since 1991 , stage 2 , 3 , and 4 idiopathic macular holes ( mhs ) have benefited from effective treatment as described by kelly and wendel . the surgical procedure comprises pars plana vitrectomy , without cataract surgery , removal of adherent cortical vitreous , stripping of epiretinal membranes , total fluid - air exchange , and sf6   gas tamponade , with strict occiput - up postoperative positioning for at least 1 week . this face - down positioning is uncomfortable , and extended periods of such positioning can also prolong immobilization , leading to ulnar nerve neuropathy   and pressure sores . first challenged the necessity of face - down positioning in mh surgery in 1997 . in their study phakic eyes underwent combined cataract extraction with posterior chamber intraocular lens ( iol ) insertion using 15% c3f8 gas and no internal limiting membrane ( ilm ) peeling , and the primary closure rate was 79% . we previously reported the results of a pilot study of 21 eyes of 21 patients that underwent vitrectomy with ilm removal , and sf6 gas tamponade without postoperative face - down positioning for mh . the surgical procedure involved cataract extraction and iol implantation in all phakic eyes ( 20 of 21 eyes ) . we present herein the results of a larger number of cases with a longer postoperative followup . this retrospective case series included 42 eyes of 42 patients undergoing combined vitrectomy with phacoemulsification performed by a single surgeon ( f. y. ) , without postoperative face - down positioning . the procedures were performed at the department of ophthalmology , toho university ohashi medical center , from september 2006 to february 2011 . patients whose mh duration was longer than 6 months or unknown who had secondary mh , such as that due to trauma , chronic cystoid macular edema , or high myopia , and patients with clear lenses or pseudophakia were excluded from the study . after the risks and benefits of combined vitrectomy with phacoemulsification without postoperative face - down positioning had been thoroughly explained , written informed consent was obtained from all patients . the informed consent process and the corresponding consent forms were approved by the ethics review committee of toho university ohashi medical center . mh was diagnosed by stereoscopic biomicroscopy and optical coherence tomography ( oct ) and graded according to the gass classification . of the 42 patients , 32 ( 76.2% ) were women and 10 ( 23.8% ) men , with mean age of 64.4 years ( range , 5279 ) . among the 42 eyes , 7 ( 16.7% ) had stage 2 , 27 ( 64.3% ) stage 3 , and 8 ( 19.0% ) stage 4 mh . mh had been present for an average of 2.5 months ( range , 16 months ) . the surgical procedure involved cataract extraction and iol implantation before standard 20  g or 25  g three - port vitrectomy . core vitrectomy was followed by surgical creation of a posterior hyaloid detachment in eyes with either stage 2 or 3 mh . indocyanine green ( icg ) diluted to a concentration of 0.125% was used to aid ilm peeling . the ilm was peeled beyond a radius of 1  disc diameter around the mh . fluid - air exchange was performed , with no attempt to aspirate fluid from the mh , and the vitreous cavity was exchanged with double - filtered 20% sf6 gas in all cases . patients were prohibited from assuming a face - down or face - up position until the gas had been completely absorbed . preoperative data collected included age at surgery , sex , eye ( left or right ) , visual acuity ( va ) and mh stage , size , and duration . the mh status of all patients was evaluated before and at 1 , 3 , and 6 months after surgery by stereoscopic biomicroscopy and oct . va was also examined at these time points using a decimal chart , and the values were then converted to the logarithm of the minimum angle of resolution ( log mar ) scale . we evaluated the longevity of 20% sf6 gas bubbles until confirmation of mh closure or nonclosure after surgery . of the 42 mhs , 40 ( 95.2% ) holes closed after the first surgery , and 2 holes did not . in these latter 2 cases , an additional 0.75  ml of 100% sf6 gas was injected with 3 days of face - down positioning after 20% of the sf6 gas used for the initial surgery had been absorbed . this resulted in closure of one mh ( case 11 ) . for the remaining eye ( case 17 ) , additional surgery was performed in which the radius of the ilm removal was enlarged to 1  disc diameter wider than that in the previous surgery . then , the vitreous cavity was exchanged with 20% sf6 , followed by face - down positioning . the final closure rate was thus 100% , and no eyes showed reopening .   the preoperative mean va ( log mar ) of 0.65 significantly improved to 0.43 at 1 month , 0.35 at 3 months , and 0.29 at 6 months after surgery ( p < 0.0001 , repeated measures anova ) . the mean longevity of 20% sf6 gas bubbles , until confirmation of mh closure or non - closure after surgery , was 7.6 days ( range 411 days ) . three ( 7.1% ) of these patients ( cases 14 , 26 , and 33 ) had postoperative rhegmatogenous retinal detachment that required additional surgery to reattach the retina . guillaubey et al .   