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Face-down positioning or posturing after pars plana vitrectomy for

macula-involving rhegmatogenous retinal detachments (Review)

Fung THM, Yim TW, Lois N, Wright DM, Liu SH, Williamson T

Fung THM, Yim TW, Lois N, Wright DM, Liu S-H, Williamson T.
Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments.
Cochrane Database of Systematic Reviews 2024, Issue 3. Art. No.: CD015514.
DOI: 10.1002/14651858.CD015514.pub2.

www.cochranelibrary.com

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal
detachments (Review)
Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 6
Figure 1.................................................................................................................................................................................................. 7
Figure 2.................................................................................................................................................................................................. 8
OBJECTIVES.................................................................................................................................................................................................. 8
METHODS..................................................................................................................................................................................................... 8
RESULTS........................................................................................................................................................................................................ 11
Figure 3.................................................................................................................................................................................................. 12
Figure 4.................................................................................................................................................................................................. 15
Figure 5.................................................................................................................................................................................................. 15
Figure 6.................................................................................................................................................................................................. 16
Figure 7.................................................................................................................................................................................................. 17
DISCUSSION.................................................................................................................................................................................................. 17
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 18
ACKNOWLEDGEMENTS................................................................................................................................................................................ 18
REFERENCES................................................................................................................................................................................................ 19
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 23
RISK OF BIAS................................................................................................................................................................................................ 32
DATA AND ANALYSES.................................................................................................................................................................................... 35
Analysis 1.1. Comparison 1: Face-down positioning versus other positioning, Outcome 1: Proportion of eyes with retinal 37
displacement at 6 months...................................................................................................................................................................
Analysis 1.2. Comparison 1: Face-down positioning versus other positioning, Outcome 2: Proportion of eyes with retinal 37
displacement within 3 months............................................................................................................................................................
Analysis 1.3. Comparison 1: Face-down positioning versus other positioning, Outcome 3: Mean change in visual acuity (logMAR) 38
at 3 months...........................................................................................................................................................................................
Analysis 1.4. Comparison 1: Face-down positioning versus other positioning, Outcome 4: Mean change in visual acuity (ETDRS)... 38
Analysis 1.5. Comparison 1: Face-down positioning versus other positioning, Outcome 5: Objective distortion score................. 39
Analysis 1.6. Comparison 1: Face-down positioning versus other positioning, Outcome 6: Quality of life score - NEI-VFQ............ 39
Analysis 1.7. Comparison 1: Face-down positioning versus other positioning, Outcome 7: Adverse events - outer retinal folds..... 40
Analysis 1.8. Comparison 1: Face-down positioning versus other positioning, Outcome 8: Adverse events - binocular diplopia 40
and elevated intraocular pressure at 6 months.................................................................................................................................
APPENDICES................................................................................................................................................................................................. 40
HISTORY........................................................................................................................................................................................................ 43
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 43
DECLARATIONS OF INTEREST..................................................................................................................................................................... 43
SOURCES OF SUPPORT............................................................................................................................................................................... 44
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 44
INDEX TERMS............................................................................................................................................................................................... 44

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[Intervention Review]

Face-down positioning or posturing after pars plana vitrectomy for

macula-involving rhegmatogenous retinal detachments

Timothy HM Fung1, Tsz Wing Yim2, Noemi Lois3, David M Wright3, Su-Hsun Liu2,4a, Tom Williamson1a

1Ophthalmology, St Thomas' Hospital, London, UK. 2Department of Ophthalmology, University of Colorado Anschutz Medical Campus,
Aurora, CO, USA. 3Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK. 4Department of Epidemiology,
University of Colorado Anschutz Medical Campus, Aurora, CO, USA

aThese authors contributed equally to this work

Contact: Timothy HM Fung, timothyfung@doctors.org.uk.

Editorial group: Cochrane Eyes and Vision Group.

Publication status and date: New, published in Issue 3, 2024.

Citation: Fung THM, Yim TW, Lois N, Wright DM, Liu S-H, Williamson T. Face-down positioning or posturing after pars plana vitrectomy for
macula-involving rhegmatogenous retinal detachments. Cochrane Database of Systematic Reviews 2024, Issue 3. Art. No.: CD015514. DOI:
10.1002/14651858.CD015514.pub2.

Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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.

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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.

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.

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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.

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Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review)
SUMMARY OF FINDINGS

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

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Face-down positioning compared with other positioning after pars plana vitrectomy and gas tamponade for primary macula-involving rhegmatogenous retinal de-
tachments

Patient or population: people with primary macula-involving rhegmatogenous retinal detachments

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Trusted evidence.
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 No. of partici- Certainty of Comments
(95% CI) pants the evidence
Assumed risk Corresponding risk (studies) (GRADE)

Other posturing Face-down positioning

Proportion of eyes with 483 per 1000 353 per 1000 (261 to 479) RR 0.73 (0.54 to 239 (1 study) ⊕⊝⊝⊝
retinal displacement at 6 0.99)
months or later Casswell 2020 Very lowa,b

(RR < 1 favored)

Mean change in logMAR or Change in BCVA in logMAR in face-up positioning MD −0.03 56 (1 study) ⊕⊝⊝⊝
Snellen visual acuity from group was 0.03 lower (95% CI 0.09 lower to 0.02 high- (−0.09 to 0.02)
baseline to 3 months or er) than in face-down positioning group at 3 months. Peiretti 2017 Very lowa,b
later
Change in BCVA in ETDRS in face-up positioning group MD −0.70 221 (1 study) Casswell 2020 reported
(lower is favored) was 0.70 lower (95% CI 4.62 lower to 3.22 higher) at (−4.62 to 3.22) ETDRS visual acuity in
Casswell 2020

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week 8. site-adjusted differences
with an MD of 0.10 (95%
CI −3.04 to 3.24) at week
26.

Mean objective distortion Change in objective distortion score in face-down po- MD 1.80 (−1.92 219 (1 study) ⊕⊝⊝⊝ Casswell 2020 report-
score at 3 months or later sitioning group was 1.80 higher (95% CI 1.92 lower to to 5.52) ed objective distortion
5.52 higher) than in support-the-break positioning Very lowa,b score in site-adjusted
(lower is favored) group at week 26. differences.

Quality of life assessments Change in quality of life assessments in support-the- MD −1.80 217 (1 study) ⊕⊝⊝⊝ Casswell 2020 report-
at 3 months or later break positioning group was 1.80 lower (95% CI 5.52 (−5.52 to 1.92) ed NEI-VFQ assessment
4
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Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review)
(higher is favored) lower to 1.92 higher) than in face-down positioning Very lowa,b score in site-adjusted
group at week 26. differences.

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Frequency of interven- Outer retinal folds 262 (1 study) ⊕⊝⊝⊝ Peiretti 2017 reported
tion-related ocular ad- outer retinal folds at
verse events 137 per 1000 54 per 1000 (23 to 124) RR 0.39 (0.17 to Very lowa,b 1 month with an RR of
0.90) 1.00 (95% CI 0.5 to 2.02)
(follow-up to 6 months) and 3 months with an RR
Binocular diplopia of 1.00 (95% CI 0.28 to
3.61).

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Trusted evidence.
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 interven- No studies measured this outcome.

tion-related non-ocular
adverse events

(follow-up 2 weeks to 6
months)

*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; log-
MAR: 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.

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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.

aDowngraded two levels for very serious imprecision.

