Sir,

We thank Drs Woo and Au Eong for their interest in our article and are pleased to offer our replies.

The study was conducted in Worthing Hospital and Moorfields Eye Hospital. To clarify, patients who were operated in Worthing were assigned to the non-posturing group and the ones who were operated in Moorfields were instructed to posture postoperatively.

Posturing instructions to study patients were given by the research staff and were clear. Patients in the posturing group were instructed to assume 10 days face down positioning. In the non-posturing group, patients were advised to carry on as normal without assuming any particular position but they should avoid lying supine for 10 days. This was done to minimise the disruption of macular hole surgery to their daily routine, which is currently one of the main limitations of conventional surgery.

They raise an interesting point regarding compliance, which is an important issue in these patients. Previous reports have shown that even when strict instructions are given, patients fail to follow them as required.1, 2, 3 Due to the difficulty in posturing, and the disruption to the postoperative quality of life, it is even less likely that patients who were not instructed to posture would do so for any significant amount of time. As the macular hole surgery in the two groups was conducted in two different units with two separate protocols regarding posturing postoperatively, it is very unlikely that any member of staff would have informed non-posturing patients about posturing and the patients would certainly not have witnessed other patients posturing on the ward. Admittedly, they could have got information via the internet, but none from this group queried the need for posturing to any of the research staff during the length of the study. Furthermore, differences in indirect signs between the two groups including more pigment on the endothelium and the development of significantly less cataract in the posturing group indicated that patients made an effort to comply with their given instructions as much as possible. Our results have also been corroborated by subsequent reports, which have found comparable success rates to ours for macular hole surgery with no posturing.4

We agree that the lack of randomisation of the two groups may have been a source of bias, and despite the prospective controlled design of our study, we recognised limitations including the small sample size, the limited post surgical follow-up and the non masking of researchers. Nevertheless, our results have encouraged a randomised controlled trial, which is currently ongoing at Moorfields Eye Hospital and will give more solid evidence regarding the role of posturing in Macular hole surgery.