR prone:ab,ti,kw OR supine:ti,ab,kw #54 'face down':ab,ti,kw OR 'facing down':ab,ti,kw OR 'faced down':ab,ti,kw #55 postoperative*:ab,ti,kw OR 'post operative*':ab,ti,kw OR postsurgical*:ab,ti,kw OR 'post surgi*':ab,ti,kw OR 'post surger*':ab,ti,kw #56 (retina* NEAR/3 displace*):ab,ti,kw #57 shift*:ab,ti,kw OR stretch*:ab,ti,kw OR slippage*:ab,ti,kw OR folds:ab,ti,kw #58 #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 #59 #41 AND #44 AND #58 #60 #32 AND #59

The search filter for trials at the beginning of the Embase strategy is adapted from the published paper by Lefebvre 2008.

Appendix 4. PubMed search strategy

#1 ((randomized controlled trial[pt]) OR (controlled clinical trial[pt]) OR (randomised[tiab] OR randomized[tiab]) OR (placebo[tiab]) OR (drug therapy[sh]) OR (randomly[tiab]) OR (trial[tiab]) OR (groups[tiab])) NOT (animals[mh] NOT humans[mh]) #2 Rhegmatogenous[tw] OR RRD[tw] #3 (retina*[tw] AND (break*[tw] OR tear*[tw] OR hole*[tw] OR detach*[tw] OR perforat*[tw])) #4 ("macula off"[tw] OR "macular off"[tw] OR "macula on"[tw] OR "macular on"[tw] OR "macula involv*"[tw] OR "macular involv*"[tw]) #5 #2 OR #3 OR #4 #6 (Vitrectom*[tw] OR PPV[tw]) #7 (postoperative*[tw] OR "post operative*"[tw] OR postsurgical*[tw] OR "post surgi*"[tw] OR "post surger*"[tw]) #8 (postur*[tw] OR position*[tw] OR prone[tw] OR supine[tw]) #9 ("face down"[tw] OR "facing down"[tw] OR "faced down"[tw]) #10 (retina*[tw] AND displace*[tw]) #11 shift*[tw] OR stretch*[tw] OR slippage*[tw] OR folds[tw] #12 #7 OR #8 OR #9 OR #10 OR #11 #13 #5 AND #6 AND #12 #14 #1 AND #13 #15 Medline[sb] #16 #14 NOT #15

Appendix 5. LILACS search strategy

(MH:C11.768.648$ OR MH:C11.768.740$ OR MH:C11.980$ OR Rhegmatogenous OR (retina$ AND (break$ OR tear$ OR hole$ OR detach$ OR perforat$)) OR "macula off" OR "macular off" OR "macula on" OR "macular on" OR "macula involving" OR "macular involving") AND (MH:E04.540.960$ OR Vitrectom$ OR PPV) AND (MH:E02.760.731.700$ OR MH:E04.604.500$ OR MH:N02.421.585.722.700$ OR MH:E04.614.750$ OR MH:N02.421.585.753.750$ OR MH:C23.550.767 OR MH:E02.760.670$ OR MH:N02.421.585.700$ OR MH:G11.427.695$ OR postoperative$ OR "post operative" OR postsurgical$ OR "post surgical" OR "post surgery" OR postur$ OR position$ OR prone OR supine OR "face down" OR "facing down" OR "faced down" OR (retina$ AND displace$) OR shift$ OR stretch$ OR slippage$ OR folds)

Appendix 6. ClinicalTrials.gov search strategy

(rhegmatogenous OR retinal break OR retinal tear OR retinal hole OR retinal detachment OR retinal perforation OR "macula off" OR "macular off" OR "macula on" OR "macular on" OR "macular involving") AND (Vitrectomy OR PPV) AND (posture OR position OR positioning OR prone OR supine OR "face down" OR "facing down" OR "faced down" OR postoperative OR "post operative" OR postsurgical OR "post surgical" OR "post surgery" OR displace OR displacement OR shift OR shifting OR stretch OR slippage OR folds)

Appendix 7. ICTRP search strategy

rhegmatogenous AND vitrectomy OR rhegmatogenous AND PPV OR retinal detachment AND vitrectomy OR retinal detachment AND PPV OR retinal break AND vitrectomy OR retinal break AND PPV OR retinal tear AND vitrectomy OR retinal tear AND PPV OR retinal hole AND vitrectomy OR retinal hole AND PPV OR retinal perforation AND vitrectomy OR retinal perforation AND PPV OR macula off AND vitrectomy OR macula off AND PPV OR macular off AND vitrectomy OR macular off AND PPV OR macula on AND vitrectomy OR macula on AND PPV OR macular on AND vitrectomy OR macular on AND PPV OR macula involving AND vitrectomy OR macula involving AND PPV OR macular involving AND vitrectomy OR macular involving AND PPV

Data and analyses

Comparison 1. Face‐down positioning versus other positioning.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Proportion of eyes with retinal displacement at 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.2 Proportion of eyes with retinal displacement within 3 months	2	289	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.61, 1.03]
1.3 Mean change in visual acuity (logMAR) at 3 months	1	56	Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.09, 0.02]
1.3.1 Without perfluoron	1	28	Mean Difference (IV, Fixed, 95% CI)	‐0.06 [‐0.15, 0.03]
1.3.2 With perfluoron	1	28	Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.09, 0.07]
1.4 Mean change in visual acuity (ETDRS)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4.1 Week 8	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4.2 Week 26	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.5 Objective distortion score	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.5.1 Week 8	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.5.2 Week 26	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6 Quality of life score ‐ NEI‐VFQ	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.7 Adverse events ‐ outer retinal folds	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.7.1 1 month	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.7.2 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.7.3 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.8 Adverse events ‐ binocular diplopia and elevated intraocular pressure at 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.8.1 Binocular diplopia	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.8.2 Elevated intraocular pressure	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Open in a new tab

1.1 — Comparison 1: Face‐down positioning versus other positioning, Outcome 1: Proportion of eyes with retinal displacement at 6 months

1.2 — Comparison 1: Face‐down positioning versus other positioning, Outcome 2: Proportion of eyes with retinal displacement within 3 months

1.7 — Comparison 1: Face‐down positioning versus other positioning, Outcome 7: Adverse events ‐ outer retinal folds

1.8 — Comparison 1: Face‐down positioning versus other positioning, Outcome 8: Adverse events ‐ binocular diplopia and elevated intraocular pressure at 6 months

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Casswell 2020.