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

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Figure 1. 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 How the intervention might work

PPV, identification and treatment of the retinal break(s), and Face-down positioning after PPV and gas tamponade for a macula-
injection of gas are performed to repair macula-involving RRDs. involving RRD is believed to reduce the risk of any residual
In some cases, removal of either the natural crystalline lens or subretinal fluid that remains at the end of surgery from displacing
an artificial lens may be performed, as required. After completion the retina inferiorly as a result of gravity (Figure 2) (Brosh 2020;
of the surgery, face-down positioning for a variable period, as Codenotti 2013; Mason 2022; Pandya 2012; Shiragami 2015).
much as 10 days, has been advocated to reduce the risk of
retinal displacement (Casswell 2020; dell’Omo 2013; Schawkat
2019; Shiragami 2015).

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Figure 2. 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 following PPV and gas tamponade for the repair of macula-
involving RRDs.
Several studies have been conducted to assess the role of face-
down positioning following PPV and gas tamponade on retinal OBJECTIVES
displacement for macula-involving RRDs (Casswell 2020; dell’Omo
2013; Schawkat 2019; Shiragami 2015). However, there is no The primary objective of this review is to determine whether face-
consensus as to whether face-down positioning following PPV and down positioning reduces the risk of retinal displacement following
gas tamponade is effective at reducing retinal displacement in PPV and gas tamponade for primary macula-involving RRDs.
order to improve the care and outcomes of people with macula-
involving RRDs. METHODS

Although no guidelines exist concerning the duration of face-down Criteria for considering studies for this review
positioning, some vitreoretinal (VR) surgeons typically advocate
strict face-down positioning for a minimum of 50 minutes of every Types of studies
hour and throughout the night for one to two weeks after PPV We included randomized controlled trials (RCTs) that compared
and gas tamponade (Casswell 2020; Seno 2015; Shiragami 2015). face-down positioning against no positioning or against another
Face-down positioning is a challenge for many patients. Elderly form of positioning on retinal displacement following PPV and gas
people and those with cervical spondylosis, obesity, or coronary tamponade for the repair of macula-involving RRDs.
heart disease have serious difficulties adhering to the face-down
position (Chen 2015). Face-down positioning may cause people to Types of participants
complain of musculoskeletal pains, and they may suffer mental
We included RCTs involving adult participants with primary (no
stress, anxiety, and a sense of psychological isolation (Harker 1996).
previous surgery for RRD) macula-involving RRDs undergoing PPV
Face-down positioning after PPV and gas tamponade also bears
and gas tamponade. We employed no restrictions with respect to
the risk of pressure sores, Treister 1996, and ulnar nerve palsies
characteristics of the RRD (e.g. extent of detached retina, location
(Brouzas 2011; Ciulla 1996).
of retinal breaks) or type of gas tamponade used.
In order to evaluate the beneficial and adverse effects of face-down
Types of interventions
positioning on retinal displacement after PPV and gas tamponade
for macula-involving RRDs, we sought to undertake a systematic The intervention under investigation is face-down positioning after
review and meta-analysis of the literature. The findings of our PPV and gas tamponade for macula-involving RRDs. We included
review are important to inform VR surgeons and patients of studies comparing face-down positioning against no positioning or
the potential benefits and side effects of face-down positioning against another form of positioning.

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Types of outcome measures • US National Institutes of Health Ongoing Trials Register

ClinicalTrials.gov (www.clinicaltrials.gov) (Appendix 6).
We assessed the following outcome measures. For studies that
reported outcomes at multiple eligible time points, we collected • World Health Organization (WHO) International Clinical Trials
outcome data reported at the longest follow-up period (for all Registry Platform (ICTRP) (www.who.int/ictrp) (Appendix 7).
outcomes).
Searching other resources
Critical outcome We searched the reference lists of included studies for other
• Proportion of eyes with retinal displacement at six months or potentially eligible studies. We did not search conference
later following PPV and gas tamponade for primary macula- proceedings for the purposes of this review.
involving RRDs.
Data collection and analysis
Important outcomes Selection of studies
• Proportion of eyes with retinal displacement within three After importing the search results into the web-based citation
months following PPV and gas tamponade for primary macula- management software Covidence (Covidence), two review authors
involving RRDs. independently screened the titles and abstracts of all records
• Mean change in logarithm of the Minimum Angle of Resolution identified. Based on the eligibility criteria, review authors classified
(logMAR) or Snellen visual acuity from baseline to three months each citation as 'No (not relevant),' 'Maybe (relevant),' or 'Yes
or later following PPV and gas tamponade. (relevant)' for full-text review. We then retrieved the full-text reports
• Mean objective distortion score (e.g. D chart test score, for records classified as 'Yes' or 'Maybe'. Two review authors
McGowan 2016) at three months or later following PPV and gas independently reviewed the full-text manuscripts according to the
tamponade. eligibility criteria, classifying them as 'exclude' or 'include'. Any
• Quality of life assessments (e.g. the National Eye Institute Visual discrepancies between the two review authors with regard to the
Function Questionnaire [NEI-VFQ, Potic 2021]) at three months above classification were resolved by discussion. We classified
or later following PPV and gas tamponade. eligible trials in progress as 'ongoing' and trials with missing
results as 'awaiting classification'. We also contacted the study
• Frequency of intervention-related ocular adverse events,
investigator to obtain information on potentially eligible ongoing
recorded following the Complications of Retinal Detachment
studies and studies awaiting classification. If they did not respond
Surgery (CORDS) classification (Xu 2021), including:
within 14 days, we used the information available from publications
◦ outer retinal folds;
or trial registries on the ongoing studies and studies awaiting
◦ binocular diplopia; classification.
◦ elevated intraocular pressure.
• Frequency of intervention-related non-ocular adverse events, if Data extraction and management
provided in the included RCTs, including: Two review authors (TF, TWY) independently extracted data using
◦ pressure sores; a data extraction form developed by Cochrane Eye and Vision US
◦ ulnar nerve palsies; Project in Covidence. We extracted the following information, if
◦ anxiety disorder. provided by the RCT:

We planned to report each ocular and non-ocular adverse event • Study methods (single center or multicenter, method of
as the proportion of participants who experienced the specific allocation, masking [blinding], exclusions after randomization,
adverse event, and grade it. losses to follow-up and compliance).
• Study participants (country(ies) where participants were
Search methods for identification of studies enrolled, number randomized, age, gender, ethnicity, inclusion
Electronic searches and exclusion criteria).
• Surgeon details (number of surgeons, grade of surgeons
The Cochrane Eyes and Vision Information Specialist searched the [attending, fellow, resident]).
following electronic databases for RCTs. There were no restrictions
• Surgical details (preoperative visual acuity, eye laterality, lens
on language or date of publication. The date of the last database
status, location and quadrants of retina detached, number
search was 28 November 2022.
and location of retinal breaks, presence or absence of
• Cochrane Central Register of Controlled Trials (CENTRAL) (which grades of proliferative vitreoretinopathy, performance of 360
contains the Cochrane Eyes and Vision Trials Register) in the degree laser barrier, use of intraoperative surgical adjuncts
Cochrane Library (2022, Issue 11) (Appendix 1). such as perfluorocarbon liquid, complete or partial fluid-gas
exchange, type of gas tamponade used [air, sulfur hexafluoride,
• MEDLINE Ovid (January 1946 to 28 November 2022) (Appendix
hexafluoroethane, perfluoropropane]).
2).
• Study interventions (test and comparison [control] intervention,
• Embase.com (January 1947 to 28 November 2022) (Appendix 3).
duration of intervention, timing of intervention).
• PubMed (1948 to 28 November 2022) (Appendix 4).
• Outcomes following surgery (presence or absence of retinal
• LILACS (Latin American and Caribbean Health Sciences displacement, quantification of retinal displacement, visual
Literature database) (1982 to 28 November 2022) (Appendix 5). acuity, distortion score, quality of life score, adverse events
following the intervention), and how they were measured.