compared results between a face - down position and a seated positioning after mh surgery . they speculated that the mechanism of mh repair with the patient seated is as follows . buoyancy is related to density and surface tension is related to the viscosity of the tamponade product . the buoyant force is maximal at the apex of the bubble , depending on gravity and tamponade product depth . after mh surgery , the buoyant force is of minor significance because the most important feature of the bubble is its surface tension , which leads to closure of the hole by keeping its edge dry , independent of buoyancy . thus , with a sufficient volume of intraocular gas , the position of the eye after intraocular tamponade should not influence surface tension around the mh . we hypothesized that it does not matter whether the patient is seated or otherwise without face - down positioning , that is , that positioning strategy is not relevant because the mechanism of mh repair is the same regardless of the postoperative position of the patient .    in 2001 , simcock and scalia   reported a 90% success rate phacovitrectomy without prone posture for stage 2 and stage 3 mh using 20% c2f8 gas and no ilm removal . in 2008 , madgula and costen   reported on 31 eyes with combined phacovitrectomy for mh using 16% c3f8 gas with ilm peeling without prone posturing . heath and rahman   reported a 92.5% success rate of 23-gauge vitrectomy with phacoemulsification without face - down posturing , using 16% c2f6 gas with ilm peeling . in the present series , surgery was performed with ilm peeling , 20% sf6 gas tamponade , and no face - down positioning and the anatomical success rate was 95.2% with a single operation and 100% with a single additional surgery . these findings suggest that combined vitrectomy with phacoemulsification without postoperative face - down positioning and 20% sf6 gas may be as effective for achieving hole closure as c3f8 gas . patients can return earlier to their usual activities after surgery with sf6 gas because this gas is absorbed more quickly than c3f8 gas . the methods and results of various studies of combined vitrectomy with phacoemulsification without postoperative face - down positioning are summarized in table 2 . vitrectomy in phakic elderly patients results in the development of nuclear sclerotic lens opacity   and large long - acting gas to fill in the vitreous cavity can induce a more immediate  gas combined vitrectomy with phacoemulsification has many advantages for both the patient and surgeon [ 1214 ] . the patient does not need to return for additional surgical procedures and the surgeon does not need to perform a technically difficult operation . this is due to the lack of vitreous support which may result in unstable anterior chamber depth and variable pupil size during cataract surgery . in patients with clear lenses , vitrectomy without phacoemulsification with postoperative face - down positioning for a few days was performed so that they did not develop cataracts .   in this study , iatrogenic retinal tears occurred intraoperatively in 14 ( 33.3% ) eyes , and 3 ( 7.1% ) of these patients had postoperative rhegmatogenous retinal detachment . this rate appears to be higher , but hotta et al .   reported that patient with peripheral retinal breaks or retinal detachment had significantly shorter duration of mh symptoms ( 3.2 months ) than those without these complications ( 10.0 months ) . in the present series , mh had been present for an average of 2.5 months ( range , 16 months ) . we plan to find between iatrogenic retinal tears or rhegmatogenous retinal detachment and duration of mh in the near future . combined vitrectomy with phacoemulsification , ilm removal and sf6 gas tamponade followed by no face - down positioning is a potentially useful option for patients in whom a postoperative face - down positioning is difficult . in addition , postoperative care without face - down positioning is simpler and more convenient . the limitations of our study include the lack of a concurrent control group and the fact that a single vitreo - retinal surgeon performed all procedures . therefore , there are no data to compare the results between different surgical procedures or between surgeons or for evaluating the accuracy of the success rate .   in conclusion , in 42 eyes of 42 patients , combined vitrectomy with phacoemulsification , ilm peeling , and sf6 gas tamponade for mh without postoperative face - down positioning achieved favorable anatomical and functional results . these surgical methods may spare patients the potentially unnecessary inconvenience of postoperative face - down positioning . the authors have no proprietary or commercial interest in any materials discussed in this paper .
purpose . to evaluate the outcome of combined vitrectomy with phacoemulsification without postoperative face - down positioning for idiopathic macular holes ( mhs ) 
 . design . 
 retrospective , observational case series . participants . 
 forty - two eyes of 42 patients with mh . methods . 
 we studied 42 eyes of 42 cases followed up for 6 months postoperatively . 
 mh closure rate and preoperative and postoperative visual acuity ( va ) were evaluated . 
 main outcome measures . 
 mh closure rate and va were evaluated after combined vitrectomy with phacoemulsification without postoperative face - down positioning . 
 results . of the 42 holes , 40 ( 95.2% ) were initially closed , and the final closure rate was 100% . compared with preoperative va , the mean va was significantly improved at 1 month and the improvement was maintained for at least 6 months postoperatively . conclusions . combined 
 vitrectomy with phacoemulsification without postoperative face - down positioning produced favorable anatomic and functional results for mh repair . 
 improvement in va can be expected for up to at least 6 months postoperatively .