*Study characteristics*
Methods	Study design: parallel‐group randomized controlled trial, multicenter Study period: 16 May 2016 to 1 May 2018 Number randomized: 262 in total; 131 for face‐down positioning and 131 for support‐the‐break positioning Unit of randomization: individual Exclusions after randomization: 23 in total; 12 for face‐down positioning and 11 for support‐the‐break positioning Losses to follow‐up: 18 in total; 10 for face‐down positioning and 8 for support‐the‐break positioning Number analyzed: 239 in total; 119 for face‐down positioning and 120 for support‐the‐break positioning Unit of analysis: 1 eye per participant Length of follow‐up: planned: NR; actual: 6 months How were missing data handled?: "if data were missing for any patients, reasons for this were investigated using logistic regression of covariates on an indicator of missingness. Sample size estimation assumed 5% of patients would be lost of follow up by 6 months post RD. If there were less than 5% of missing data due to missing completely at random an available case analysis was conducted as the main analysis. If there were more than 5% of subjects with missing primary outcome data then a missing at random assumption was made and the multiple imputation method was considered." Power calculation: total sample size: 262 participants; power: 85% at the 5% level
Participants	Country: England/Scotland Setting: Moorfields Eye Hospital, London, and the Tennent Institute of Ophthalmology, Glasgow Characteristics by intervention group: Group 1 (face‐down positioning): Age, mean ± SD: 60.3 ± 11.1 Gender, n (%), (male: female): 83 (69.7%) : 36 (30.3%) Race/ethnicity, n(%), (white : Asian/Asian British : black/black British: other) : 98 (82.3%) : 17 (14.2%) : 4 (3.3%) : 0 (0%) Preoperative visual acuity, BCVA, median (IQR), Snellen: 3/60 (HM, 6/36)^a Lens status, n (%), (phakic : PCIOL : aphakic: ACIOL) : 80 (67.2%) : 37 (31.1%) : 1 (0.8%) : 1 (0.8%) Retinal breaks, median (IQR): 2 (1 to 3) Retinal break location, n (%), (superotemporal : superonasal : inferotemporal: inferonasal)^b : 100 (84.0%) : 36 (30.3%) : 32 (26.9%) : 15 (12.6%) Proliferative vitreoretinopathy (n, %), (none : PVR B: PVR C): 115 (96.6%) : 4 (3.4%) : 0 (0%) PFCL used, n (%): 2 (1.7%) Tamponade used, n(%), (SF6 : C2F6: C3F8): 94 (79.0%) : 4 (3.4%) : 21 (17.6%) Group 2 (support‐the‐break positioning): Age, mean ± SD: 61.3 ± 8.2 Gender, n (%), (male: female): 88 (73.3%) : 32 (26.7%) Race/ ethnicity, n(%), (white : Asian/Asian British : black/black British: other): 105 (87.5%) : 9 (7.5%) : 4 (3.3%) : 2 (1.6%) Preoperative visual acuity, BCVA, median (IQR), Snellen: 3/60 (HM, 6/24)^a Lens status, n (%), (phakic : PCIOL : aphakic: ACIOL): 72 (60.0%) : 48 (40.0%) : 0 (0%) : 0 (0%) Retinal breaks, median (IQR): 2 (1 to 3) Retinal break location, n (%), (superotemporal : superonasal : inferotemporal: inferonasal)^b: 91 (75.8%) : 50 (41.7%) : 28 (23.3%) : 19 (15.8%) Proliferative vitreoretinopathy (n, %), (none : PVR B: PVR C): 115 (95.8%) : 3 (2.5%) : 2 (1.7%) PFCL used, n (%): 1 (0.8%) Tamponade used, n(%), (SF6 : C2F6: C3F8): 104 (86.7%) : 5 (4.2%) : 11 (9.2%) Overall: Age, mean ± SD: 60.8 ± 9.8 Gender, n (%), (male: female): 171 (71.5%) : 68 (28.5%) Race/ ethnicity, n(%), (white : Asian/Asian British : black/black British: other): 203 (84.9%) : 26 (10.9%) : 8 (3.3%) : 2 (0.8%) Preoperative visual acuity, BCVA, median (IQR), Snellen: NR Lens status, n (%), (phakic : PCIOL : aphakic: ACIOL): 152 (63.6%) : 85 (35.6%) : 1 (0.4%) : 1 (0.4%) Retinal breaks, median (IQR): NR Retinal break location, n (%), (superotemporal : superonasal : inferotemporal: inferonasal)^b: 191 (79.9%) : 86 (36.0%) : 60 (25.1%) : 34 (14.2%) Proliferative vitreoretinopathy (n, %), (none : PVR B: PVR C): 230 (96.2%) : 7 (2.9%) : 2 (0.8%) PFCL used, n (%): 3 (1.3%) Tamponade used, n(%), (SF6 : C2F6: C3F8): 198 (82.8%) : 9 (3.8%) : 32 (13.4%) Inclusion criteria: Age 18 years and older Fovea‐involving rhegmatogenous RD Central visual loss within 14 days Patients undergoing primary vitrectomy and gas surgery under local anesthetic Patients able to give written informed consent Exclusion criteria: Previous vitrectomy or cryobuckle surgery RD surgery requiring silicone oil tamponade A pre‐existing ophthalmic condition that limited the patient's visual acuity (BCVA) 6/36 or worse (approximate Snellen equivalent 20/125) Inability to position postoperatively or commit to follow‐up visits
Interventions	Intervention 1 (face‐down positioning): immediate face‐down positioning after completion of the surgery. Position for a minimum of 50 minutes of every hour and throughout the night for a 24‐hour period. After 24 hours, support‐the‐break positioning is performed for a further 6 days. Intervention 2 (support‐the‐break positioning): immediate support‐the‐break positioning (detachments with superior breaks positioned upright, whereas those with nasal, temporal, or inferior breaks were positioned on the contralateral cheek) after completion of the surgery. Position for a minimum of 50 minutes of every hour and throughout the night for a 24‐hour period. After 24 hours, support‐the‐break positioning is performed for a further 6 days. Surgical details: 3‐port pars plana vitrectomy, retinopexy to breaks by cryotherapy or laser, and intraocular gas tamponade. Subretinal fluid was drained via either a retinal break or a retinotomy at the surgeon's discretion.
Outcomes	Primary outcome(s): the proportion of participants in each treatment group with retinal displacement on autofluorescence imaging at 6 months postoperatively Secondary outcome(s): The proportion of participants in each group with retinal displacement on autofluorescence imaging at 2 months postoperatively The degree of retinal displacement on autofluorescence imaging at 2 and 6 months The mean (SD)/median (IQR) corrected ETDRS visual acuity score at 2 and 6 months postoperatively in each treatment group The mean (SD)/median (IQR) objective distortion score at 2 and 6 months postoperatively in each treatment group ‐ with objective distortion measured with D charts The mean (SD)/median (IQR) visual function score as measured using the NEI‐VFQ 25 in each treatment group at 6 months postoperatively Adverse outcome(s): Ocular adverse outcomes: Elevated IOP Hypotony Retinal detachment Full thickness macula fold Further ocular surgery Further retinal laser Endophthalmitis Scleritis Uveitis Cystoid macular edema Non‐ocular adverse outcomes: Neck pain Neck stiffness Sleep disturbance Nerve palsies Shortness of breath during period of posturing
Notes	Funding sources: "Dr Casswell was supported by the Royal College of Surgeons in Edinburgh and the Special Trustees of Moorfields Eye Hospital. Dr Heeren was supported by the Lowy Medical Research Institute. Dr Bunce was part funded/supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London. Dr Charteris was supported by the NIHR Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology." Disclosures of interest: "Dr Casswell reported grants from Royal College of Surgeons(Edinburgh) and grants from Special Trustees of Moorfields Eye Hospital during the conduct of the study. Dr Zvobgo reported grants from Royal College of Surgeons Edinburgh and grants from Moorfields Special Trustees during the conduct of the study. Dr Xing reported grants from The Royal College of Surgeons (Edinburgh) and grants from Moorfields Special Trustees during the conduct of the study. Dr Keane reported grants from National Institute for Health Research, personal fees from Roche, personal fees from Novartis, personal fees from Apellis, personal fees from Topcon, personal fees from Bayer, personal fees from Allergan, and personal fees from Heidelberg Engineering outside the submitted work. No other disclosures were reported." Trial registry: NCT02748538 Publication language: English

Open in a new tab

Peiretti 2017.

*Study characteristics*
Methods	Study design: parallel‐group randomized controlled trial, single center Study period: NR Number randomized: 56 in total; 14 for each group (4 groups) Unit of randomization: individual Exclusions after randomization: none Losses to follow‐up: none Number analyzed: 56 in total; 14 for each group (4 groups) Unit of analysis: 1 eye per participant Length of follow‐up: planned: NR; actual: 3 months How were missing data handled?: NA Power calculation: NR
Participants	Country: the Netherlands Setting: academic medical center (university hospital) Characteristics by intervention group: Group 1 (prone without perfluoron): Age, mean ± SD: 63 ± 10.63 Gender, n (%), (male: female): 10 (71.4%) : 4 (28.6%) Race/ethnicity, n(%): NR Lens status, n, (pseudophakic, phakic): 2, 12 Quadrants involved, n, (2, 3, 4)^c: 12, 0, 2 Group 2 (prone with perfluoron): Age, mean ± SD: 65 ± 10.51 Gender, n (%), (male: female): 10 (71.4%) : 4 (28.6%) Race/ethnicity, n(%): NR Lens status, n, (pseudophakic, phakic): 8, 6 Quadrants involved, n, (2, 3, 4): 4, 4, 6 Group 3 (supine without perfluoron): Age, mean ± SD: 63 ± 10.95 Gender, n (%), (male: female): 8 (57.1%) : 6 (42.9%) Race/ethnicity, n(%): NR Lens status, n, (pseudophakic, phakic): 2, 12 Quadrants involved, n, (2, 3, 4): 12, 2, 0 Group 4 (supine with perfluoron): Age, mean ± SD: 61 ± 10.84 Gender, n (%), (male: female): 10 (71.4%) : 4 (28.6%) Race/ethnicity, n(%): NR Lens status, n, (pseudophakic, phakic): 6, 8 Quadrants involved, n, (2, 3, 4): 4, 6, 4 Overall: Age, mean ± SD: 63 ± 10.73 Gender, n (%), (male: female): 38 (67.9%) : 18 (32.1%) Race/ethnicity, n(%): NR Lens status, n, (pseudophakic, phakic): 18, 38 Quadrants involved, n, (2, 3, 4): 38, 12, 12 Inclusion criteria: Patients with primary macular‐off RRD involving 1 or more quadrants Patients underwent a successful 23‐ or 25‐gauge PPV Patients in whom it was possible to obtain a good‐quality preoperative SD‐OCT scan of the macula Fovea‐involving rhegmatogenous Exclusion criteria: Patients with any pre‐existing ocular disease affecting the central vision function Patients with any previous history of retinal surgery or laser therapy
Interventions	Prone without perfluoron Prone with perfluoron Supine without perfluoron Supine with perfluoron General: "Patients were positioned in prone or supine position for 5 hr after surgery depending on the randomization of our series. This position was kept by the patient only 5 hr immediately after surgery to see whether the mechanic pressure of the gas could affect the possible formation of any fold at the posterior pole. After the 5‐hr posturing implied by the randomization, the patient was then requested to keep a further position on the basis of the break position: patients with superior break were kept in sitting position and sleeping at 45 degrees for the following 5 days, patients with temporal or nasal breaks were kept in supine position in the opposite side of the break at day and night for the following 5 days, and the patients with inferior break were kept in supine position laying in the left or right side at the patients discretion for the next 5 days." Surgical details: "23‐ or 25‐gauge PPV. A complete vitrectomy with relief of all vitreous traction on retinal tears was performed using the Alcon Constellation (Alcon Labs, Fort Worth, TX, USA). After performing complete vitreous removal, particular care was paid to maximal drainage of the subretinal fluid during air–fluid exchange through a preexisting retinal break or through a drainage retinotomy if necessary; then, cryopexy or laser was applied to the single or multiple breaks found in the retina. Twenty per cent of sulphur hexafluoride gas (SF6) was used as internal tamponade in all cases."
Outcomes	Primary outcome(s): BCVA evaluation (logMAR), intraocular pressure, the presence of inner retinal folds and/or outer retinal folds such as ellipsoid zone drop‐out in optical coherence tomography images, metamorphopsia Secondary outcome(s): NR Adverse outcome(s): NR
Notes	Funding sources: NR Disclosures of interest: NR Trial registry: NR Publication language: English

