A Conversation with Antonio Capone, Jr., MD on the Topic of Face-Down Positioning after Macular Hole Surgery

First published in 2015 by Maureen Duffy.  Updated 2023.

Antonio Capone: I’m honored that you asked. My parents emigrated from Italy in the mid-1950s. I grew up in New England and went to undergraduate and medical school at Brown University. I did my residency in ophthalmology at the University of Pittsburgh and a Fellowship in Vitreoretinal Diseases and Surgery at Emory University in Atlanta.

I clearly remember deciding to be a doctor in the third grade. My dad was a psychiatrist, and someone came up to me while I was in school, speaking about my father in such glowing terms that it made a big impression on me. I aspired to be the man folks would one day see in a similar light.

I started in a psychiatry residency, anticipating that I would finish my training and work with my father. As it happened, the work was incredibly interesting intellectually, but the day-to-day practice of psychiatry wasn’t a good match for me temperamentally. The other experiences I had in medical school which were attractive to me as a specialty were surgical subspecialties. The meticulous precision of eye surgery appealed to me and proved to be a much better match for my temperament.

I did a pre-residency research fellowship in cornea and went through my residency thinking I would want to be an orbital [i.e., having to do with the eye socket] surgeon. However, once I did my retina rotation during residency, I found the career path I’d been looking for. On a personal level, it is highly impactful and incredibly gratifying work. Intellectually, I knew the vast majority of discoveries about understanding retinal disease and novel therapies were yet to be explained and analyzed; therefore, it was an endeavor that would be intellectually stimulating for my entire professional career.

One of the most-visited pages on the VisionAware website is our five-part first-person series on Surviving Recovery from Macular Hole Surgery by Joy R. Efron, Ed.D., which includes Suggestions for Maintaining Face-Down Positioning. We also have a subsequent series updated in 2017. Your research, however, indicates that face-down positioning is not required for a successful outcome. Can you share the highlights of your research with our readers?

AC: Macular hole surgery has an exciting and relatively recent evolution and history. In the late 1980s-early 1990s, the macular hole was a diagnosis without surgical intervention. Kelly and Wendel, two retinal surgeons from northern California, first sought to operate on folks with macular hole and demonstrated that they could be successfully closed in some patients with subsequent improvement in vision. Interestingly, this was a controversial topic then, as many patients with macular holes are affected in only one eye, and both before and after surgery, the better eye is the unoperated eye.

The “pros/cons of repair” controversy was followed by a debate on whether removing an intrinsic inner layer of the retina known as the internal limiting membrane (ILM) was safe. Until then, only a thin layer of scar tissue that grew on the retinal surface (epiretinal membrane, or macular “pucker”) was surgically removed. Taking off scar tissue is something that sounds logical. Removing an intrinsic layer of the retina itself seemed counterintuitive. This, too, was controversial at the time. Doing so improved outcomes (meaning the percentage of eyes with successfully closed holes).

The opposing school of thought was that while macular holes may be closed more effectively by removing the ILM, removing an inner layer of the retina itself couldn’t help but be detrimental in the long run. As it turns out, this latter concern has proven unfounded. Removing ILM in most surgeons’ hands improves the success rate in macular hole surgery from 70%-80% to 90-95%.

The other big controversy related to the issue of face-down positioning. In the early 1990s, some surgeons asked patients to lie face down for up to a month after surgery. Little by little, as my success rate in macular hole closure improved, I started to whittle away at the duration of face-down positioning. Many people hated This aspect of surgery the most, and I became less and less convinced that it was imperative for success. Over the years, I went from asking patients for a week of face-down positioning, to three days of face-down positioning, to overnight positioning.  Over the last several years, a shorter period of face-down positioning including has been more widely embraced.

What was your “hunch” or “instinct” that led to your initial decision to use a one-day recovery period after macular hole surgery? You first used this technique in 2001, correct?

AC: Yes – Since 2001, I’ve only been down to as little as overnight face-down positioning on the day of surgery. There were two main drivers to the decision to do short-duration positioning. First, my results were as good as others’ – irrespective of the positioning duration – suggesting that the positioning wasn’t the most important but the ILM peeling described above.

Second, data started to come to publication that macular hole closure could be demonstrated within 24 hours of surgery using an imaging technology known as optical coherence tomography (OCT). [Editor’s note: OCT is a medical imaging technology that produces high-resolution cross-sectional and three-dimensional eye images.]

We published our results on the one day of face-down positioning, entitled Surgical outcomes of idiopathic macular hole repair with limited postoperative positioning, which were as good as those published by anyone else. Currently, I don’t require face-down positioning at all for typical macular holes.

MD: I’m interested to know your thoughts about many of the great strides that have been made during the past ten years in eye care, especially with the early, yet positive, results from stem cell clinical trials for Stargardt disease and dry macular degeneration and gene therapy for retinal disease.

AC: Stem cell therapy is an interesting topic. The notion of stem cell therapy is very attractive. The idea that you can take a so-called pleuri-potential cell, which has the theoretical capacity to become any needed cell and be normal in structure and function, and place that cell anywhere in the body is extremely attractive.

Conversely, the scientific reality of stem cell therapy is nowhere near as advanced as this notion. A good analogy would be taking a wrench and throwing it at a car with an engine problem and hoping that the wrench will somehow know how to fix the car. Unsurprisingly, the early days of stem cell therapy, and I don’t think we are far from that now, have been fraught with stops and starts, high expectations, and frequent disappointment.

All of that said, it is an incredibly promising therapy. However, stem cell therapy will become a reality in small methodical steps, as is typically the case in scientific endeavors. While there is a role for stem cell therapy in the management of hereditary and degenerative diseases, there is yet a long piece of road before that role is realized. That we are in a day and time when stem cell clinical trials are ongoing is very exciting. However, I think this work is still in its infancy.

Gene therapy has a similar appeal, as our understanding of disease increasingly demonstrates a genetic/molecular basis. The notion of fixing cells with the wrong genetics by inserting the right genetics again has appeal by its simplicity. And again, the reality is a bit more daunting, but this approach has incredible promise. Also, the technology is in the clinical trial phase, which generally means approximately 2-6 years before implementation in routine clinical care.

MD: What do you consider the next great frontier in ophthalmology or vision science?

AC: For all of medicine, understanding the molecular basis of a disease is the linchpin for developing effective therapeutic interventions. For example, right now, we have very effective therapies directed against vascular endothelial growth factor, the overproduction of which is important in several clinical conditions. [Editor’s note: When used in the context of ophthalmology, vascular endothelial growth factor, or VEGF, is a protein that stimulates abnormal blood vessel growth in the retina and macula.] After understanding the molecular mechanism of a disease, delivering the drug therapy is the next big step, typically taking 2-5 years to get to clinical trials.

Another area of great interest and activity is regenerative medicine.  The vision in this line of work is to move beyond prevention and repair to the restoration of lost tissues.

Once we unravel the therapeutic riddles leading to new effective therapies, the next challenge is drug delivery. I’d expect big strides in the next 5-10 years in this area of research as well. The time when a disease with a specific molecular fix can be treated with a sustained delivery approach will be soon upon us. It’s a very exciting time for research into diseases of the retina and vitreous.

We thank Dr. Antonio Capone for his support of VisionAware and his longstanding research and practice on behalf of blind and visually persons worldwide. It has been a privilege to speak with you.