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• Source(s) of funding and potential conflicts of interest. the included studies did not use the classification, we could not
• Details and contact information of the corresponding author. determine the severity of the adverse events. When only a single
study reported the outcome, and it did not provide analyzable
Any discrepancies between the two review authors regarding data for RR, we presented the estimates derived from the original
extracted data were resolved by discussion. One review author analysis in the study. We calculated mean differences (MDs) when
(TWY) entered data into RevMan (RevMan 2023), and a second comparing continuous outcomes, such as visual acuity in logMAR
review author (TF) verified the data entry. or Snellen lines (or letters) or distortion scores (Li 2022).

Assessment of risk of bias in included studies Unit of analysis issues

Two review authors independently judged risk of bias in the We included trials where the unit of analysis for outcomes was the
included studies reporting outcomes listed in the summary of eyes of individuals. Whenever both eyes of all or some individuals
findings table (see Summary of findings and assessment of the were included in an RCT, we documented how many participants
certainty of the evidence), using the RoB 2 tool outlined in Chapter contributed data for both eyes to the study.
8 of the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2022). This tool incorporates assessment of bias arising Dealing with missing data
from the randomization process (random sequence generation and Lack of information about the characteristics of any data will raise
allocation concealment), bias due to deviations from intended concerns as to whether the missing data may have introduced bias.
interventions (masking of participants and treatment providers), Where statistical data were missing or unclear, we contacted the
bias due to missing outcome data (incomplete outcome data), bias primary trial investigators for clarification and further information.
in measurement of the outcome (blinding of outcome assessment), When we received no responses within two weeks, we proceeded
and bias in selection of the reported results. with complete-case analysis, assuming that data were missing
at random (Bhaskaran 2014). We evaluated our assumption by
We quantified the effect of assignment to the interventions at
collecting data on the numbers of participants (or eyes) excluded
baseline, regardless of whether the interventions were received as
or lost to follow-up after randomization and the reasons, when
intended (the 'intention-to-treat effect') (Hernán 2017). We judged
available.
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 Assessment of heterogeneity
of each domain was guided by signaling questions (with 'yes,'
'probably yes,' 'no,' 'probably no,' or 'no information') using the We evaluated the overall characteristics of the included
Excel tool available at www.riskofbias.info (Sterne 2019). studies, especially characteristics of study participants, types of
interventions, and study design, to assess the extent of clinical and
We applied the RoB 2 tool to the critical outcome (proportion methodological heterogeneity before conducting meta-analysis.
of eyes with retinal displacement at six months), important We assessed statistical heterogeneity by inspecting the distribution
outcomes within or at three months (proportion of eyes with of effect size estimates presented in the forest plots and using the
retinal displacement, mean change in visual acuity from baseline, I2 statistic to assess the proportion of total variability explained by
objective distortion scores, and quality of life assessments), as well heterogeneity among studies. As suggested in Chapter 10 of the
as frequencies of ocular adverse events. Cochrane Handbook (Deeks 2022), we used the following thresholds
for interpreting I2 values:
We considered the overall risk of bias for each trial as follows.
• 0% to 40%: may not be important;
• Low risk of bias: the trial was of low risk of bias for all domains
for this result. • 30% to 60%: may represent moderate heterogeneity;
• Some concerns: the trial was judged to raise some concerns in at • 50% to 90%: may represent substantial heterogeneity;
least one domain for this result, but was not at high risk of bias • 75% to 100%: considerable heterogeneity.
for any domain.
Assessment of reporting biases
• 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 We assessed selective result reporting of the review outcomes by
domains such that confidence in the result is substantially the associated signaling questions of the RoB 2 tool (Higgins 2022).
lowered. Because there were only three eligible trials, we did not use funnel
plots to assess the presence of small-study effects as suggested in
We contacted trial investigators for clarification of trial information Chapter 13 of the Cochrane Handbook (Page 2022).
or results. When the trial investigators did not respond to our
multiple inquiries within 14 days, we assessed the risk of bias based Data synthesis
on the available information. We resolved any disagreements
We provided qualitative synthesis for each review outcome
through discussion within the review author team.
specified for all included trials. We performed quantitative data
Measures of treatment effect synthesis according to the guidelines in Chapter 9 of the Cochrane
Handbook (McKenzie 2022a). We used random-effects models
We calculated risk ratios (RR) with 95% confidence intervals (CI) when there are three or more trials providing data for a given
when comparing dichotomous outcomes, including proportion of outcome; otherwise, we used a fixed-effect model. When the
eyes with retinal displacement and proportion of each specified direction of treatment effects was inconsistent across trials,
ocular adverse event. We planned to record specified ocular or we noted evidence of substantial or considerable statistical
adverse events following the CORDS classification; however, as heterogeneity, we did not combine trial results in a meta-analysis,
Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review) 10
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but presented a narrative synthesis of results instead, according to • Mean objective distortion score at three months or later
the guidance in Chapter 12 of the Cochrane Handbook (McKenzie following PPV and gas tamponade.
2022b). • Quality of life assessments at three months or later following
PPV and gas tamponade.
Subgroup analysis and investigation of heterogeneity
• Frequency of intervention-related ocular adverse events,
We did not plan any subgroup analysis. recorded following the CORDS classification.
• Frequency of intervention-related non-ocular adverse events.
Sensitivity analysis
For analyses relevant to the critical outcome, we planned to For each outcome, we graded the certainty of evidence as 'high,'
conduct a sensitivity analysis to determine the impact of exclusion 'moderate,' 'low,' or 'very low' according to the five GRADE
of studies at overall high risk of bias and industry-funded studies. considerations (overall risk of bias, unexplained heterogeneity or
However, sensitivity analysis was precluded by insufficient data. inconsistency of results, indirectness of evidence, imprecision of
results, and publication bias) (Schünemann 2013). We resolved any
Summary of findings and assessment of the certainty of the disagreements by discussion.
evidence
RESULTS
We prepared a summary of findings table for the following
outcomes that included the assumed absolute risks based on the Description of studies
relative risks estimated across the included studies. Two review
authors (TF, TWY) independently rated the certainty of the evidence Results of the search
for each outcome using the GRADE classification (Schünemann Our search of the electronic databases in November 2022 yielded
2022): 3935 records. After removal of duplicates, we screened 2966
titles and abstracts (Figure 3). We retrieved 16 full-text reports
• Proportion of eyes with retinal displacement at six months or
for further screening and excluded 6 studies (8 records), with
later following PPV and gas tamponade for primary macula-
reasons that are reported in Characteristics of excluded studies.
involving RRDs.
We included three studies (five records); identified two ongoing
• Mean change in logMAR or Snellen visual acuity from baseline to studies (Characteristics of ongoing studies); and listed one study
three months or later following PPV and gas tamponade. as awaiting classification (Characteristics of studies awaiting
classification).