Open in a new tab

Schawkat 2019.

*Study characteristics*
Methods	Study design: parallel‐group randomized controlled trial, single center Study period: June 2017 to June 2018 Number randomized: NR Unit of randomization: individual Exclusions after randomization: NR Losses to follow‐up: none Number analyzed: 49 participants (50 eyes) in total; 26 for log‐roll group and 24 for lie‐flat group Unit of analysis: eyes Length of follow‐up: planned: NR; actual: 6 weeks How were missing data handled?: NR Power calculation: sample size: 23 per cohort; power: 90%
Participants	Country: Switzerland Setting: Eye Clinic, Cantonal Hospital Sankt Gallen Age: overall: median age 69; range 43 to 90 years; group: NR Gender, n (%): overall: 36 (72%) male and 14 (28%) female; group: NR Race/ ethnicity, n (%): NR Quadrants of retinal detached, n (%), (1 : 2 : 3: 4): overall: 2 (4%) : 23 (46%) : 17 (34%) : 8 (16%); group: NR PFCL, n (%): overall: 25 (50%) yes and 25 (50%) no; group: NR Tamponade, n (%): overall: 44 (88%) SF6 and 6 (12%) C3F8; group: NR Inclusion criteria: Patients who presented with a macula‐off retinal detachment Exclusion criteria: Patients suffering from other forms of retinal detachment such as exudative or tractional Patients with proliferative vitreoretinopathy, retinal reattachments, and patients who needed a primary oil fill
Interventions	Intervention 1 (log‐roll): "30 minutes face to temporal followed by 30 minutes face down before moving into the end position (final position taken according to location of retinal break). Final position was maintained for about 7 days postoperatively." Intervention 2 (lie‐flat): "lie flat on back for at least 6 hours before moving into the end position (final position taken according to location of retinal break). Final position was maintained for about 7 days postoperatively." Surgical details: "A standard core and peripheral 3‐port PPV (23‐ gauge)was performed in all patients. Surgery was done with general anesthesia. After the vitrectomy and separation of the posterior hyaloids using the suction method, retinal reattachment was achieved directly through fluid–air exchange with subretinal fluid drainage via main peripheral breaks or through perfluorooctane liquid followed by fluid–air exchange. Adjuvant posterior retinotomies were not performed. Retinopexy was done using endolaser or transconjunctival cryocoagulation. 12% Perfluoropropane (C3F8) or 20% sulfur hexafluoride (SF6) gas tamponade was applied after the surgery. Rhegmatogenous retinal detachment characteristics determined the selection of intraocular tamponade. Nevertheless, in principle, an injection of SF6 gas was employed for retinal breaks within the upper 240 retinal degrees, whereas an injection of C3F8 gas was used when inferior retinal tears appeared and for patients with a low‐compliance posture. For phakic eyes, PPV and phacoemulsification were conducted in a single procedure. Postoperatively, patients were asked to perform initial posturing according to randomization before moving into the end position."
Outcomes	Primary outcome(s): type of posture influenced the occurrence of postoperative macular shift postoperation Secondary outcome(s): use of heavy liquid, type of gas used, number of quadrants detached, and age of the patient postoperation Adverse outcome(s): NR
Notes	Funding sources: no funding or sponsorship was received for this study. Disclosures of interest: Josef Guber, Megir Schawkat, Christophe Valmaggia, Corina Lang, Hendrik Scholl, Steven Harsum, and Ivo Guber have nothing to declare. Trial registry: NR Publication language: English

Open in a new tab

^aApproximate Snellen equivalent for 3/60 is 20/400; for 6/36 is 20/125, and for 6/24 is 20/80. ^bNumbers are mutually exclusive. ^cQuadrants of the eye, i.e. supertemporal, superonasal, inferotemporal, inferonasal.

ACIOL: anterior chamber intraocular lens BCVA: best‐corrected visual acuity C2F6: hexafluoroethane C3F8: perfluoropropane ETDRS: Early Treatment Diabetic Retinopathy Study HM: hand motion IOP: intraocular pressure IQR: interquartile range logMAR: logarithm of the Minimum Angle of Resolution NA: not applicable NR: not reported NEI‐VFQ 25: 25‐item version of the 41‐item National Eye Institute Visual Function Questionnaire PCIOL: posterior chamber intraocular lens PFCL: perfluorocarbon liquid PPV: pars plana vitrectomy PVR: proliferative vitreoretinopathy PVR B: inner retinal wrinkling, retinal stiffness, rolled retinal break edges, vitreous stiffness PVR C: full‐thickness retinal folds or subretinal strands RCT: randomized controlled trial RD: retinal detachment RRD: rhegmatogenous retinal detachment SD: standard deviation SD‐OCT: spectral domain optical coherence tomography SF6: sulfur hexafluoride gas

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Chen 2015	Ineligible study design: not a randomized controlled trial
dell'Omo 2013	Ineligible study design: not a randomized controlled trial
Guber 2019	Ineligible intervention: none of the groups performed face‐down positioning
JPRN‐UMIN000023598	Ineligible comparison: all participants in both intervention and control groups performed face‐down positioning
Kim 2021	Ineligible comparator: control group did not perform either no positioning or another form of positioning
Shiragami 2015	Ineligible study design: not a randomized controlled trial

Open in a new tab

Characteristics of studies awaiting classification [ordered by study ID]

JPRN‐UMIN000023272.

Methods	Parallel‐group, randomized controlled trial
Participants	Inclusion criteria: Age > 20 years Participants required keeping a strict face‐down positioning to treat rhegmatogenous retinal detachment Ability to give informed consent Exclusion criteria: Spinal or lumbar disorder Hump back History of previous spinal or lumbar operation Allergy to fomentation Mental disorder Blindness in non‐study eye Under 19 years old Inability to give informed consent
Interventions	Intervention 1: the stretch method group (during postoperative 2 weeks, 15 minutes/set, 2 set/day) Intervention 2: traditional care; the fomentation or thermotherapy at patient's desire
Outcomes	Primary outcome(s): face‐down posture‐related pain (visual analog scale) during postoperative 2 weeks Secondary outcome(s): Short‐Form 8 Geriatric Depression Scale
Notes	Public title: Palliative care on face‐down posture‐related pain after vitrectomy: a randomized control trial

Open in a new tab

Characteristics of ongoing studies [ordered by study ID]

CTRI/2022/10/046837.

Study name	Evaluation of positioning after surgery for retinal detachment
Methods	Parallel‐group, randomized controlled trial
Participants	Inclusion criteria: Patients with age: 20 to 60 years Patients with RRD < 3 months Patients with primary rhegmatogenous retinal detachment Patients with PVR Patients willing to give consent Exclusion criteria: Patients having any other retinal disorder, including diabetic retinopathy, macular hole, glaucoma, etc. Patient having combined RD
Interventions	Intervention 1: prone positioning in the postoperative outcome of PPV with gas tamponade Intervention 2: supine positioning in the postoperative outcome of PPV with gas tamponade
Outcomes	Primary outcome(s): anatomical outcomes (rates of reattachment) of supine versus prone positioning in vitrectomy for RRD at 1 week, 1 month, and 3 months Secondary outcome(s): BCVA, IOP, changes in the lens status in the 2 groups allotted supine and prone positioning at 1 week, 1 month, and 3 months
Starting date	23 November 2022 (date of first enrollment)
Contact information	Dr Vinod Kumar; drvinod_agg@yahoo.com
Notes

Open in a new tab

NCT04035343.

Study name	Effect of type of head positioning on retinal displacement in vitrectomy for retinal detachment (DIAMOND)
Methods	Parallel‐group, randomized controlled trial
Participants	Inclusion criteria: Age ≥ 18 Diagnosis of primary RRD needing PPV with the detachment involving at least 1 of the temporal vascular arcades, which would allow retinal displacement to be detected on fundus autofluorescence photography Exclusion criteria: RRD with an attached macula Proliferative retinopathy grade C or worst Prior vitrectomy for retinal detachment Patients having had pneumatic retinopexy that failed to completely reattach the retina and therefore now needing vitrectomy are allowed into the study History of preoperative binocular diplopia Tamponade with silicone oil instead of gas Inability to maintain postoperation head positioning Mental incapacity
Interventions	Intervention 1: face‐down positioning Intervention 2: supine positioning
Outcomes	Primary outcome(s): the presence of retinal vessels printing on fundus autofluorescence imaging at 3 months Secondary outcome(s): Visual distortion at 3 months measured with M chart Aniseikonia at 3 months measured with aniseikonia testing. The aniseikonia test measures the ratio of image size difference between the 2 eyes. OCT changes at 3 months. Changes seen on OCT OCTA changes at 3 months. Changes seen on OCTA Metamorphopsia at 3 months. Metamorphopsia is the image distortion experienced by the patient. It will be recorded in a data collection sheet as "yes" or "no" according to the patient subjective complain on metamorphopsia. BCVA measured in ETDRS letters at 3 months
Starting date	26 August 2019
Contact information	Rajeev Muni, MD Msc FRCSC; Rajeev.Muni@unityhealth.to
Notes	Estimated study completion date: October 2024

Open in a new tab

BCVA: best‐corrected visual acuity ETDRS: Early Treatment of Diabetic Retinopathy Study IOP: intraocular pressure OCT: optical coherence tomography  OCTA: optical coherence tomography angiography PPV: pars plana vitrectomy PVR: proliferative vitreoretinopathy RD: retinal detachment RRD: rhegmatogenous retinal detachment

Differences between protocol and review

We initially planned to apply the RoB 2 tool only to the critical outcome (proportion of eyes with retinal displacement at six months) and two important outcomes (quality of life assessments and objective distortion scores). However, we decided to apply the RoB 2 tool to one additional important outcome (proportion of eyes with retinal displacement within three months) because one of the included studies only reported this outcome at this time frame.
We did not perform planned sensitivity analysis, as only three trials were included in meta‐analysis.
We planned to record specified ocular adverse events following the Complications of Retinal Detachment Surgery (CORDS) classification; however, the included studies did not use the classification and only reported the proportion of the adverse events. We could not classify the severity of any reported ocular adverse events in the summary of findings table.

Contributions of authors

Substantial contributions to the conception or design of the work (THMF, TWY, NL, DW, SL, TW), the acquisition (THMF, TWY, SL), analysis (THMF, TWY, SL), or interpretation (THMF, TWY, NL, DW, SL, TW) of data for the work.
All authors have drafted the work or revised it critically for important intellectual content.
All authors approved the final version to be published.
All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Sources of support

Internal sources

None, Other

No internal source of support

External sources

National Eye Institute, National Institutes of Health, USA

Cochrane Eyes and Vision US Project, supported by grant UG1EY020522 (PI: Tianjing Li, MD, MHS, PhD)
Public Health Agency, UK

The HSC Research and Development (R&D) Division of the Public Health Agency funds the Cochrane Eyes and Vision editorial base at Queen's University Belfast (ended in April 2023).
Queen’s University Belfast, UK

The work of Gianni Virgili, Co‐ordinating Editor for Cochrane Eyes and Vision, is funded by the Centre for Public Health, Queen’s University of Belfast, Northern Ireland (ended in April 2023).

Declarations of interest

THMF: no relevant interests.

TWY: reports grant UG1 EY020522 from the National Eye Institute, National Institutes of Health, USA; payment to institution; Cochrane methodologist but was not involved in the editorial process for this review.

NL: no relevant interests; Cochrane editor, but was not involved in the editorial process for this review.

DMW: no relevant interests.

SL: reports grant UG1 EY020522 from the National Eye Institute, National Institutes of Health, USA; payment to institution; managing editor of Cochrane Review Group, but was not involved in the editorial process for this review.

TW: reports royalty agreement with AxSys Technologies (sales of the ophthalmology module of the Excellicare electronic patient record system), CRC Press (textbook publication on Vitreoretinal Disorders in Primary Care), and Springer‐Verlag (textbook publications on Vitreoretinal Surgery, Intraocular Surgery and Suprachoroidal Space Interventions); consultant fees from Bausch and Lomb and Daybreak Medical, outside the submitted work; ownership of stocks in Expert Clinics Scotland, Expert Dry Eye, Infinite Medical Ventures and Medsales Academy; patent on prepdose safety syringe.

These authors contributed equally to this work

New

References

References to studies included in this review

Casswell 2020 {published data only}

Casswell E, Yorston D, Lee E, Heeren T, Harris N, Zvobgo T, et al. The posturing after retinal detachment (PostRD) trial. Investigative Ophthalmology & Visual Science 2019;60(9):6421. [Google Scholar]
Casswell EJ, Yorston D, Lee E, Heeren TFC, Harris N, Zvobgo TM, et al. Effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomized clinical trial. JAMA Ophthalmology 2020;138(6):634‐42. [DOI] [PMC free article] [PubMed] [Google Scholar]
Sadiq SN, Mehta A, Song A, Ghareeb A, Al-Zubaidy M, Mostafa I, et al. Infographic: effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomised clinical trial. Eye (London, England) 2022;36(2):350‐1. [DOI] [PMC free article] [PubMed] [Google Scholar]

Peiretti 2017 {published data only}

Peiretti E, Nasini F, Buschini E, Caminiti G, Lesnik OSY, Willig A, et al. Optical coherence tomography evaluation of patients with macula-off retinal detachment after different postoperative posturing: a randomized pilot study. Acta Ophthalmologica 2017;95(5):e379‐84. [DOI] [PubMed] [Google Scholar]

Schawkat 2019 {published data only}

Schawkat M, Valmaggia C, Lang C, Scholl HPN, Harsum S, Guber I, et al. Influence of postoperative posture on macular slippage after macula-off retinal detachment: a randomized controlled trial. Ophthalmology and Therapy 2019;8(4):519‐25. [DOI] [PMC free article] [PubMed] [Google Scholar]

References to studies excluded from this review

Chen 2015 {published data only}

Chen X, Yan Y, Hong L, Zhu L. A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment. Retina 2015;35(5):892-8. [DOI] [PubMed] [Google Scholar]

dell'Omo 2013 {published data only}

dell'Omo R, Semeraro F, Guerra G, Verolino M, Cinelli M, Montagnani S, et al. Short-time prone posturing is well-tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment. BMC Surgery 2013;13 Suppl 2:S55. [DOI] [PMC free article] [PubMed] [Google Scholar]

Guber 2019 {published data only}

Casswell EJ, Charteris DG. Re. Guber et al: how to prevent retinal shift after rhegmatogenous retinal detachment repair: a prospective, randomized study. Ophthalmology Retina 2020;4(7):e5. [DOI] [PubMed] [Google Scholar]
Guber J, Schawkat M, Lang C, Scholl HPN, Valmaggia C. How to prevent retinal shift after rhegmatogenous retinal detachment repair: a prospective, randomized study. Ophthalmology Retina 2019;3(5):417‐21. [DOI] [PubMed] [Google Scholar]
Muni RH, Figueiredo N, Hillier RJ. Re: Guber et al: how to prevent retinal shift after rhegmatogenous retinal detachment repair. Ophthalmology Retina 2020;4(7):e5-6. [DOI] [PubMed] [Google Scholar]

JPRN‐UMIN000023598 {published and unpublished data}

JPRN-UMIN000023598. Impact of postoperative positioning on the outcome of pars plana vitrectomy with gas tamponade for primary rhegmatogenous retinal detachment: Comparison between supine and prone positioning. center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000027168 (first received 1 September 2016).

