Treatment Options
The only widely studied treatment option for macular hole repair at this time is pars plana vitrectomy.
Step 1 – Learn the basics about a macular hole
Step 2 – Learn about the surgery and what to expect
Step 3 – Learn about the other options
Step 4 – Learn about the potential risks of the procedure
Step 5 – Learn to maximize your results
The eye can be thought of as similar to a camera, with two main parts, a lens and a film. In addition, there is a gel called the vitreous that is located in front of the retina and is very firmly adherent to it. The film layer is called the retina and lines the back wall of the eye. The area of the retina responsible for our central vision is called the macula. A macular hole causes the central vision to be very blurry, but the peripheral vision remains intact.
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 pulling away from the retina may be strong enough that it causes a full-thickness retinal hole to form in the macula. An additional component of pulling which maintains the hole in an open position comes from one of the layers of the retina called the internal limiting membrane.
A macular hole is repaired with an outpatient surgical procedure called a pars plana vitrectomy. It may be performed under under twilight (monitored anesthesia care) or general anesthesia.
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 vitreous cavity while the surgeon uses a vitrectomy probe to carefully removes the vitreous. The surgeon then carefully peels the internal limiting membrane off of the macula. The eye is filled up with a self-absorbing gas bubble and evaluated carefully for retinal tears. An eye patch and eye shield are placed on the eye. The purpose of the gas bubble is to serve as a bridge for cells on either site of the hole to migrate across, and close the hole. The patient is typically asked to maintain a face down position for approximately 7 days following surgery. Face down positioning is the ideal position to allow 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 breath.
There are two different types of self-absorbing gas: SF6 and C3F8. SF6 typically lasts approximately 2 weeks and C3F8 approximately 6-8 weeks. It is not possible to see through the gas bubble. The gas bubble will resolve over a period of several weeks. Patients will notice a clear area at the top of their visual field which represents the area of 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. At this point, the central vision will slowly become clearer. This process will occur until the gas bubble resolves completely. The central vision is typically blurry, but improves slowly over a period of several months.
Patients may not travel to high altitudes or fly when they have a gas bubble in the eye. The gas bubble expands rapidly in high altitudes causing high eye pressure and blindness.
The only widely studied treatment option for macular hole repair at this time is pars plana vitrectomy.
The retina specialists who recommends the treatment will discuss the risks, benefits, and alternatives to the procedure. It is up to the judgement of the physician to weigh the benefit of the procedure to the potential risks. It is only once the decision is made that the benefits outweigh the potential risks is the procedure offered to the patient.
Pars plana vitrectomy is reported to be successful in repairing a macular hole in 1 surgery approximately 92% of the time.
The most significant risk of pars plana vitrectomy is failure of the procedure to repair the macular hole. In this case, another surgery, such as an additional pars plans vitrectomy is typically required. There is an approximately 85% closure rate of patients undergoing a second surgery for macular hole.
Additional risks of the surgery include retinal detachment, infection, and progression of cataract.
Symptoms of retinal detachment include the sudden onset of many new floaters, new onset flashing lights, or noting a progressive decrease in the peripheral vision (like a curtain coming down at a play). This is urgent and the treating physician should be made aware the same day.
There is a small risk of infection following the procedure. If this is going to occur, it typically occurs 3-5 days following the procedure. Symptoms include redness around the eye that gets worse not better, extreme light sensitivity, and worsening pain. This is a medical emergency and requires immediate treatment by a retina specialist.
Patients who still have their nature lens will experience progression of their cataract following vitrectomy surgery. Approximately 90% of patients who are 50 years or older will require cataract surgery within 2 years.
All surgeries are associated with a number of other uncommon, but possible problems. Potential complications of pars plana vitrectomy include high eye pressure, bleeding within the eye, development of new retinal tears, and the need for further procedures.
Positioning correctly is very important to the success of the surgery. It is strongly recommended to prepare for the positioning requirements prior to proceeding with the surgery. We would recommend purchasing Vitrectomy with Face-Down Recovery: A Nurse’s Journey if you are interested in optimizing your face down experience and comfort.
There may also be value in purchasing additional equipment to make the process more convenient.
It is critical to the success of the procedure to maintain the positioning requested for 50 minutes per hour, 24 hours per day (including during sleep). Most physicians will recommend 1 week of positioning.
It is not possible to see through the gas bubble. The gas bubble will resolve over a period of several weeks. The central vision will become clearer over several weeks to months.
It is important to use eye drops as prescribed by your retina specialist. Patients should ask if they need to continue to use prescription eye drops they were using prior to surgery(such as for glaucoma).
Peripheral vision – The peripheral vision should gradually become clearer. If the peripheral vision becomes dark and starts to become larger, this is a sign of a recurrent retinal detachment. Infection – The eye should continue feeling better following surgery. Infection is characterized by a combination of severe eye pain, profound light sensitivity, and a decrease in vision. This must be treated emergently.
Traveling to high altitudes results in rapid expansion of the gas bubble and subsequent blindness. Patient may not travel to high altitudes until the gas bubble resolves.
Administration of nitric oxide for anesthesia may cause rapid expansion of the gas bubble and blindness. Patients should make their anesthesiologist aware they have a gas bubble in the eye if they are undergoing surgery.
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