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Figure 3. Study flow diagram.

3935 records
identified through
database searching

2966 records after

duplicates removed

2966 records 2950 records

screened excluded

2 ongoing studies

1 study awaiting
16 full-text articles
classification
assessed for
eligibility 6 studies (8
records) excluded,
with reasons

3 studies (5
records) included
in qualitative
synthesis

3 studies included
in quantitative
synthesis
(meta-analysis)

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We contacted the study investigators of one study to clarify study Types of outcomes
eligibility, but did not receive a response (JPRN-UMIN000023272).
Critical outcome
One ongoing study started in 2022 and is estimated to be
completed in 2024 (NCT04035343); another ongoing study started Proportion of eyes with retinal displacement at six months or later
in 2019 but did not provide the estimated completion time Casswell 2020 was the only trial to report the proportion of study
(CTRI/2022/10/046837). eyes with retinal displacement at six months or later. Investigators
of Casswell 2020 recruited participants from two study sites
Included studies
(London and Glasgow), and consistently reported study outcomes
Types of studies based on invariant regression models with adjustment for study
site.
All three included studies were parallel-group RCTs and were
published between 2017 and 2020. The trials were conducted in Important outcomes
England and Scotland (Casswell 2020), the Netherlands (Peiretti
2017), and Switzerland (Schawkat 2019). Only one trial had a Proportion of eyes with retinal displacement within three months
multicenter design (Casswell 2020). Two trials provided power and Two trials reported the proportion of study participants whose
sample size calculation (Casswell 2020; Schawkat 2019). Only one eyes had retinal displacement within three months, reporting this
trial was registered on a trial registry, and reported funding sources outcome at eight weeks, Casswell 2020, and six weeks, Schawkat
from the affiliated institution and the government (Casswell 2020). 2019.
Two trials randomized the intervention at the participant level, and
one trial analyzed findings at the eye level as the trial included two Mean change in logMAR or Snellen visual acuity
eyes for one of the participants (Schawkat 2019). Peiretti 2017 reported best-corrected visual acuity (BCVA) in logMAR
at baseline and three months after surgery. Casswell 2020 reported
Types of participants
the corrected Early Treatment Diabetic Retinopathy Study (ETDRS)
The three included trials enrolled a total of 368 randomized visual acuity in median and IQR at week 8 and week 26, as well
participants (369 eyes); the median (interquartile range [IQR]) was as differences between the two comparison groups, adjusted for
56 (53, 148). The average age of study participants in 2 trials was differences between sites using linear regression models.
61 years (Casswell 2020; Schawkat 2019), and the median age of
1 trial was 63 years, ranging from 43 to 90 years (Peiretti 2017). Mean objective distortion score
In three trials, more than 70% of enrolled participants were male Casswell 2020 was the only trial that reported median distortion
(range: 68% to 72%). One trial reported that the majority of the score and its IQR at week 8 and week 26, as well as differences
study participants were white (Casswell 2020); the other two trials between the two comparison groups, adjusted for differences
did not provide any race and ethnicity information. between sites using linear regression models.
Types of interventions Quality of life assessments
All three trials compared face-down positioning with other Casswell 2020 was the only trial that reported this outcome using
positioning. Casswell 2020 compared face-down positioning with the National Eye Institute Visual Function Questionnaire (NEI-VFQ
support-the-break positioning. Face-down positioning involved 25) in median and IQR at week 26, and differences between the two
24 hours of face-down positioning, started immediately after comparison groups adjusted for differences between sites using
surgery, for a minimum of 50 minutes in every hour, with linear regression models.
compliance assessed through participant diaries. Support-the-
break positioning involved head positioning dependent on the Frequency of intervention-related ocular adverse events
location of retinal breaks: detachments with nasal, temporal, or Two trials reported the frequency of the intervention-related ocular
inferior breaks were positioned on the contralateral cheek, whereas adverse event outer retinal folds at one, three, and six months
those with superior breaks were positioned upright. After the (Casswell 2020; Peiretti 2017). Only one trial reported on binocular
initial 24 hours of positioning, all participants were positioned diplopia and elevated intraocular pressure at six months (Casswell
in the support-the-break regimen for another 6 days. Schawkat 2020). No classification systems were used to grade ocular adverse
2019 compared log-roll postoperative positioning (30 minutes events in any of the included trials.
face to temporal followed by 30 minutes face-down postoperative
positioning) with face-up postoperative positioning. Peiretti 2017 Frequency of intervention-related non-ocular adverse events
compared five hours of immediate face-down postoperative
None of the included trials reported this outcome.
positioning with five hours of face-up postoperative positioning.
After five hours, all participants were positioned in the support-the- Excluded studies
break regimen for a further five days.
We excluded six studies at the full-text stage. We excluded
All trials reported on the use of perfluorocarbon liquid during three studies because they were not RCTs, and the other three
surgery. Two trials reported intraoperative use of adjuvant studies because the intervention or comparator was irrelevant
perfluorocarbon liquid in 50% of participants (Peiretti 2017; (Characteristics of excluded studies).
Schawkat 2019); the third trial reported perfluorocarbon liquid use
in 1.3% of participants (Casswell 2020). In two trials (Casswell 2020; Risk of bias in included studies
Schawkat 2019), more than 82% of participants received sulfur
We applied the RoB 2 tool to assess risk of bias for the following five
hexafluoride gas tamponade.
outcomes presented in Summary of findings 1:

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• proportion of eyes with retinal displacement (Casswell 2020; For mean change in visual acuity at three months (Risk of bias
Schawkat 2019); table for Analysis 1.3; Risk of bias table for Analysis 1.4) and ocular
• mean change in visual acuity from baseline to three months or adverse events (Risk of bias table for Analysis 1.7; Risk of bias table
later (Casswell 2020; Peiretti 2017); for Analysis 1.8), we judged Peiretti 2017 to have some concerns due
• objective distortion scores (Casswell 2020); to lack of detail about allocation concealment. We judged Casswell
2020 as at low risk of bias for this domain.
• quality of life assessments (Casswell 2020); and
• frequency of intervention-related ocular adverse events For objective distortion scores, we judged Casswell 2020 as at low
(Casswell 2020; Peiretti 2017). risk of bias for this domain (Risk of bias table for Analysis 1.5).