Kim 2021 {published data only}

Kim AY, Hwang S, Kang SW, Shin SY, Chang WH, Kim SJ, et al. A structured exercise to relieve musculoskeletal pain caused by face-down posture after retinal surgery: a randomized controlled trial. Scientific Reports 2021;11(1):22074. [DOI] [PMC free article] [PubMed] [Google Scholar]

Shiragami 2015 {published data only}

Shiragami C, Fukuda K, Yamaji H, Morita M, Shiraga F. A method to decrease the frequency of unintentional slippage after vitrectomy for rhegmatogenous retinal detachment. Retina 2015;35(4):758-63. [DOI] [PubMed] [Google Scholar]

References to studies awaiting assessment

JPRN‐UMIN000023272 {unpublished data only}

JPRN-UMIN000023272. Palliative care on face-down posture-related pain after vitrectomy: a randomized control trial. center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000026810 (first received 21 July 2016).

References to ongoing studies

CTRI/2022/10/046837 {published data only}

CTRI/2022/10/046837. Evaluation of positioning after surgery for retinal detachment. trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2022/10/046837 (first received 27 October 2022).

NCT04035343 {published data only}

NCT04035343. Effect of type of head positioning on retinal displacement in vitrectomy for retinal detachment. clinicaltrials.gov/show/NCT04035343 (first received 29 July 2019).

Additional references

Algvere 1999

Algvere PV, Jahnberg P, Textorius O. The Swedish Retinal Detachment Register. I. A database for epidemiological and clinical studies. Graefe’s Archive for Clinical and Experimental Ophthalmology 1999;237(2):137-44. [DOI] [PubMed] [Google Scholar]

Ashrafzadeh 1973

Ashrafzadeh MT, Schepens CL, Elzeneiny II, Moura R, Morse P, Kraushar MF. Aphakic and phakic retinal detachments. I. Preoperative findings. Archives of Ophthalmology 1973;89(6):476-83. [DOI] [PubMed] [Google Scholar]

Benson 1978

Benson WE, Morse PH. The prognosis of retinal detachment due to lattice degeneration. Annals of Ophthalmology 1978;10(9):1197-200. [PubMed] [Google Scholar]

Bhaskaran 2014

Bhaskaran K, Smeeth L. What is the difference between missing completely at random and missing at random? International Journal of Epidemiology 2014;43(4):1336-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

Brosh 2020

Brosh K, Francisconi CM, Qian J, Sabatino F, Juncal VR, Hillier RJ, et al. Retinal displacement following pneumatic retinopexy vs pars plana vitrectomy for rhegmatogenous retinal detachment. JAMA Ophthalmology 2020;138(6):652-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

Brouzas 2011

Brouzas D, Gourgounis N, Davou S, Loukianou E, Georgalas I, Koursandrea C. Ulnar neuropathy as a complication of retinal detachment surgery and face-down positioning. Case Reports in Ophthalmology 2011;2(2):243-5. [DOI] [PMC free article] [PubMed] [Google Scholar]

Casswell 2020

Casswell EJ, Yortston D, Lee E, Heeran TF, Harris N, Zvobgo TM, et al. Effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomized clinical trial. JAMA Ophthalmology 2020;138(6):634-42. [DOI] [PMC free article] [PubMed] [Google Scholar]

Chen 2015

Chen X, Yan Y, Hong L, Zhu L. A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment. Retina 2015;35(5):892-8. [DOI] [PubMed] [Google Scholar]

Ciulla 1996

Ciulla TA, Frederick AR, Kelly C Jr, Amrein R. Postvitrectomy positioning complicated by ulnar nerve palsy. American Journal of Ophthalmology 1996;122(5):739-40. [DOI] [PubMed] [Google Scholar]

Clayman 1981

Clayman HM, Jaffe NS, Light DS, Jaffe MS, Cassady JC. Intraocular lenses, axial length, and retinal detachment. American Journal of Ophthalmology 1981;92(6):778-80. [DOI] [PubMed] [Google Scholar]

Codenotti 2013

Codenotti M, Fogliato G, Luliano L, Querques G, Maestranzi G, Prati M, et al. Influence of intraocular tamponade on unintentional retinal displacement after vitrectomy for rhegmatogenous retinal detachment. Retina 2013;33(2):349-55. [DOI] [PubMed] [Google Scholar]

Covidence [Computer program]

Covidence. Version accessed 4 November 2022. Melbourne, Australia: Veritas Health Innovation. Available at covidence.org.

Cox 1969

Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Archives of Ophthalmology 1969;76(5):678-85. [DOI] [PubMed] [Google Scholar]

Davis 1999

Davis JL. Management of CMV retinal detachments in the new era of antiretroviral therapy. Ocular Immunology and Inflammation 1999;7(3-4):205-13. [DOI] [PubMed] [Google Scholar]

Deeks 2022

Deeks JJ, Higgins JP, Altman DG. Chapter 10: Analysing data and undertaking meta-analyses. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

dell’Omo 2013

dell’Omo R, Semeraro F, Guerra G, Verolino M, Cinelli M, Montagnani S, et al. Short-time prone posturing is well tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment. BMC Surgery 2013;13(2):S55. [DOI] [PMC free article] [PubMed] [Google Scholar]

Doft 2000

Doft BM, Kelsey SF, Wisniewski SR. Retinal detachment in the endophthalmitis vitrectomy study. Archives of Ophthalmology 2000;118(12):1661-5. [DOI] [PubMed] [Google Scholar]

Gariano 2004

Gariano RF, Kim CH. Evaluation and management of suspected retinal detachment. American Family Physician 2004;69(7):1691-8. [PubMed] [Google Scholar]

Ghazi 2002

Ghazi NG, Green WR. Pathology and pathogenesis of retinal detachment. Eye 2002;16(4):411-21. [DOI] [PubMed] [Google Scholar]

Glanville 2006

Glanville JM, Lefebvre C, Miles JN, Camosso-Stefinovic J. How to identify randomized controlled trials in MEDLINE: ten years on. Journal of the Medical Library Association 2006;94(3):354. [PMC free article] [PubMed] [Google Scholar]

Goezinne 2009

Goezinne F, Heij EC, Berendschot TT, Tahzib NG, Koetsier LS, Hoevenaars JG, et al. Patient ignorance is the main reason for treatment delay in primary rhegmatogenous retinal detachment in the Netherlands. Eye 2009;23(6):1393-9. [DOI] [PubMed] [Google Scholar]

Grey 1989

Grey RH, Burns-Cox CJ, Hughes A. Blind and partial sight registration in Avon. British Journal of Ophthalmology 1989;73(2):88-94. [DOI] [PMC free article] [PubMed] [Google Scholar]

Harker 1996

Harker R, McLauchlan R, MacDonald H, Waterman C, Waterman H. Endless nights: Patients’ experiences of posturing face-down following vitreoretinal surgery. Journal of Ophthalmic Nursing 1996;6(2):11-5. [Google Scholar]

Hernán 2017

Hernán MA, Robins JM. Per-protocol analyses of pragmatic trials. New England Journal of Medicine 2017;377(14):1391-8. [DOI] [PubMed] [Google Scholar]

Higgins 2022

Higgins JP, Savovic J, Page MJ, Elbers RG, Sterne JA. Chapter 8: Assessing risk of bias in a randomized trial. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

Jackson 2014

Jackson TL, Donachie PH, Sallam A, Sparrow JM, Johnston RL. United Kingdom National Ophthalmology Database study of vitreoretinal surgery: report 3, retinal detachment. Ophthalmology 2014;121(3):643-8. [DOI] [PubMed] [Google Scholar]

Kusaka 1998

Kusaka S, Toshino A, Ohashi Y, Sakaue E. Long-term visual recovery after scleral buckling for macular-off retinal detachments. Japanese Journal of Ophthalmology 1998;42(3):218-22. [DOI] [PubMed] [Google Scholar]

Lee 2013

Lee E, Williamson TH, Hysi P, Shunmugam M, Dogramaci M, Wong R, et al. Macular displacement following rhegmatogenous retinal detachment repair. British Journal of Ophthalmology 2013;97(10):1297-302. [DOI] [PubMed] [Google Scholar]

Lefebvre 2008

Lefebvre C, Eisinga A, McDonald S, Paul N. Enhancing access to reports of randomized trials published world-wide - the contribution of EMBASE records to the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. Emerging Themes in Epidemiology 2008;30(5):13. [DOI] [PMC free article] [PubMed] [Google Scholar]

Li 2003

Li X, Beijing Rhegmatogenous Retinal Detachment Study Group. Incidence and epidemiological characteristics of rhegmatogenous retinal detachment in Beijing, China. Ophthalmology 2003;110(12):2413-7. [DOI] [PubMed] [Google Scholar]

