Q: Description of the macula.
A: The macula is the center of the retina. It is responsible for central vision (straight ahead vision), your best vision, and most color vision. The center of the macula is called the fovea.
Q: Description of a macular hole.
A: A macular hole is a defect in the macula.
Q: Symptoms of a macular hole.
A: They are decreased or complete loss of central vision. Other eye problems can cause similar symptoms; the presence of a macular hole can only be determined by a dilated eye exam.
Q: Can macular holes cause total blindness?
A: No, they can only cause loss of central vision.
Q: Are there different types of macular holes?
A: Yes, they fall into the following categories:
Classic macular holes: also called idiopathic or degenerative macular holes, these are much more common than other types. These are of
the type that will likely benefit most from surgery, if certain criteria are met.
Traumatic macular holes: these usually occur with direct impact occurring on the eye or head. Some of the traumatic cases spontaneously
heal ("close" or "seal"). Surgery is less successful in this group but can be performed if the doctor thinks the retina and underlying
retinal pigment epithelium are functioning well.
Macular holes caused by long-standing macular edema (swelling), which can be caused by diabetic retinopathy, branch vein occlusion, pars
planitis, or other inflammatory eye disease. Patients with holes of this type should not be treated with surgery.
Q: How common are classic macular holes?
A: Classic macular holes are a moderately common cause of irreversible central visual loss in people over age fifty. They are three times as common in women as in men, for unknown reasons.
Q: What is the cause of classic macular holes?
A: Most classic macular holes are apparently related to posterior vitreous separation.
Residual vitreous humor remaining on the retinal surface after this event probably contracts, pulling on the macula and fovea
in an outward direction.
Some macular holes are caused by a thin layer of tissue known as an epiretinal membrane. These holes typically have no cuff of fluid
around them and are associated with retinal "wrinkles".
Q: Does hardening of the arteries cause macular holes?
A: No, circulation problems have not been shown to have any relationship to macular holes.
Q: Are eye strain, nutrition, general health, smoking or emotional stress related to macular holes?
A: No, there is no known relationship between macular holes and any of these problems.
Q: If one eye develops a macular hole, will the other eye develop one?
A: Usually not; most patients develop holes in one eye only. The odds are about 6% of developing a hole in the second eye.
Q: What is the treatment for macular holes?
A: Vitreous surgery, placement of a gas bubble inside the eye, tissue peeling using forceps (FORM), and head down positioning for several weeks after surgery are required to repair macular holes.
Vitreous surgery consists of removing the vitreous to enable injection of a large gas bubble and, in many instances, peeling of tissue from the retinal surface to stimulate hole closure.
The tissue on the retinal surface may be residual vitreous, epiretinal membrane, or ILM. Most but not all surgeons peel ("strip") this tissue away from the retinal surface during vitreous surgery.
Dr. