Understanding macular hole surgery

Following on from his article on Macular Holes, Mr Bhaskar Gupta gives us an insight into the operation. He explains what the operation will involve, the process, and the aftercare.

What does the operation involve?

Macular hole surgery 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 retinal surface around the hole. A temporary gas bubble is injected into the eye to cover the hole and help it heal. The gas bubble obscures the vision as long as it is there, but it gradually fades away after about 8 weeks.

In General choice of gas tamponade depends on size and duration of macular hole: They generally last as follows

• Air – which can stay in your eye for up to two weeks.
• SF6 which can stay in your eye for up to four weeks.
• C2F6 which can stay in your eye for up to eight weeks.
• C3F8 which is long acting and can stay in your eye for up to 12 weeks.

You will be told after your surgery which type of gas bubble was used.

In rare cases, that may need chronic, recurrent macular hole a very long-term tamponade like silicone oil bubble is used as a tamponade agent, which will require further surgery for removing it.

I will routinely undertake the cataract surgery and put in a new artificial lens if you have not had one already. There is usually early cataract and vitrectomy accelerates progression of cataract. From a patient perspective having both done in one go will result in fewer visits to the hospital, one less operation and getting the sight back more quickly. Once the cataract is out, I normally take the back of the capsule away saving a YAG laser procedure on a later day. In younger patient’s cataract may take many years and we can discuss options for leaving the lens alone.

How long does the operation take? Will I need a general anaesthetic?

The operation for macular hole usually lasts between 45 and 90 minutes and can be performed with the patient either awake or asleep, often without staying overnight in the hospital. Most patients choose to be awake, which means they get an injection to numb the eye and prevent any pain during the surgery; they may also get some medicine to help them relax (sedation).

Does it matter how long I have had the macular hole?

It seems that the sooner the condition is treated (within months), the more likely it is to improve the vision. But surgery may still help some patients who have had macular holes for a long time to see better.

Am I able to travel after macular hole surgery?

Do not fly or go to high places on land while you still have the gas bubble in your eye (up to 10 weeks). If you do, the bubble will swell at altitude, causing very high pressure that leads to severe pain and permanent vision loss. Also, if you need a general anaesthetic while you have gas in your eye, then you must tell the anaesthetist this fact so they can avoid certain anaesthetic agents that can make the bubble expand in the same way. These restrictions do not apply once the gas is fully gone. You will see the bubble getting smaller and you will know when it has completely disappeared.

Do I have to posture face down after the operation?

You used to have to keep your face down to make sure the gas bubble touched the hole as much as possible, to help it heal. You usually do not have to do this anymore, but you may be told not to lie on your back for one or two weeks after the surgery.

How much time will I need off work?

You will probably need to take two weeks off work. The gas bubble in your eye makes your vision worse and also affects how you judge distances. But it depends on what kind of work you do and how fast you recover.

What are the potential complications of macular hole surgery?

Like any procedure, there may be some risks involved and you should talk to the consultant about them before your operation. In a few cases, the vision may get worse than before the surgery, and there is even a very small chance of losing all sight. Below are six specific complications of macular hole surgery that you need to know about:

1. The macular hole does not close: this happens to 1 in 10 patients. In most cases, the surgery can be done again. If the hole does not close, the vision may be slightly worse than before the surgery.
2. Cataract: this means that the natural lens in the 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 inescapable, you will be offered combined surgery with cataract extraction at the same time as the macular hole repair.
3. Retinal detachment: the retina comes off from the back of the eye in 1-2% of patients who have macular hole surgery. Most retinal detachments can be fixed, but more surgery is needed and this can be a very serious complication that can cause blindness.
4. Bleeding: this is rare, but severe bleeding can result in blindness.
5. Infection: this is very rare and would be expected to occur in about 1 in 1000 patients, but needs urgent treatment and can lead to blindness.
6. High eye pressure: a rise in pressure inside the eye is quite common in the days after macular hole surgery, usually because of the gas bubble getting bigger. In most cases it is temporary and controlled with extra eye drops and/or tablets to lower the pressure, preventing any damage to the eye. If the high pressure is very severe or lasts for a long time, there may be some harm to the optic nerve as a result. In most cases, this harm does not affect the vision, but some patients need long term treatment to keep the eye pressure under control.

Will I have to take any drops or medication after the operation?

Three types of drops are usually prescribed after surgery: an antibiotic, a steroid and eye pressure lowering medicine.

When will I need to be seen again after the surgery?

Patients come back to the clinic about two weeks after the surgery. If everything is fine, then the drops are lowered over the next 2-4 weeks and another appointment is set for 2 months after the surgery. If the eye pressure is high after surgery, more drops and/or tablets may be given to treat this.

Will I have to get my glasses changed?

Most people will need to get new glasses at some point after surgery. This would usually be at about 3 months after the operation, when the gas bubble has disappeared. As each case is different, please ask your surgeon before going to an optician.

Mr Bhaskar Gupta is a highly experienced Ophthalmologist with over 15 years of experience in his field. To schedule an appointment with Mr Gupta, visit his Top Doctor’s profile today.