Li 2022

Li T, Higgins JP, Deeks JJ. Chapter 5: Collecting data. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

Limeira‐Soares 2007

Limeira-Soares PH, Lira RP, Arieta CE, Kara-Jose N. Demand incidence of retinal detachment in Brazil. Eye 2007;21(3):348-52. [DOI] [PubMed] [Google Scholar]

Lina 2016

Lina G, Xuemin Q, Qinmei W, Lijun S. Vision-related quality of life, metamorphopsia, and stereopsis after successful surgery for rhegmatogenous retinal detachment. Eye 2016;30(1):40-5. [DOI] [PMC free article] [PubMed] [Google Scholar]

Lois 2003

Lois N, Wong D. Pseudophakic retinal detachment. Survey of Ophthalmology 2003;48(5):467-87. [DOI] [PubMed] [Google Scholar]

Mason 2022

Mason RH, Minaker SA, Marafon SB, Figueiredo N, Hillier RJ, Muni RH. Retinal displacement following rhegmatogenous retinal detachment: a systematic review and meta-analysis. Survey of Ophthalmology 2022;67(4):950-64. [DOI] [PubMed] [Google Scholar]

McGowan 2016

McGowan G, Yorston D, Strang NC, Manahilov V. D-CHART: a novel method of measuring metamorphopsia in epiretinal membrane and macular hole. Retina 2016;36(4):703-8. [DOI] [PubMed] [Google Scholar]

McKenzie 2022a

McKenzie JE, Brennan SE, Ryan RE, Thomson HJ, Johnston RV. Chapter 9: Summarizing study characteristics and preparing for synthesis. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

McKenzie 2022b

McKenzie JE, Brennan SE. Chapter 12: Synthesizing and presenting findings using other methods. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

Mitry 2010

Mitry D, Charteris DG, Yorston D, Siddiqui MA, Campbell H, Murphy AL, et al. The epidemiology and socioeconomic associations of retinal detachment in Scotland: a two-year prospective population-based study. Investigative Ophthalmology & Visual Science 2010;51(10):4963-8. [DOI] [PubMed] [Google Scholar]

Mitry 2011

Mitry D, Singh J, Yorston D, Siddiqui MA, Wright A, Fleck BW, et al. The predisposing pathology and clinical characteristics in the Scottish retinal detachment study. Ophthalmology 2011;118(7):1429-34. [DOI] [PubMed] [Google Scholar]

Moher 2010

Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Journal of Clinical Epidemiology 2010;63(8):e1-37. [DOI] [PubMed] [Google Scholar]

Mowatt 2003

Mowatt L, Shun-Shin G, Price N. Ethnic differences in the demand incidence of retinal detachments in two districts in the West Midlands. Eye 2003;17(1):63-70. [DOI] [PubMed] [Google Scholar]

Nagpal 2004

Nagpal M, Nagpal K, Rishi P, Nagpal PN. Juvenile rhegmatogenous retinal detachment. Indian Journal of Ophthalmology 2004;52(4):297-302. [PubMed] [Google Scholar]

Ninn‐Pedersen 1996

Ninn-Pedersen K, Bauer B. Cataract patients in a defined Swedish population, 1986 to 1990. V. Postoperative retinal detachments. Archives of Ophthalmology 1996;114(4):382-6. [DOI] [PubMed] [Google Scholar]

Okuda 2018

Okuda T, Higashide T, Sugiyama K. Metamorphopsia and outer retinal morphologic changes after successful vitrectomy surgery for macula-off rhegmatogenous retinal detachment. Retina 2018;38(1):148-154. [DOI] [PubMed] [Google Scholar]

Page 2022

Page MJ, Higgins JP, Sterne JA. Chapter 13: Assessing risk of bias due to missing results in a synthesis. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

Pandya 2012

Pandya VB, Hophd IV, Hunyor AP. Does unintentional macular translocation after retinal detachment repair influence visual outcome? Clinical & Experimental Ophthalmology 2012;40(1):88-92. [DOI] [PubMed] [Google Scholar]

Potic 2021

Potic J, Bergin C, Giacuzzo C, Konstantinidis L, Daruich A, Wolfensberger TJ. Application of modified NEI VFQ-25 after retinal detachment to vision-related quality of life. Retina 2021;41(3):653-60. [DOI] [PMC free article] [PubMed] [Google Scholar]

Quintyn 2006

Quintyn JC, Benouaich X, Pagot-Mathis V, Mathis A. Retinal detachment, a condition little known to patients. Retina 2006;26(9):1077-8. [DOI] [PubMed] [Google Scholar]

RevMan 2023 [Computer program]

Review Manager (RevMan). Version 5.2.0. The Cochrane Collaboration, 2023. Available at revman.cochrane.org.

Schawkat 2019

Schawkat M, Valmaggia C, Lang C, Scholl HP, Harsum S, Guber I, et al. Influence of postoperative posture on macular slippage after macula-off retinal detachment: a randomized controlled trial. Ophthalmology and Therapy 2019;8(4):519-25. [DOI] [PMC free article] [PubMed] [Google Scholar]

Schünemann 2013

Schünemann H, Brożek J, Guyatt G, Oxman A, editor(s). Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). Available from guidelinedevelopment.org/handbook.

Schünemann 2022

Schünemann HJ, Higgins JP, Vist GE, Glasziou P, Akl EA, Skoetz N, et al. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

Seno 2015

Seno Y, Shimada Y, Mizuguchi T, Tanikawa A, Horiguchi M. Compliance with the face-down positioning after vitrectomy and gas tamponade for rhegmatogenous retinal detachments. Retina 2015;35(7):1436-40. [DOI] [PubMed] [Google Scholar]

Shiragami 2010

Shiragami C, Shiraga F, Yamaji H, Fukuda K, Takagishi M, Morita M, et al. Unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment. Ophthalmology 2010;117(1):86-92. [DOI] [PubMed] [Google Scholar]

Shiragami 2015

Shiragami C, Fukuda K, Yamaji H, Morita M, Shiraga F. A method to decrease the frequency of unintentional slippage after vitrectomy for rhegmatogenous retinal detachment. Retina 2015;35(4):758-63. [DOI] [PubMed] [Google Scholar]

Siddiqui 2010

Siddiqui MA, Abdelkader E, Hammam T, Murdoch JR, Lois N. Socioeconomic status and delayed presentation in rhegmatogenous retinal detachment. Acta Ophthalmologica 2010;88(8):e353-353. [DOI] [PubMed] [Google Scholar]

Sodhi 2008

Sodhi A, Leung LS, Do DV, Gower EW, Schein OD, Handa JT. Recent trends in the management of rhegmatogenous retinal detachment. Survey of Ophthalmology 2008;53(1):50-67. [DOI] [PubMed] [Google Scholar]

Sterne 2019

Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. [DOI] [PubMed] [Google Scholar]

Treister 1996

Treister G, Wygnanski T. Pressure sore in a patient who underwent repair of a retinal tear with gas injection. Graefe’s Archive for Clinical and Experimental Ophthalmology 1996;234(10):657-8. [DOI] [PubMed] [Google Scholar]

Xu 2021

Xu ZY, Azuara-Blanco A, Kadonosono K, Murray T, Natarajan S, Sii S, et al. New classification for the reporting of complications in retinal detachment surgical trials. JAMA Ophthalmology 2021;139(8):857-64. [DOI] [PMC free article] [PubMed] [Google Scholar]

Xu 2023

Xu J, Davoudi S, Yoon J, Chen X, Siegel NH, Subramanian ML, et al. Effect of race and ethnicity on surgical outcomes for rhegmatogenous retinal detachments. Canadian Journal of Ophthalmology 2023;S0008-4182(22):00374-X. [DOI] [PubMed] [Google Scholar]

References to other published versions of this review

Fung 2022

Fung T, Lois N, Wright DM, Liu S-H, Williamson T. Face‐down positioning or posturing after vitrectomy for macula‐involving rhegmatogenous retinal detachments. Cochrane Database of Systematic Reviews 2022, Issue 12. Art. No: CD015514. [DOI: 10.1002/14651858.CD015514] [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0001] Casswell E, Yorston D, Lee E, Heeren T, Harris N, Zvobgo T, et al. The posturing after retinal detachment (PostRD) trial. Investigative Ophthalmology & Visual Science 2019;60(9):6421. [Google Scholar]

