Patient information: Macular hole

What is the macula? The retina lines the inside of the back of the eye.  It functions a bit like the film in the back of a camera, in that it absorbs light to form an image of the outside world.  The most important part of the retina is the macula - this is the part of the retina that the light is focussed on.  It gives the central vision that is important for fine visual tasks such as reading and driving.
What is a macular hole? As the name suggests, it is a hole in the macula. It produces blurred or distorted vision although some patients are more affected than others.

Macular hole
Laser image (OCT) of a macular hole

Do I need surgery? This depends on a number of factors.  Firstly, the severity or stage of the hole. Early, less severe holes may not respond to surgery, and equally, neither may very advanced, longstanding holes.   Without surgery most holes remain much the same and they do not go on to cause total loss of vision. Occasionally they heal themselves but this is rare in cases other than very mild macular holes. For most patients the best chance of visual improvement is with surgery.      

What does surgery involve? The name of the operation used to treat macular hole is vitrectomy, internal limiting membrane peel, and intraocular gas injection.  Dealing with each in turn: vitrectomy involves a microsurgical procedure to remove the clear gel (vitreous) that fills the inside of the eyeball.  This gel is 99% water and the body will refill the eyeball with water again after surgery.  Internal limiting membrane peel involves removal of the innermost layer of the macular - this is thought to promote closure of the macular hole. Last, a gas is injected into the eye, until such time as the body replaces it with its own water.  This gas helps push the hole closed and for this reason many patients are asked to assume a face down position after surgery to float the gas bubble into the correct position, although the benefit of face down posturing is hotly debated amongst retinal surgeons.  The operation can be performed under a local anaesthetic (awake but with an injection to numb the eye), or general anaesthetic (asleep).  It takes about 45-60 minutes.  

What are the potential benefits of surgery?  In about 80-90% of patients the macular hole closes after surgery, but the effect on vision is variable.  About two-thirds to three-quarters experience a useful improvement in vision but few obtain 100% normal vision. If the hole fails to close after the first operation it is usually possible to re-operate.

What are the risks of surgery? Any eye operation caries some risk.  Serious, sight-threatening complications such as haemorrhage or infection are thankfully extremely rare and occur in only about 1 in 500 patients.  In those that haven't previously had cataract surgery the macular hole surgery will tend to promote cataract formation and it is likely that this will need surgical treatment at some time in the future.    Other complications such as retinal breaks or retinal detachment occur in less than 5% of cases but they can usually be treated.

Are there any particular precautions after surgery? Yes. Your nurse will go through the general instructions for someone who has just had an operation such as keeping the eye clean, use of eyedrops, and follow-up appointments, however after macular hole surgery there are two specific restrictions. Firstly you must not go up to high altitude as the gas in the eye will expand and this puts the eye pressure up.  Hence you cannot fly, or go up high mountains until the gas absorbs -this can take 1-2 months depending on what type of gas is used.  Secondly, if you need a general anaesthetic you must inform the anaesthetist that you have gas in the eye to avoid certain anaesthetic gases.    

Any further questions? When you come for a consultation we will go through the pros and cons of surgery but if you have any further questions please do not hesitate to ask me or one of my team.  It may be possible to arrange for you to talk to someone who has had macular hole surgery - just ask.  If you drive you should check with us whether it is safe to continue.

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