We did not apply the RoB 2 tool to non-ocular adverse events For quality of life assessments, we judged Casswell 2020 to have
because no studies measured or reported this outcome. We high risk of bias, as this patient-reported outcome could potentially
summarized assessment results and supporting statements for have been influenced by participants knowing what intervention
each signaling question in the corresponding risk of bias tables. they received (Risk of bias table for Analysis 1.6).
Detailed risk of bias assessments are also available upon request.
Domain 5: Bias in selection of the reported result
For proportion of eyes with retinal displacement, we judged the
For proportion of eyes with retinal displacement, we judged
overall risk of bias for one study as at low risk of bias (Casswell
Casswell 2020 to be at a low risk of bias. The statistical analysis plan
2020), and one study as at high risk of bias (Schawkat 2019). For
and protocol were not available for Schawkat 2019, therefore we
mean change in visual acuity from baseline to three months or later
had some concerns for this domain (Risk of bias table for Analysis
and ocular adverse events, we judged one study to have an overall
1.1; Risk of bias table for Analysis 1.2).
low risk of bias (Casswell 2020), and the other study to have some
concerns (Peiretti 2017). For objection distortion scores, we judged For the other four outcomes, we judged Casswell 2020 and Peiretti
Casswell 2020 as having an overall low risk of bias. For quality of life 2017 to have a low risk of bias (Risk of bias table for Analysis 1.3;
assessments, we judged Casswell 2020 to have an overall high risk Risk of bias table for Analysis 1.4; Risk of bias table for Analysis 1.5;
of bias due to this being a patient-reported outcome. Risk of bias table for Analysis 1.6; Risk of bias table for Analysis 1.7;
Risk of bias table for Analysis 1.8).
Domain 1: Bias arising from the randomization process
We judged Casswell 2020 as at low risk of bias for this domain. Effects of interventions
Peiretti 2017 and Schawkat 2019 did not provide sufficient
See: Summary of findings 1 Face-down positioning compared with
information on the method of allocation concealment and were
other positioning
judged as having some concerns.
Absolute and relative effects for all prespecified outcomes in the
Domain 2: Bias due to deviations from intended interventions
Methods are summarized with their respective GRADE ratings in
We judged all three trials as at low risk of bias for this domain. Summary of findings 1.

Domain 3: Bias due to missing outcome data Critical outcome

We judged all three trials as at low risk of bias for all five outcomes Proportion of eyes with retinal displacement at six months or
assessed. later

Domain 4: Bias in measurement of the outcome Only one trial reported this outcome at six months (Casswell 2020).
The single study estimate suggested that immediate face-down
For proportion of eyes with retinal displacement, we judged positioning after PPV and gas tamponade for a macula-involving
Casswell 2020 to be at a low risk of bias. We judged Schawkat 2019 RRD may reduce the incidence of retinal displacement compared
to be at high risk of bias because it was unclear whether outcome with support-the-break positioning at six months (risk ratio [RR]
assessors were aware of the intervention received by the study 0.73, 95% confidence interval [CI] 0.54 to 0.99; 239 participants;
participants (Risk of bias table for Analysis 1.1; Risk of bias table for Figure 4). We assessed the certainty of evidence for this outcome as
Analysis 1.2). very low, downgraded for imprecision of the estimate (−2) and risk
of bias (−1).

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Figure 4. Forest plot of face-down positioning versus support-the-break positioning, outcome 1.1 Proportion of
eyes with retinal displacement at 6 months.

Face-down Support-the-break Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

Casswell 2020 (1) 42 119 58 120 0.73 [0.54 , 0.99] + + + + + +

0.5 0.7 1 1.5 2

Footnotes Favors face-down Favors support-the-break
(1) support-the-break

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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

Figure 5. Forest plot of face-down positioning versus other positioning, outcome 1.2: Proportion of eyes with
retinal displacement at 3 months.

Face-down Other positioning Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

Casswell 2020 (1) 45 119 67 120 92.8% 0.68 [0.51 , 0.90] + + + + + +

Schawkat 2019 (2) 12 26 5 24 7.2% 2.22 [0.92 , 5.36] ? + + − ? −

Total (95% CI) 145 144 100.0% 0.79 [0.61 , 1.03]

Total events: 57 72
Heterogeneity: Chi² = 6.38, df = 1 (P = 0.01); I² = 84% 0.1 0.2 0.5 1 2 5 10
Test for overall effect: Z = 1.77 (P = 0.08) Favors face-down Favors other positioning
Test for subgroup differences: Not applicable

Footnotes
(1) support-the-break; 8 weeks
(2) face-up; 6 weeks

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Mean change in logMAR or Snellen visual acuity no evidence of a difference in visual acuity comparing
postoperative face-up with face-down positioning with or without
Only one trial reported BCVA in logMAR at three months after
perfluorocarbon liquid (mean difference [MD] −0.03, 95% CI −0.09
surgery (Peiretti 2017). The single study estimate indicated
to 0.02; I2 = 0%; 56 participants; Analysis 1.3). The single study
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estimate also indicated no evidence of a difference in visual acuity evidence for this outcome as very low because of risk of bias (−1)
comparing face-up with face-down positioning with (MD −0.01, 95% and imprecision (−2).
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). Quality of life assessments
Casswell 2020 only reported NEI-VFQ 25 assessment score in
One trial reported ETDRS visual acuity in site-adjusted differences
site-adjusted differences at week 26. The single study estimate
at week 8 and week 26, although the data were not normally
suggested no evidence of difference in quality of life when
distributed (Casswell 2020). The single study estimate from
comparing immediate face-down positioning with support-the-
the trial suggested no evidence of difference in visual acuity
break positioning at week 26 (MD −1.80, 95% CI −5.52 to 1.92; 217
when comparing immediate face-down with support-the-break
participants; Analysis 1.6). We assessed the certainty of evidence
positioning at week 8 (MD −0.70, 95% CI −4.62 to 3.22; 221
for this outcome as very low because of risk of bias (−1) and
participants; Analysis 1.4) and week 26 (MD 0.10, 95% CI −3.04 to
imprecision (−2).
3.24; 220 participants; Analysis 1.4). We assessed the certainty of
evidence for this outcome as very low because of imprecision (−2) Frequency of intervention-related ocular adverse events
and risk of bias (−1).
Peiretti 2017 reported the intervention-related ocular adverse
Mean objective distortion score event of outer retinal folds. The estimates suggested no evidence
of a difference in the adverse event of outer retinal folds when
Casswell 2020 only reported distortion scores in site-adjusted
comparing face-down with face-up positioning at one month (RR
differences at week 8 and week 26. The single study estimate
1.00, 95% CI 0.50 to 2.02; 56 participants) or three months (RR
from the trial suggested no evidence of difference in distortion
1.00, 95% CI 0.28 to 3.61; 56 participants; Figure 6). Casswell 2020
score when comparing immediate face-down with support-the-
reported proportions of participants with outer retinal folds at
break positioning at week 8 (MD 2.70, 95% CI −0.83 to 6.23; 220
six months. The estimate suggested that immediate face-down
participants; Analysis 1.5) and week 26 (MD 1.80, 95% CI −1.92 to
positioning may reduce the adverse event of outer retinal folds
5.52; 219 participants; Analysis 1.5). We assessed the certainty of
compared with support-the-break positioning (RR 0.39, 95% CI 0.17
to 0.90; 262 participants; Figure 6).

Figure 6. Forest plot of face-down positioning versus other positioning, outcome 1.7: Adverse events - outer retinal
folds.

Face-down Other positioning Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

1.7.1 1 month
Peiretti 2017 (1) 10 28 10 28 1.00 [0.50 , 2.02] ? + + + + ?

1.7.2 3 months
Peiretti 2017 (2) 4 28 4 28 1.00 [0.28 , 3.61] ? + + + + ?

1.7.3 6 months
Casswell 2020 (3) 7 131 18 131 0.39 [0.17 , 0.90] + + + + + +

0.1 0.2 0.5 1 2 5 10

Footnotes Favors face-down Favors other positioning
(1) Face-down: 4 participants with perfluoron; Face-up: 6 participants with perfluoron
(2) Face-down: 2 participants with perfluoron; Face-up: 2 participants with perfluoron
(3) Support-the-break

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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

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Figure 7. 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.