[CD015514-bib-0002] Casswell EJ, Yorston D, Lee E, Heeren TFC, Harris N, Zvobgo TM, et al. Effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomized clinical trial. JAMA Ophthalmology 2020;138(6):634‐42. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0003] Sadiq SN, Mehta A, Song A, Ghareeb A, Al-Zubaidy M, Mostafa I, et al. Infographic: effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomised clinical trial. Eye (London, England) 2022;36(2):350‐1. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0004] Peiretti E, Nasini F, Buschini E, Caminiti G, Lesnik OSY, Willig A, et al. Optical coherence tomography evaluation of patients with macula-off retinal detachment after different postoperative posturing: a randomized pilot study. Acta Ophthalmologica 2017;95(5):e379‐84. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0005] Schawkat M, Valmaggia C, Lang C, Scholl HPN, Harsum S, Guber I, et al. Influence of postoperative posture on macular slippage after macula-off retinal detachment: a randomized controlled trial. Ophthalmology and Therapy 2019;8(4):519‐25. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0006] Chen X, Yan Y, Hong L, Zhu L. A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment. Retina 2015;35(5):892-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0007] dell'Omo R, Semeraro F, Guerra G, Verolino M, Cinelli M, Montagnani S, et al. Short-time prone posturing is well-tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment. BMC Surgery 2013;13 Suppl 2:S55. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0008] Casswell EJ, Charteris DG. Re. Guber et al: how to prevent retinal shift after rhegmatogenous retinal detachment repair: a prospective, randomized study. Ophthalmology Retina 2020;4(7):e5. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0009] Guber J, Schawkat M, Lang C, Scholl HPN, Valmaggia C. How to prevent retinal shift after rhegmatogenous retinal detachment repair: a prospective, randomized study. Ophthalmology Retina 2019;3(5):417‐21. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0010] Muni RH, Figueiredo N, Hillier RJ. Re: Guber et al: how to prevent retinal shift after rhegmatogenous retinal detachment repair. Ophthalmology Retina 2020;4(7):e5-6. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0011] JPRN-UMIN000023598. Impact of postoperative positioning on the outcome of pars plana vitrectomy with gas tamponade for primary rhegmatogenous retinal detachment: Comparison between supine and prone positioning. center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000027168 (first received 1 September 2016).

[CD015514-bib-0012] Kim AY, Hwang S, Kang SW, Shin SY, Chang WH, Kim SJ, et al. A structured exercise to relieve musculoskeletal pain caused by face-down posture after retinal surgery: a randomized controlled trial. Scientific Reports 2021;11(1):22074. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0013] Shiragami C, Fukuda K, Yamaji H, Morita M, Shiraga F. A method to decrease the frequency of unintentional slippage after vitrectomy for rhegmatogenous retinal detachment. Retina 2015;35(4):758-63. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0014] JPRN-UMIN000023272. Palliative care on face-down posture-related pain after vitrectomy: a randomized control trial. center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000026810 (first received 21 July 2016).

[CD015514-bib-0015] CTRI/2022/10/046837. Evaluation of positioning after surgery for retinal detachment. trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2022/10/046837 (first received 27 October 2022).

[CD015514-bib-0016] NCT04035343. Effect of type of head positioning on retinal displacement in vitrectomy for retinal detachment. clinicaltrials.gov/show/NCT04035343 (first received 29 July 2019).

[CD015514-bib-0017] Algvere PV, Jahnberg P, Textorius O. The Swedish Retinal Detachment Register. I. A database for epidemiological and clinical studies. Graefe’s Archive for Clinical and Experimental Ophthalmology 1999;237(2):137-44. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0018] Ashrafzadeh MT, Schepens CL, Elzeneiny II, Moura R, Morse P, Kraushar MF. Aphakic and phakic retinal detachments. I. Preoperative findings. Archives of Ophthalmology 1973;89(6):476-83. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0019] Benson WE, Morse PH. The prognosis of retinal detachment due to lattice degeneration. Annals of Ophthalmology 1978;10(9):1197-200. [PubMed] [Google Scholar]

[CD015514-bib-0020] Bhaskaran K, Smeeth L. What is the difference between missing completely at random and missing at random? International Journal of Epidemiology 2014;43(4):1336-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0021] Brosh K, Francisconi CM, Qian J, Sabatino F, Juncal VR, Hillier RJ, et al. Retinal displacement following pneumatic retinopexy vs pars plana vitrectomy for rhegmatogenous retinal detachment. JAMA Ophthalmology 2020;138(6):652-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0022] Brouzas D, Gourgounis N, Davou S, Loukianou E, Georgalas I, Koursandrea C. Ulnar neuropathy as a complication of retinal detachment surgery and face-down positioning. Case Reports in Ophthalmology 2011;2(2):243-5. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0023] Casswell EJ, Yortston D, Lee E, Heeran TF, Harris N, Zvobgo TM, et al. Effect of face-down positioning vs support-the-break positioning after macula-involving retinal detachment repair: the PostRD randomized clinical trial. JAMA Ophthalmology 2020;138(6):634-42. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0024] Chen X, Yan Y, Hong L, Zhu L. A comparison of strict face-down positioning with adjustable positioning after pars plana vitrectomy and gas tamponade for rhegmatogenous retinal detachment. Retina 2015;35(5):892-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0025] Ciulla TA, Frederick AR, Kelly C Jr, Amrein R. Postvitrectomy positioning complicated by ulnar nerve palsy. American Journal of Ophthalmology 1996;122(5):739-40. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0026] Clayman HM, Jaffe NS, Light DS, Jaffe MS, Cassady JC. Intraocular lenses, axial length, and retinal detachment. American Journal of Ophthalmology 1981;92(6):778-80. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0027] Codenotti M, Fogliato G, Luliano L, Querques G, Maestranzi G, Prati M, et al. Influence of intraocular tamponade on unintentional retinal displacement after vitrectomy for rhegmatogenous retinal detachment. Retina 2013;33(2):349-55. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0028] Covidence. Version accessed 4 November 2022. Melbourne, Australia: Veritas Health Innovation. Available at covidence.org.

[CD015514-bib-0029] Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Archives of Ophthalmology 1969;76(5):678-85. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0030] Davis JL. Management of CMV retinal detachments in the new era of antiretroviral therapy. Ocular Immunology and Inflammation 1999;7(3-4):205-13. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0031] Deeks JJ, Higgins JP, Altman DG. Chapter 10: Analysing data and undertaking meta-analyses. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0032] dell’Omo R, Semeraro F, Guerra G, Verolino M, Cinelli M, Montagnani S, et al. Short-time prone posturing is well tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment. BMC Surgery 2013;13(2):S55. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0033] Doft BM, Kelsey SF, Wisniewski SR. Retinal detachment in the endophthalmitis vitrectomy study. Archives of Ophthalmology 2000;118(12):1661-5. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0034] Gariano RF, Kim CH. Evaluation and management of suspected retinal detachment. American Family Physician 2004;69(7):1691-8. [PubMed] [Google Scholar]

[CD015514-bib-0035] Ghazi NG, Green WR. Pathology and pathogenesis of retinal detachment. Eye 2002;16(4):411-21. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0036] Glanville JM, Lefebvre C, Miles JN, Camosso-Stefinovic J. How to identify randomized controlled trials in MEDLINE: ten years on. Journal of the Medical Library Association 2006;94(3):354. [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0037] Goezinne F, Heij EC, Berendschot TT, Tahzib NG, Koetsier LS, Hoevenaars JG, et al. Patient ignorance is the main reason for treatment delay in primary rhegmatogenous retinal detachment in the Netherlands. Eye 2009;23(6):1393-9. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0038] Grey RH, Burns-Cox CJ, Hughes A. Blind and partial sight registration in Avon. British Journal of Ophthalmology 1989;73(2):88-94. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0039] Harker R, McLauchlan R, MacDonald H, Waterman C, Waterman H. Endless nights: Patients’ experiences of posturing face-down following vitreoretinal surgery. Journal of Ophthalmic Nursing 1996;6(2):11-5. [Google Scholar]

