What is a Macular Hole?
What is the macula?
The back of the eye has a light-sensitive lining called the retina, similar to the film in a camera. Light is focused through the eye onto the retina, allowing us to see. The centre part of the retina is called the macula – it is here that light must be focused for us to see fine detail, to be able to read and to see in colour.
What is a macular hole?
A macular hole is a small, circular gap which opens up at the centre of the retina. This causes blurred vision and often distorted vision where straight lines or letters look wavy or bowed. There may also be a patch of missing vision at the centre.
Is a macular hole the same as age-related macular degeneration?
No, macular holes and macular degeneration are different conditions although they affect the same area of the eye. They can sometimes both be present in the same eye.
Why do Macular Holes happen?
We do not know why macular holes develop. They most often occur in people aged 60-80, and are twice as common in women as men. Mainly slightly long sighted people are affected. Other causes of macular holes include severe trauma to the eye, being very short sighted (myopic), those who have had a retinal detachment or as a result of longstanding swelling of the central retina (cystoid macular oedema).
Do I have to have macular hole surgery?
What would happen if I did not have my macular hole treated?
If untreated, there is a small chance that some very small macular holes can close spontaneously, with improvement in vision. In the majority of patients the central vision will gradually get worse to a level where the patient is unable to read even the largest print on an eye test chart. The condition does not affect the peripheral vision, and so patients will not go completely blind from this condition.
Can I develop a macular hole in my other eye?
Careful examination can assess the risk of developing a macular hole in the other eye. This may be from extremely unlikely to a 1 in 10 chance. It is very important to monitor for any changes in the vision of the fellow eye, and report these as soon as possible.
Questions I usually ask
· Are you having difficulty seeing the TV screen clearly or reading subtitles?
· Are you struggling to recognize bus numbers or people’s faces until they are really close?
· Is it difficult reading small print unless the lighting is really bright?
· Do you feel that your glasses aren’t giving you clear vision, and your optician has said that
they can’t improve with a new prescription?
· Do you have hazy vision?
· Is it difficult to see clearly when you are driving?
· Do you have glare with night driving or in bright lights (such as supermarket lighting)?
· Are you having difficulty reading music?
· Is your vision affecting your work?
· Do have a particular hobby or interest that your vision is affecting?
Even if some of these are affecting one eye you may feel you can manage because the vision is better in the other eye.
If the hole has been present for less than a year, the operation will be successful in closing the hole in about 90% of cases. Of these, more than 70% will be able to see two or three lines more down a standard vision chart, compared to before the operation. Even if this degree of improvement does not occur, the vision is at least stabilized and many patients find that they have less distortion, which is helpful. In a minority of patients the hole does not close despite surgery and the central vision can continue to deteriorate; however, a second operation can still be successful in closing the hole. It is important to understand that return to completely normal vision is not possible.
What happens if I don’t want to have surgery for macular hole?
If you do not want to have surgery for your macular hole because it is not causing you any problems, or because you didn’t know you had a problem until you went for a routine check, then you may feel that you don’t want an operation. A Macular Hole left untreated does not spread to involve the whole of the retina, so only your central vision will be affected. Over time, the hole may get slightly larger, and you may notice the central blind spot becomes a little larger. Macular holes have a lower chance of closure after surgery if they have been present for over 1-2 years.
I generally recommend earlier surgery for macular holes, as, in my experience, early surgery results in a better chance of closure.
What sort of vision can I expect if my macular holes closes?
Once a hole has closed, the distortion usually gets better – it may not go away completely, but it will interfere less when you are using other eyes together. The vision usually gets better as well, but it will not go back to normal. We can’t predict how much better it will be, and this varies from person to person. Most people find that macular hole surgery has been helpful to their vision.
A macular hole can often be repaired by an operation called a Vitrectomy, peel and gas. However, for some types of macular hole, a newer treatment called ocriplasmin, or Jetrea, may be suitable. Ocriplasmin (Jetrea) is injected into the eye on a once only basis, and may close small holes, eliminating the need for vitrectomy surgery if it is successful.
What are the potential complications of macular hole vitrectomy surgery?
As with any procedure there may be risks involved and we will discuss these fully prior to your operation, however it is unlikely that you will suffer harmful effects from a macular hole operation. In a small minority, the vision may end up worse than before the surgery, and there is even a tiny chance of total loss of sight. Six specific complications of macular hole surgery, which you must be aware of, are outlined below:
1. Failure of the macular hole to close: this occurs in 1-2 out of 10 patients. In most circumstances, it is possible to repeat the surgery. If the hole fails to close, then the vision may be a little worse than prior to the surgery.
2. Cataract: this means that the natural lens in eye has gone cloudy. If you have not already had a cataract operation, you will almost certainly get a cataract after the surgery, usually within a year but it can happen very rapidly. As cataract is inevitable, you may be offered combined surgery with cataract extraction at the same time as the macular hole repair.
3. Retinal detachment: the retina detaches from the back of the eye in 1-2% of patients undergoing macular hole surgery. The vast majority of retinal detachments are repairable, but further surgery is required and this can be a potentially blinding complication.
4. Bleeding: this occurs very rarely, but severe bleeding within the eye can result in blindness.
5. Infection: this is also very rare and would be expected to occur in about 1 in 1000 patients, but if it occurs needs further treatments and can lead to blindness.
