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Macular Hole
Royal Hallamshire Hospital
Information for patients
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What is the macula?
The back of the eye has a light-sensitivelining called the retina, similar to the filmin a camera.
Light is focused through the eye onto theretina, allowing us to see.
The centre part of the retina is called themacula - it is here that light must befocused for us to see fine detail, to be ableto read and to see in colour.
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*Image courtesy of the National Eye Institute http://www.nei.nih.gov
Vitreous gel
Optic nerve
MaculaFovea
Retina
Iris
Cornea
Pupil
Lens
Iris
What is a macular hole?
A macular hole is a small, circular gap whichopens up at the centre of the retina. This causes blurred vision and oftendistorted vision where straight lines orletters look wavy or bowed. There may alsobe a patch of missing vision at the centre.
Is a macular hole the same as age-relatedmacular degeneration?
No, macular holes and maculardegeneration are different conditionsalthough they affect the same area of theeye. They can sometimes both be present inthe same eye.
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Macularhole
Why does it happen?
We do not know why macular holes develop.They most often occur in people aged 60-80,and is twice as common in women as men.We are increasingly aware that it is mainlyslightly long sighted people who areaffected. Other causes of macular holesinclude severe trauma to the eye, being veryshort sighted (myopic), those who have hada retinal detachment or as a result of long-standing swelling of the central retina(cystoid macular oedema).
What would happen if I did not have my macular hole treated?
If untreated, there is a small chance thatsome macular holes can close spontaneously,with improvement in vision. In the majorityof patients the central vision will graduallyget worse to a level where the patient isunable to read even the largest print on aneye test chart. The condition does not affect the peripheralvision, and so patients will not go completelyblind from this condition.
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Can I develop a macular hole in my othereye?
Careful examination can assess the risk ofdeveloping a macular hole in the other eye.Your surgeon will tell you your risk but this may be from extremely unlikely to a 1 in 10 chance. It is very important tomonitor for any changes in vision of thefellow eye, and report these to your eyespecialist/family doctor/optician urgently.
What is the treatment and howsuccessful is it?
A macular hole can often be repaired by an operation called a Vitrectomy, peel andgas.
If the hole has been present for less than a year, the operation will be successful inclosing the hole in about 90% of cases. Of these, more than 70% will be able to seetwo or three lines more down a standardvision chart compared to before theoperation. Even if this degree ofimprovement does not occur, the vision is atleast stabilised and many patients find that
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they have less distortion. In a minority ofpatients the hole does not close despitesurgery and the central vision can continueto deteriorate; however, a second operationcan still be successful in closing the hole. Itis important to understand that return tocompletely normal vision is not possible.
Does it matter how long I have had themacular hole if I am interested in havingthe surgery done?
There is evidence that relatively earlytreatment (within months) gives a betteroutcome in terms of improvement in vision.Studies have shown, however, that visionimprovement may be possible in somepatients with long-standing macular holes.
What does the operation involve?
Macular hole surgery is a form of keyholesurgery performed under a microscope,using 3 small incisions (1-2 mm in size) inthe white of the eye for insertion of veryfine instruments. Firstly the vitreous jelly isremoved (vitrectomy), and then a very
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delicate layer (the inner limiting membrane)is carefully peeled off the surface of theretina around the hole to release thetraction forces that keep the hole open. The eye is then filled with a temporary gasbubble, which presses against the hole tohelp it seal. The bubble of gas blocks thevision whilst it is present, but slowlydisappears over a period of about 8 weeks.
How long does the operation take anddo I need to have a general anaesthetic?
Macular hole surgery usually takes 45-90minutes and can be done with the patientawake (local anaesthetic), or asleep (generalanaesthetic), often as a day case procedure.
Most patients opt for a local anaesthetic,which involves a numbing injection aroundthe eye so that no pain is felt during theoperation; this is sometimes supplementedwith medication to reduce anxiety(sedation).
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Do I have to posture face down after theoperation?
The aim of face down posturing is to keepthe gas bubble in contact with the hole asmuch as possible to encourage it to close.Whether you are required to posture, andfor how long, will depend on the size ofthe macular hole and also the preferencesof your surgeon. There is evidence thatposturing improves the success rate forlarger holes, but it may not be needed forsmaller holes.
If you are asked to do some face downposturing, your head should be positionedso that the tip of your nose points straightdown to the ground. This could be donesitting at a table, or lying flat on yourstomach on a bed or sofa.
You should try to remain in this position forusually 50 minutes in each hour for theduration advised (usually 2-5 days after theoperation). A short break of 10-15 minutescan be taken every hour to allow eating,trips to the bathroom etc. Your surgicalteam will advise on aids that can make face
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down posturing easier to manage e.g. ahorseshoe-shaped pillow or frame. Pleaseremember that if you are not able toposture then there is still a good chancethat the hole will close successfully.