[CD015514-bib-0040] Hernán MA, Robins JM. Per-protocol analyses of pragmatic trials. New England Journal of Medicine 2017;377(14):1391-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0041] Higgins JP, Savovic J, Page MJ, Elbers RG, Sterne JA. Chapter 8: Assessing risk of bias in a randomized trial. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0042] Jackson TL, Donachie PH, Sallam A, Sparrow JM, Johnston RL. United Kingdom National Ophthalmology Database study of vitreoretinal surgery: report 3, retinal detachment. Ophthalmology 2014;121(3):643-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0043] Kusaka S, Toshino A, Ohashi Y, Sakaue E. Long-term visual recovery after scleral buckling for macular-off retinal detachments. Japanese Journal of Ophthalmology 1998;42(3):218-22. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0044] Lee E, Williamson TH, Hysi P, Shunmugam M, Dogramaci M, Wong R, et al. Macular displacement following rhegmatogenous retinal detachment repair. British Journal of Ophthalmology 2013;97(10):1297-302. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0045] Lefebvre C, Eisinga A, McDonald S, Paul N. Enhancing access to reports of randomized trials published world-wide - the contribution of EMBASE records to the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. Emerging Themes in Epidemiology 2008;30(5):13. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0046] Li X, Beijing Rhegmatogenous Retinal Detachment Study Group. Incidence and epidemiological characteristics of rhegmatogenous retinal detachment in Beijing, China. Ophthalmology 2003;110(12):2413-7. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0047] Li T, Higgins JP, Deeks JJ. Chapter 5: Collecting data. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0048] Limeira-Soares PH, Lira RP, Arieta CE, Kara-Jose N. Demand incidence of retinal detachment in Brazil. Eye 2007;21(3):348-52. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0049] Lina G, Xuemin Q, Qinmei W, Lijun S. Vision-related quality of life, metamorphopsia, and stereopsis after successful surgery for rhegmatogenous retinal detachment. Eye 2016;30(1):40-5. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0050] Lois N, Wong D. Pseudophakic retinal detachment. Survey of Ophthalmology 2003;48(5):467-87. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0051] Mason RH, Minaker SA, Marafon SB, Figueiredo N, Hillier RJ, Muni RH. Retinal displacement following rhegmatogenous retinal detachment: a systematic review and meta-analysis. Survey of Ophthalmology 2022;67(4):950-64. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0052] McGowan G, Yorston D, Strang NC, Manahilov V. D-CHART: a novel method of measuring metamorphopsia in epiretinal membrane and macular hole. Retina 2016;36(4):703-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0053] McKenzie JE, Brennan SE, Ryan RE, Thomson HJ, Johnston RV. Chapter 9: Summarizing study characteristics and preparing for synthesis. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0054] McKenzie JE, Brennan SE. Chapter 12: Synthesizing and presenting findings using other methods. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0055] Mitry D, Charteris DG, Yorston D, Siddiqui MA, Campbell H, Murphy AL, et al. The epidemiology and socioeconomic associations of retinal detachment in Scotland: a two-year prospective population-based study. Investigative Ophthalmology & Visual Science 2010;51(10):4963-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0056] Mitry D, Singh J, Yorston D, Siddiqui MA, Wright A, Fleck BW, et al. The predisposing pathology and clinical characteristics in the Scottish retinal detachment study. Ophthalmology 2011;118(7):1429-34. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0057] Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Journal of Clinical Epidemiology 2010;63(8):e1-37. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0058] Mowatt L, Shun-Shin G, Price N. Ethnic differences in the demand incidence of retinal detachments in two districts in the West Midlands. Eye 2003;17(1):63-70. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0059] Nagpal M, Nagpal K, Rishi P, Nagpal PN. Juvenile rhegmatogenous retinal detachment. Indian Journal of Ophthalmology 2004;52(4):297-302. [PubMed] [Google Scholar]

[CD015514-bib-0060] Ninn-Pedersen K, Bauer B. Cataract patients in a defined Swedish population, 1986 to 1990. V. Postoperative retinal detachments. Archives of Ophthalmology 1996;114(4):382-6. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0061] Okuda T, Higashide T, Sugiyama K. Metamorphopsia and outer retinal morphologic changes after successful vitrectomy surgery for macula-off rhegmatogenous retinal detachment. Retina 2018;38(1):148-154. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0062] Page MJ, Higgins JP, Sterne JA. Chapter 13: Assessing risk of bias due to missing results in a synthesis. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0063] Pandya VB, Hophd IV, Hunyor AP. Does unintentional macular translocation after retinal detachment repair influence visual outcome? Clinical & Experimental Ophthalmology 2012;40(1):88-92. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0064] Potic J, Bergin C, Giacuzzo C, Konstantinidis L, Daruich A, Wolfensberger TJ. Application of modified NEI VFQ-25 after retinal detachment to vision-related quality of life. Retina 2021;41(3):653-60. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0065] Quintyn JC, Benouaich X, Pagot-Mathis V, Mathis A. Retinal detachment, a condition little known to patients. Retina 2006;26(9):1077-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0066] Review Manager (RevMan). Version 5.2.0. The Cochrane Collaboration, 2023. Available at revman.cochrane.org.

[CD015514-bib-0067] Schawkat M, Valmaggia C, Lang C, Scholl HP, Harsum S, Guber I, et al. Influence of postoperative posture on macular slippage after macula-off retinal detachment: a randomized controlled trial. Ophthalmology and Therapy 2019;8(4):519-25. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0068] Schünemann H, Brożek J, Guyatt G, Oxman A, editor(s). Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). Available from guidelinedevelopment.org/handbook.

[CD015514-bib-0069] Schünemann HJ, Higgins JP, Vist GE, Glasziou P, Akl EA, Skoetz N, et al. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from training.cochrane.org/handbook/archive/v6.3.

[CD015514-bib-0070] Seno Y, Shimada Y, Mizuguchi T, Tanikawa A, Horiguchi M. Compliance with the face-down positioning after vitrectomy and gas tamponade for rhegmatogenous retinal detachments. Retina 2015;35(7):1436-40. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0071] Shiragami C, Shiraga F, Yamaji H, Fukuda K, Takagishi M, Morita M, et al. Unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment. Ophthalmology 2010;117(1):86-92. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0072] Shiragami C, Fukuda K, Yamaji H, Morita M, Shiraga F. A method to decrease the frequency of unintentional slippage after vitrectomy for rhegmatogenous retinal detachment. Retina 2015;35(4):758-63. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0073] Siddiqui MA, Abdelkader E, Hammam T, Murdoch JR, Lois N. Socioeconomic status and delayed presentation in rhegmatogenous retinal detachment. Acta Ophthalmologica 2010;88(8):e353-353. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0074] Sodhi A, Leung LS, Do DV, Gower EW, Schein OD, Handa JT. Recent trends in the management of rhegmatogenous retinal detachment. Survey of Ophthalmology 2008;53(1):50-67. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0075] Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0076] Treister G, Wygnanski T. Pressure sore in a patient who underwent repair of a retinal tear with gas injection. Graefe’s Archive for Clinical and Experimental Ophthalmology 1996;234(10):657-8. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0077] Xu ZY, Azuara-Blanco A, Kadonosono K, Murray T, Natarajan S, Sii S, et al. New classification for the reporting of complications in retinal detachment surgical trials. JAMA Ophthalmology 2021;139(8):857-64. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CD015514-bib-0078] Xu J, Davoudi S, Yoon J, Chen X, Siegel NH, Subramanian ML, et al. Effect of race and ethnicity on surgical outcomes for rhegmatogenous retinal detachments. Canadian Journal of Ophthalmology 2023;S0008-4182(22):00374-X. [DOI] [PubMed] [Google Scholar]

[CD015514-bib-0079] Fung T, Lois N, Wright DM, Liu S-H, Williamson T. Face‐down positioning or posturing after vitrectomy for macula‐involving rhegmatogenous retinal detachments. Cochrane Database of Systematic Reviews 2022, Issue 12. Art. No: CD015514. [DOI: 10.1002/14651858.CD015514] [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Face‐down positioning or posturing after pars plana vitrectomy for macula‐involving rhegmatogenous retinal detachments

Timothy HM Fung

Tsz Wing Yim

Noemi Lois

David M Wright

Su-Hsun Liu

Tom Williamson

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings 1. Face‐down positioning compared with other positioning.

Background

Description of the condition

1.

Description of the intervention

How the intervention might work

2.

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Critical outcome

Important outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

3.

Included studies

Types of studies

Types of participants

Types of interventions

Types of outcomes

Critical outcome

Proportion of eyes with retinal displacement at six months or later

Important outcomes

Proportion of eyes with retinal displacement within three months

Mean change in logMAR or Snellen visual acuity

Mean objective distortion score

Quality of life assessments

Frequency of intervention‐related ocular adverse events

Frequency of intervention‐related non‐ocular adverse events

Excluded studies

Risk of bias in included studies

Domain 1: Bias arising from the randomization process

Domain 2: Bias due to deviations from intended interventions

Domain 3: Bias due to missing outcome data

Domain 4: Bias in measurement of the outcome

Risk of bias for analysis 1.1 Proportion of eyes with retinal displacement at 6 months.

Risk of bias for analysis 1.2 Proportion of eyes with retinal displacement within 3 months.

Risk of bias for analysis 1.3 Mean change in visual acuity (logMAR) at 3 months.

Risk of bias for analysis 1.4 Mean change in visual acuity (ETDRS).

Risk of bias for analysis 1.7 Adverse events ‐ outer retinal folds.