6. Raised eye pressure: an increase in pressure within the eye is quite common in the days after macular hole surgery, usually due to the expanding gas bubble. In most cases it is short-lived and controlled with extra eye drops and/or tablets to reduce the pressure, preventing any harm coming to the eye. If the high pressure is extreme or becomes prolonged, there may be some damage to the optic nerve as a consequence. In the majority, this damage does not adversely affect the vision, but some patients require long term treatment to keep the eye pressure controlled.
Will I have to take any drops or medication after the operation?
Drops are always prescribed after surgery: an antibiotic and a steroid. Patients are seen again in the clinic one to two weeks after the surgery. If all is well, then the drops are reduced over the following 2-4 weeks. If the eye pressure is raised following surgery, additional drops and/or tablets may be prescribed to treat this.
When will I need to be seen again after the surgery?
Post-operative review is usually performed the next day (or within a few days) after surgery; then 7-14 days later and, provided all is well, about 1-3 months later.
Will I have to get my glasses changed?
Most people will need to change their spectacle prescription at some point after surgery. This would normally be at about 3 months following the operation, after the gas bubble has gone. As each case is different, please check with me before visiting an optician.
What does Macular Hole surgery involve?
What does a Vitrectomy operation for Macular Hole involve?
Macular hole surgery requires vitrectomy which is a form of keyhole surgery performed under a microscope, using 3 small incisions (1-2 mm in size) in the white of the eye for insertion of very fine instruments. Firstly the vitreous jelly is removed (vitrectomy), and then a very delicate layer (the inner limiting membrane) is carefully peeled off the surface of the retina around the hole to release the traction forces that keep the hole open. The eye is then filled with a temporary gas bubble, which presses against the hole to help it seal. The bubble of gas blocks the vision whilst it is present, but slowly disappears over a period of about 8 weeks.
How long does the operation take and do I need to have a general anaesthetic?
Macular hole surgery usually takes 45-90 minutes and can be done with the patient awake (local anaesthetic), or asleep (general anaesthetic), often as a day case procedure. Some patients opt for a local anaesthetic, which involves a numbing injection around the eye so that no pain is felt during the operation; this is sometimes supplemented with medication to reduce anxiety (sedation).
Do I have to posture face down after the operation?
The aim of face down posturing is to keep the gas bubble in contact with the hole as much as possible to encourage it to close. There is evidence that posturing improves the success rate for larger holes, but it may not be needed for smaller holes.
I generally ask patients to maintain an ‘eyes down’ position, similar to reading a book in your lap. You should try to remain in this position for usually 45 minutes in each hour for 3-5 days after the operation. A short break of 15 minutes can be taken every hour to allow eating, trips to the bathroom etc. Aids are available that can make face down posturing easier to manage e.g. a horseshoe-shaped pillow or a purpose-made cushioned frame. Please remember that if you are not able to posture then there is still a good chance that the hole will close successfully.
Am I able to travel after macular hole surgery?
You must not fly or travel to high altitude on land whilst the gas bubble is still in the eye (between 4 to 8 weeks). If ignored, the bubble will expand at altitude, causing very high pressure resulting in severe pain and permanent loss of vision. You will notice the bubble shrinking and will be aware when it has completely gone.
Other precautions related to gas
If you need a general anaesthetic whilst gas is in your eye, then it is vital that you tell the anaesthetist this so they can avoid certain anaesthetic agents which can cause similar expansion of the bubble. None of these exclusions apply once the gas has fully absorbed.
What should I do following surgery?
Following surgery, you will be given eye drops to use for a few weeks, which will help the eye settle from surgery. The operation does not require staying in hospital longer than one night and patients are typically reviewed in clinic one to two weeks after surgery. If a gas bubble has been used, you may be asked to position your head in a certain way for some part of the day for a number of days. Otherwise, you can do most daily activities although you should abstain from unhygienic environments and anything that puts the eye at risk of injury.
When to seek further advice
All operations carry a risk of complications either during or after surgery. One of the most important complications is infection, although the risk is very low at less than 1 in 500. Infections can be treated with prompt antibiotics. Your eye will usually be red and uncomfortable immediately after surgery, and this is to be expected, but you should contact us if you notice any of the following:-
· Increasing pain
· Increasing redness
· Worsening vision
If you have had a gas or oil bubble in the eye I will have checked the pressure in the eye after surgery. Sometimes, the pressure is normal in the first 24 hours but becomes high in the following few days. High pressure in the eye may cause pain in and around the eye, and you will need to be seen for a repeat pressure check. If the pressure is high it usually responds very well to some additional eye drops that bring the pressure down, and you will be prescribed these for a few weeks.
General precautions after eye surgery
· Use your drops as prescribed. Please do arrange for help with eye drops after your operation if you do not feel you can put them in yourself.
· Cleanse the eye gently with boiled, cooled water.
· Avoid rubbing the eye.
· Do wear the eye shield at night for the first few nights, as it will reduce the risk of accidentally rubbing the eye in your sleep.
· You can be as mobile as you feel comfortable with, but do remember that you have had a big operation and you may feel tired.
· Do not drive in the first few days after surgery as you may not have clear vision with both eyes open and your judgement of distances and your awareness in your peripheral vision may be impaired.
· You may use your vision as much as is comfortable.
How much time will I need off work?
Most people will need 10-14 days off work. Your vision is reduced while the gas bubble is in the eye and this also affects depth perception. However, it depends on the type of work you do and the speed of recovery. We will discuss this at your consultation.
Where can I find more information?