Face-down positioning Support-the-break Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

1.8.1 Binocular diplopia

Casswell 2020 2 131 10 131 0.20 [0.04 , 0.90] + + + + + +

1.8.2 Elevated intraocular pressure

Casswell 2020 (1) 40 131 23 131 1.74 [1.11 , 2.73] + + + + + +

0.02 0.1 1 10 50
Footnotes Favors face-down Favors support-the-break
(1) Elevated intraocular pressure defined as > 25 mm Hg

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Frequency of intervention-related non-ocular adverse events Of the three included trials, only Casswell 2020 examined our
critical outcome. Some important outcomes, such as postoperative
None of the included trials reported this outcome.
distortion (reported in one RCT) and quality of life (reported in
DISCUSSION one RCT) assessment scores were largely neglected, and evidence
regarding these outcomes is incomplete. Of the few important
Summary of main results outcomes reported across RCTs, variation in findings was evident,
which may be due in part to the small sample sizes of two of
We identified three RCTs (369 eyes of 368 participants) that the three included RCTs. Findings may also differ as a result
addressed our critical and important outcomes. Participants of the differing methods of study design (both regarding the
were recruited from four European countries and followed up positioning or posturing comparators and the duration and timing
for a maximum of six months. All studies examined face-down of intervention used), as well as the short follow-up period of some
positioning versus other positioning regimens after PPV and gas of the studies (only six weeks in one RCT). Although most patients
tamponade in the management of macula-involving RRDs. who undergo macula-involving retinal detachment surgery have
stable vision three to six months after surgery, vision continues to
Very low certainty evidence from one RCT suggested that improve in a subgroup of patients up to five years after surgery
immediate face-down positioning after surgery may result in (Kusaka 1998). Metamorphopsia also continues to improve over the
reduced postoperative retinal displacement, outer retinal folds, long-term after surgery for macula-involving retinal detachments
and binocular diplopia, but may increase the chance of (Okuda 2018). More studies with longer follow-up are therefore
postoperative raised intraocular pressure compared with support- needed to fully appraise the long-term effects of the interventions
the-break positioning at six months (Casswell 2020). There was evaluated in this review. Patient preferences were not assessed in
little to no effect on postoperative distortion and quality of life any of the included RCTs, and future studies may wish to consider
assessment scores. Very low certainty evidence from two RCTs exploring this.
(239 eyes of 239 participants in Casswell 2020 and 56 eyes of 56
participants in Peiretti 2017) found no evidence of a difference in We identified two ongoing RCTs. However, we have not
postoperative BCVA when comparing face-down positioning versus incorporated the data from these ongoing trials in this review
face-up or support-the-break positioning at three to six months. because no interim or final results were as yet available. This topic
should be revisited in the future once additional RCTs have been
Overall completeness and applicability of evidence published to collate and critique evidence and guide practice.
Despite conducting a highly sensitive search strategy for published
Certainty of the evidence
RCTs, we identified only three eligible trials. All participants
were recruited from a European population (England, Scotland, We assessed the certainty of the evidence across the outcomes
the Netherlands, and Switzerland) (Casswell 2020; Peiretti 2017; examined in this review as very low (Summary of findings 1). In
Schawkat 2019). Only Casswell 2020 included eyes from a black accordance with the GRADE classification (Schünemann 2022), we
(3%) or Asian (11%) population. Black patients have been shown downgraded the certainty of the evidence for all reported outcomes
to have worse visual outcomes compared to white patients primarily due to potential risk of bias and imprecision. There was a
undergoing surgery for RRDs (Xu 2023). Differences in ethnic group lack of clarity on sequence generation and allocation concealment,
representation could therefore potentially hinder the applicability as well as an inability to mask (blind) participants and personnel
of the results found in this review to non-white populations. to the intervention received and to mask assessors to some of the
Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review) 17
Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews

outcomes measured. Our confidence in the evidence was further the findings of these ongoing trials may help improve the overall
reduced by its reliance on single study estimates, relatively small certainty of evidence in this review. Future RCTs should be
sample sizes, or both. designed with standardized comparisons and outcomes. Study
investigators should analyze outcome data appropriately and
Potential biases in the review process report adequate information by following the CONSORT statement
for RCTs to provide evidence of high certainty (Moher 2010).
We followed Cochrane methodology in conducting this review
In particular, future trials may follow a recently published
and adhered to the Methodological Expectations of Cochrane
international consensus on reporting the severity as well as the
Intervention Reviews (MECIR) standards for the reporting of
frequency of complications of RRD surgery (Xu 2021). In addition
Cochrane Intervention Reviews in order to minimize any bias
to clinically important outcomes and adverse event outcomes,
in the review process (Higgins 2022). An Information Specialist
patient-important outcomes such as quality of life and patient
performed highly sensitive searches to identify all relevant studies,
acceptability and satisfaction should be considered by future trials.
thus ensuring a comprehensive search. In addition, we reached out
It is also essential for future research to have a strong patient and
to the authors to seek clarification on study eligibility and outcomes
public involvement in the trial design and conductance.
of interest. No authors had any conflicts of interest in the review
topic.
ACKNOWLEDGEMENTS
Agreements and disagreements with other studies or
Acknowledgements from the authors
reviews
We would like to acknowledge the contributions of Raphael Killian
There have been no reviews evaluating the value of face- (University of Verona), Henry Jampel (Johns Hopkins University),
down positioning in terms of retinal displacement, visual acuity, and Andrew Eller (University of Pittsburgh) for their comments on
distortion, and quality of life following PPV and gas tamponade the protocol.
for a macula-involving RRD. One comparative study of 86 eyes
that underwent PPV and gas tamponade showed a lower rate Editorial and peer-reviewer contributions
of postoperative retinal displacement with face-down positioning
immediately after surgery compared with face-down positioning at The Cochrane Eyes and Vision US Project (CEV@US) supported the
least 10 minutes after the end of the surgery (Shiragami 2015). This authors in the development of this review.
study was a retrospective study performed at a single institution.
The following people conducted the editorial process for this
The presence of selection bias and the low number of participants
review:
enrolled in the study may have affected the accuracy of the results
and reliability of the conclusions. • Sign-off Editors (final editorial decision via the Central Editorial
Service): Dr Gianni Virgilli (Queen's University Belfast, Ireland;
AUTHORS' CONCLUSIONS
University of Florence, Italy); (final editorial decision at
Implications for practice CEV@US): Dr Tianjing Li (University of Colorado Anschutz
Medical Campus), Dr Roberta W Scherer (Johns Hopkins
Three randomized controlled trials (RCTs) addressed the value University);
of face-down positioning following pars plana vitrectomy (PPV) • Managing Editors (selected peer reviewers, provided editorial
and gas tamponade for macula-involving rhegmatogenous retinal guidance to authors, edited the article): Anupa Shah, Cochrane
detachments (RRDs). Heterogeneity in the timing and durations of Central Editorial Service;
positioning and outcomes reported at different time points meant
• Editorial Assistant (conducted editorial policy checks, collated
that the studies were not directly comparable. peer-reviewer comments, and supported the editorial team):
Although the number of studies reporting on our critical and Sara Hales-Brittain, Cochrane Central Editorial Service;
important outcomes is insufficient, very low certainty evidence • Methodologist (provided methodological and editorial guidance
suggests that immediate face-down positioning after PPV and to authors, edited the article): Sueko Ng (University of Colorado
gas tamponade may result in reduced postoperative retinal Anschutz Medical Campus);
displacement, outer retinal folds, and binocular diplopia compared • Information Specialist: Lori Rosman (Johns Hopkins University);
to support-the-break positioning. Given its possibility for reducing • Copy Editor (copy-editing and production): Lisa Winer, Cochrane
troublesome postoperative complications, immediate face-down Central Production Service;
positioning after PPV and gas tamponade may be considered in • Peer reviewers (provided comments and recommended an
people with macula-involving RRDs. Because of imprecision with editorial decision): Peter J Kertes, MD CM, FRCSC, Department
wide estimate and a small sample size, clinical decisions should be of Ophthalmology and Vision Sciences Temerty Faculty of
tailored to each individual following comprehensive consultations Medicine, The University of Toronto (clinical/content review),
with patients and their families. Amin Nabavi, MD, FICO, Department of Ophthalmology, Guilan
University of Medical Sciences, Rasht, Iran (clinical/content
Implications for research
review), Jennifer Hilgart, Cochrane (methods review), Jo Platt,
In addition to the three included RCTs, we also identified Central Editorial Information Specialist (search review). One
two ongoing trials that aim to compare face-down positioning additional peer reviewer provided clinical/content peer review
with face-up positioning following PPV and gas tamponade in but chose not to be publicly acknowledged.
participants with primary macula-involving RRDs. Once available,

