The eye can be thought of as a camera, with two main parts, a lens, and a film. The film layer is called the retina and lines the back wall of the eye. There is a gel called the vitreous that is located in front of the retina and is very firmly adherent to it. The part of the retina responsible for central vision is called the macula.
What is a Macular Hole?
A macular hole causes the central vision to become blurry, but without any change to the peripheral vision.
The vitreous separates from the back of the eye towards the front of the eye as a normal part of aging (posterior vitreous detachment). The pulling force of the vitreous separating from the retina may be strong enough that it causes a full-thickness retinal hole to form in the macula. The topmost layer of the retina called the internal limiting membrane prevents the hole from closing by itself.
Macular Hole Procedure
A macular hole is repaired with an outpatient surgical procedure called a pars plana vitrectomy. It may be performed with the patient awake (painless) or asleep (general anesthesia).
Pars Plana Virectomy
The retina specialist places 3 small ports that are approximately one-half (0.5) millimeters in thickness through the white of the eye and into the vitreous cavity. Fluid is infused into the eye while the vitreous (gel) is removed. The retina specialist then carefully peels off the internal limiting membrane that is in close proximity and overlying the macular hole. The fluid in the eye is replaced with a self-absorbing gas bubble and evaluated carefully for retinal tears. An eye patch and eyeshield are placed on the eye.
The purpose of the gas bubble is to serve as a bridge for cells on either side of the hole to migrate across and close the hole. The patient is typically asked to maintain a gaze down or face down position for approximately 3-7 days following surgery. Gaze-down positioning allows the gas bubble to come in contact with the macula. Most physicians will ask the patient to maintain face-down positioning for 50 minutes of every single hour of the day. It may be helpful during sleep for patients to rest the cheek of the non-operative side on the corner of the pillow and tilt their head slightly to the side so they may still breathe.
What To Expect After Your Macular Hole Procedure
The single most important action patients may take to increase their chance of successful macular hole repair is to follow the positioning requirements strictly. Patients who do not follow instructions are at much higher risk of the macular hole not closing with one surgery.
The most common type of self-absorbing gas that we use lasts approximately 2 weeks. The vision while looking through a gas bubble is extremely blurry. Most patients are only able to see motion, but no detail. Patients will notice a clear area at the top of their visual field which represents the area of the retina not covered by the gas bubble. This area will become larger over time until the gas bubble no longer covers the area of central vision. This usually occurs approximately 1 week following surgery. The gas bubble will slowly move lower in the vision and then form several tiny bubbles before resolving completely.
Patients will notice that the vision which was affected by the macular hole remains blurry even after the gas bubble migrates below the part of the retina responsible for central vision. This is because the cells responsible for vision (photoreceptors) migrate from either side of the pre-existing hole towards the center much more slowly. The vision will slowly improve over several months as these cells finish migrating towards the center and reorganize. There is no special diet, vitamins, or activities that patients need to follow to optimize this process.
What To Avoid
Patients may not travel to high altitudes or fly when they have a gas bubble in their eye. The gas bubble expands rapidly in high altitudes causing high eye pressure and blindness. Patients will typically be re-evaluated one day after surgery. An ophthalmic technician will remove the patch, shield, and prepare the patient to see the doctor. The doctor will discuss positioning requirements as well as provide instructions on eye drops to use in the post-operative period. Patients are then typically seen 1-2 weeks following surgery for an additional postoperative evaluation.
Patients are unable to drive immediately after surgery or the following day. It is safest to avoid driving until the gas bubble resolves. Most retina specialists will ask patients to avoid lifting greater than 20 pounds for at least two weeks. It is also recommended to avoid high-impact activity or rapid acceleration/deceleration for at least 4 weeks following surgery.
Benefits & Risks
This surgery is generally considered to be safe and effective. However, all surgeries have some associated risks. Your retina specialist believes the benefits far outweigh the risks. Please see the primary risks of macular hole repair below.
- Macular hole repair has a greater than 95% chance of successfully repairing the hole with one surgery. There is a less than 5 percent risk that additional surgery would be needed to repair the hole.
- Patients who have not already undergone cataract surgery will experience a worsening of cataracts. Patients who are 50 years or older have a 90% chance of requiring cataract surgery within 2 years of vitrectomy
- There is less than a 1% chance of developing a retinal detachment following surgery. Signs of a retinal detachment include the sudden onset of new flashing lights, many new floaters, or see a new dark curtain in a previously clear area of vision. Patients experiencing these symptoms should reach out to their retina specialist promptly.
- There is an approximately 1/5000 chance of developing an eye infection following macular hole repair. Patients may decrease their risk of developing this condition by avoiding touching, rubbing, or allowing water to enter the eye for at least one week. The sudden onset of severe eye redness decreased vision, and severe sensitivity to light may be the sign of an eye infection. Patients experiencing these symptoms should reach out to their retina specialist promptly.
- Macular hole repair is a highly successful surgery that significantly improves vision in the vast majority of patients.