If face down posturing is not prescribed,you may be simply advised not to lie onyour back for a period of two weeks afterthe surgery, with some surgeonsrecommending sleeping in a chair or at 45ºin bed, supported by pillows for the sameperiod.
Am I able to travel after macular holesurgery?
You must not fly or travel to high altitudeon land whilst the gas bubble is still in theeye (up to 12 weeks).
If ignored, the bubble will expand ataltitude, causing very high pressureresulting in severe pain and permanent lossof vision. In addition, if you need a generalanaesthetic whilst gas is in your eye, then itis vital that you tell the anaesthetist thisfact so they can avoid certain anaesthetic
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agents which can cause similar expansion ofthe bubble. None of these exclusions applyonce the gas has fully absorbed. You willnotice the bubble shrinking and will beaware when it has completely gone.
How much time will I need off work?
Most people will need at least two weeksoff work after surgery. The amount of timeoff work will depend on the kind of workyou do and the kind of surgery that is done.This will need to be discussed with yoursurgeon.
What are the potential complications ofmacular hole surgery?
As with any procedure there may be risksinvolved and you should discuss these fullywith the consultant involved prior to youroperation, however it is unlikely that youwill suffer harmful effects from a macularhole operation. In a small minority, thevision may end up worse than before thesurgery, and there is even a tiny chance oftotal loss of sight.
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Six specific complications of macular holesurgery, which you must be aware of, areoutlined below:
1. Failure of the macular hole to close:this occurs in 1-2 out of 10 patients. In most circumstances, it is possible torepeat the surgery. If the hole fails toclose, then the vision may be a littleworse than prior to the surgery.
2. Cataract: this means that the natural lensin the eye has gone cloudy. If you havenot already had a cataract operation,you will almost certainly get a cataractafter the surgery, usually within a yearbut it can happen very rapidly.
As cataract is inevitable, you may beoffered combined surgery with cataractextraction at the same time as themacular hole repair.
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3. Retinal detachment: the retina detachesfrom the back of the eye in 1-2% ofpatients undergoing macular holesurgery. The vast majority of retinaldetachments are repairable, but furthersurgery is required and this can be apotentially blinding complication.
4. Bleeding: this occurs very rarely, butsevere bleeding within the eye can resultin blindness.
5. Infection: this is also very rare and wouldbe expected to occur in about 1 in 1000patients, but if it occurs it needs furthertreatments and can lead to blindness.
6. Raised eye pressure: an increase inpressure within the eye is quite commonin the days after macular hole surgery,usually due to the expanding gas bubble.In most cases it is short-lived andcontrolled with extra eye drops and/ortablets to reduce the pressure,preventing any harm coming to the eye.If the high pressure is extreme orbecomes prolonged, there may be somedamage to the optic nerve as aconsequence.
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In the majority, this damage does notadversely affect the vision, but somepatients require long term treatment tokeep the eye pressure controlled.
Will I have to take any drops ormedication after the operation?
Three types of drops are usually prescribedafter surgery: an antibiotic, a steroid and apupil-dilating agent. Patients are seen againin the clinic about two weeks after thesurgery. If all is well, then the drops arereduced over the following 2-4 weeks.
If the eye pressure is raised followingsurgery, additional drops and/or tablets maybe prescribed to treat this.
When will I need to be seen again afterthe surgery?
Post-operative review is usually performedthe next day (or within a few days) aftersurgery; then 10-14 days later and, providedall is well, about 3 months later.
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Will I have to get my glasses changed?
Most people will need to change theirspectacle prescription at some point aftersurgery. This would normally be at about 3 months following the operation, after thegas bubble has gone.
As each case is different please check withyour surgeon before visiting an optician.
Where can I find more information?
The RNIB have further information onmacular holes, especially some practicaladvice:
Helpline: 0303 123 9999
Internet: www.rnib.org.uk
Email: [email protected]
The Macular Disease Society:
Helpline: 0845 241 2041
Internet: www.maculardisease.org
Email: [email protected]
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PD6618-PIL2574v1
Issue date: July 2012. Review date: July 2014.
© Sheffield Teaching Hospitals NHS Foundation Trust 2012. Re-use of all or any part of this document is governed by copyright and the “Re-use of Public SectorInformation Regulations 2005” SI 2005 No.1515. Information on re-use can be obtained from the InformationGovernance Department, Sheffield Teaching Hospitals. Email [email protected]
This information can be made available on request in alternativeformats including Braille, large print, audio, electronically and otherlanguages. For further details email: [email protected]
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Scientific Evidence
The advice in this booklet is based on avariety of sources, including latest researchpublished in peer-reviewed scientificjournals. It has also been scrutinised by apanel of experts from the Britain & EireAssociation of Vitreoretinal Surgeons(BEAVRS).
If you require further information aboutthis, please ask your surgeon.