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review) 18
Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews

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of recommendations using the GRADE approach (updated
October 2013). Available from guidelinedevelopment.org/ Xu J, Davoudi S, Yoon J, Chen X, Siegel NH, Subramanian ML,
handbook. et al. Effect of race and ethnicity on surgical outcomes for
rhegmatogenous retinal detachments. Canadian Journal of
Schünemann 2022 Ophthalmology 2023;S0008-4182(22):00374-X.
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 References to other published versions of this review
JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch Fung 2022
VA, editor(s). Cochrane Handbook for Systematic Reviews of Fung T, Lois N, Wright DM, Liu S-H, Williamson T. Face-down
Interventions version 6.3 (updated February 2022). Cochrane, positioning or posturing after vitrectomy for macula-involving

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review) 22
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rhegmatogenous retinal detachments. Cochrane Database of

Systematic Reviews 2022, Issue 12. Art. No: CD015514. [DOI: * Indicates the major publication for the study
10.1002/14651858.CD015514]

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 position-
ing

Number analyzed: 239 in total; 119 for face-down positioning and 120 for support-the-break posi-
tioning

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 in-
vestigated using logistic regression of covariates on an indicator of missingness. Sample size esti-
mation 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 con-
ducted 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%)

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Casswell 2020 (Continued)

◦ 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 (de-

tachments with superior breaks positioned upright, whereas those with nasal, temporal, or infe-
rior 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.

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Casswell 2020 (Continued)

Surgical details: 3-port pars plana vitrectomy, retinopexy to breaks by cryotherapy or laser, and in-
traocular 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 displace-
ment on autofluorescence imaging at 6 months postoperatively

Secondary outcome(s):

• The proportion of participants in each group with retinal displacement on autofluorescence imag-
ing 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 postopera-
tively 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 treat-
ment 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 Re-
search (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 Spe-
cial 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

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Casswell 2020 (Continued)

Publication language: English

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

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Peiretti 2017 (Continued)

◦ 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 lay-
ing 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 sub-
retinal 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 reti-
nal folds and/or outer retinal folds such as ellipsoid zone drop-out in optical coherence tomogra-
phy images, metamorphopsia

Secondary outcome(s): NR

Adverse outcome(s): NR

Notes Funding sources: NR

Disclosures of interest: NR

Trial registry: NR

Publication language: English

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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 posi-
tion 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 posi-
tion (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 pa-
tients. Surgery was done with general anesthesia. After the vitrectomy and separation of the pos-
terior hyaloids using the suction method, retinal reattachment was achieved directly through flu-

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Schawkat 2019 (Continued)

id–air exchange with subretinal fluid drainage via main peripheral breaks or through perfluorooc-
tane 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. Rhegmatoge-
nous retinal detachment characteristics determined the selection of intraocular tamponade. Nev-
ertheless, 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 pos-
turing 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

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]

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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 posi-
tioning

Shiragami 2015 Ineligible study design: not a randomized controlled trial

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 de-
tachment
• 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 con-
trol trial

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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, glauco-
ma, 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 posi-
tioning 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

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 autofluores-
cence photography

Exclusion criteria:

• RRD with an attached macula

• Proliferative retinopathy grade C or worst
• Prior vitrectomy for retinal detachment

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NCT04035343 (Continued)
• Patients having had pneumatic retinopexy that failed to completely reattach the retina and there-
fore 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 pa-
tient. It will be recorded in a data collection sheet as "yes" or "no" according to the patient sub-
jective 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

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

RISK OF BIAS

Legend: Low risk of bias High risk of bias Some concerns

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

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Casswell 2020

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

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Casswell 2020

Schawkat 2019

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

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Subgroup 1.3.1 Without perfluoron

Peiretti 2017

Subgroup 1.3.2 With perfluoron

Peiretti 2017

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

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Subgroup 1.4.1 Week 8

Casswell 2020

Subgroup 1.4.2 Week 26

Casswell 2020

Risk of bias for analysis 1.5 Objective distortion score

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Subgroup 1.5.1 Week 8

Casswell 2020

Subgroup 1.5.2 Week 26

Casswell 2020

Risk of bias for analysis 1.6 Quality of life score - NEI-VFQ

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Casswell 2020

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Risk of bias for analysis 1.7 Adverse events - outer retinal folds

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Subgroup 1.7.1 1 month

Peiretti 2017

Subgroup 1.7.2 3 months

Peiretti 2017

Subgroup 1.7.3 6 months

Casswell 2020

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

Bias

Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results

Subgroup 1.8.1 Binocular diplopia

Casswell 2020

Subgroup 1.8.2 Elevated intraocular pressure

Casswell 2020

DATA AND ANALYSES

Comparison 1. Face-down positioning versus other positioning

Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants

1.1 Proportion of eyes with reti- 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
nal displacement at 6 months

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Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants

1.2 Proportion of eyes with 2 289 Risk Ratio (M-H, Fixed, 95% CI) 0.79 [0.61, 1.03]
retinal displacement within 3
months

1.3 Mean change in visual acuity 1 56 Mean Difference (IV, Fixed, 95% -0.03 [-0.09, 0.02]
(logMAR) at 3 months CI)

1.3.1 Without perfluoron 1 28 Mean Difference (IV, Fixed, 95% -0.06 [-0.15, 0.03]
CI)

1.3.2 With perfluoron 1 28 Mean Difference (IV, Fixed, 95% -0.01 [-0.09, 0.07]
CI)

1.4 Mean change in visual acuity 1 Mean Difference (IV, Fixed, 95% Totals not selected
(ETDRS) CI)

1.4.1 Week 8 1 Mean Difference (IV, Fixed, 95% Totals not selected
CI)

1.4.2 Week 26 1 Mean Difference (IV, Fixed, 95% Totals not selected
CI)

1.5 Objective distortion score 1 Mean Difference (IV, Fixed, 95% Totals not selected
CI)

1.5.1 Week 8 1 Mean Difference (IV, Fixed, 95% Totals not selected
CI)

1.5.2 Week 26 1 Mean Difference (IV, Fixed, 95% Totals not selected
CI)

1.6 Quality of life score - NEI- 1 Mean Difference (IV, Fixed, 95% Totals not selected
VFQ CI)

1.7 Adverse events - outer reti- 2 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
nal folds

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 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
diplopia and elevated intraocu-
lar pressure at 6 months

1.8.1 Binocular diplopia 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected

1.8.2 Elevated intraocular pres- 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
sure

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Analysis 1.1. Comparison 1: Face-down positioning versus other positioning,

Outcome 1: Proportion of eyes with retinal displacement at 6 months

Face-down Support-the-break Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

Casswell 2020 (1) 42 119 58 120 0.73 [0.54 , 0.99] + + + + + +

0.5 0.7 1 1.5 2

Footnotes Favors face-down Favors support-the-break
(1) support-the-break

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Analysis 1.2. Comparison 1: Face-down positioning versus other positioning,

Outcome 2: Proportion of eyes with retinal displacement within 3 months

Face-down Other positioning Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

Casswell 2020 (1) 45 119 67 120 92.8% 0.68 [0.51 , 0.90] + + + + + +

Schawkat 2019 (2) 12 26 5 24 7.2% 2.22 [0.92 , 5.36] ? + + − ? −

Total (95% CI) 145 144 100.0% 0.79 [0.61 , 1.03]

Total events: 57 72
Heterogeneity: Chi² = 6.38, df = 1 (P = 0.01); I² = 84% 0.1 0.2 0.5 1 2 5 10
Test for overall effect: Z = 1.77 (P = 0.08) Favors face-down Favors other positioning
Test for subgroup differences: Not applicable

Footnotes
(1) support-the-break; 8 weeks
(2) face-up; 6 weeks

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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Analysis 1.3. Comparison 1: Face-down positioning versus other

positioning, Outcome 3: Mean change in visual acuity (logMAR) at 3 months
Face-down Face-up Mean Difference Mean Difference Risk of Bias
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI A B C D E F

1.3.1 Without perfluoron

Peiretti 2017 (1) 0.22 0.11 14 0.28 0.12 14 45.9% -0.06 [-0.15 , 0.03] ? + + + + ?
Subtotal (95% CI) 14 14 45.9% -0.06 [-0.15 , 0.03]
Heterogeneity: Not applicable
Test for overall effect: Z = 1.38 (P = 0.17)

1.3.2 With perfluoron

Peiretti 2017 (1) 0.29 0.09 14 0.3 0.12 14 54.1% -0.01 [-0.09 , 0.07] ? + + + + ?
Subtotal (95% CI) 14 14 54.1% -0.01 [-0.09 , 0.07]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.25 (P = 0.80)

Total (95% CI) 28 28 100.0% -0.03 [-0.09 , 0.02]

Heterogeneity: Chi² = 0.71, df = 1 (P = 0.40); I² = 0%
Test for overall effect: Z = 1.12 (P = 0.26) -1 -0.5 0 0.5 1
Test for subgroup differences: Chi² = 0.71, df = 1 (P = 0.40), I² = 0% Favors face-down Favors face-up

Footnotes
(1) Post-intervention values

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Analysis 1.4. Comparison 1: Face-down positioning versus other

positioning, Outcome 4: Mean change in visual acuity (ETDRS)

Mean Difference Mean Difference Risk of Bias

Study or Subgroup Mean Difference SE IV, Fixed, 95% CI IV, Fixed, 95% CI A B C D E F

1.4.1 Week 8
Casswell 2020 (1) -0.7 2 -0.70 [-4.62 , 3.22] + + + + + +

1.4.2 Week 26
Casswell 2020 (1) 0.1 1.6 0.10 [-3.04 , 3.24] + + + + + +

-10 -5 0 5 10
Footnotes Favors support-the-break Favors face-down
(1) Site-adjusted linear regression coefficient, standard error was calculated from the reported 95% confidence interval using small sample size approximation

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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Analysis 1.5. Comparison 1: Face-down positioning versus other positioning, Outcome 5: Objective distortion score

Mean Difference Mean Difference Risk of Bias

Study or Subgroup Mean Difference SE IV, Fixed, 95% CI IV, Fixed, 95% CI A B C D E F

1.5.1 Week 8
Casswell 2020 (1) 2.7 1.8 2.70 [-0.83 , 6.23] + + + + + +

1.5.2 Week 26
Casswell 2020 (1) 1.8 1.9 1.80 [-1.92 , 5.52] + + + + + +

-10 -5 0 5 10
Footnotes Favors support-the-break Favors face-down
(1) Unweighted

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Analysis 1.6. Comparison 1: Face-down positioning versus

other positioning, Outcome 6: Quality of life score - NEI-VFQ

Mean Difference Mean Difference Risk of Bias

Study or Subgroup Mean Difference SE IV, Fixed, 95% CI IV, Fixed, 95% CI A B C D E F

Casswell 2020 (1) -1.8 1.9 -1.80 [-5.52 , 1.92] + + + − + −

-10 -5 0 5 10
Footnotes Favors face-down Favors support-the-break
(1) Week 26

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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Analysis 1.7. Comparison 1: Face-down positioning versus other

positioning, Outcome 7: Adverse events - outer retinal folds

Face-down Other positioning Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

1.7.1 1 month
Peiretti 2017 (1) 10 28 10 28 1.00 [0.50 , 2.02] ? + + + + ?

1.7.2 3 months
Peiretti 2017 (2) 4 28 4 28 1.00 [0.28 , 3.61] ? + + + + ?

1.7.3 6 months
Casswell 2020 (3) 7 131 18 131 0.39 [0.17 , 0.90] + + + + + +

0.1 0.2 0.5 1 2 5 10

Footnotes Favors face-down Favors other positioning
(1) Face-down: 4 participants with perfluoron; Face-up: 6 participants with perfluoron
(2) Face-down: 2 participants with perfluoron; Face-up: 2 participants with perfluoron
(3) Support-the-break

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

Analysis 1.8. Comparison 1: Face-down positioning versus other positioning, Outcome

8: Adverse events - binocular diplopia and elevated intraocular pressure at 6 months

Face-down positioning Support-the-break Risk Ratio Risk Ratio Risk of Bias

Study or Subgroup Events Total Events Total M-H, Fixed, 95% CI M-H, Fixed, 95% CI A B C D E F

1.8.1 Binocular diplopia

Casswell 2020 2 131 10 131 0.20 [0.04 , 0.90] + + + + + +

1.8.2 Elevated intraocular pressure

Casswell 2020 (1) 40 131 23 131 1.74 [1.11 , 2.73] + + + + + +

0.02 0.1 1 10 50
Footnotes Favors face-down Favors support-the-break
(1) Elevated intraocular pressure defined as > 25 mm Hg

Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions
(C) Bias due to missing outcome data
(D) Bias in measurement of the outcome
(E) Bias in selection of the reported result
(F) Overall bias

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

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#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

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#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.

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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

HISTORY
Protocol first published: Issue 12, 2022

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.

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.

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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.

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).

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.

INDEX TERMS

Medical Subject Headings (MeSH)

Diplopia [complications]; *Glaucoma; *Macula Lutea [surgery]; *Retinal Detachment [etiology] [surgery]; *Retinal Diseases;
Vitrectomy [adverse effects]

MeSH check words

Female; Humans; Male

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments (Review) 44
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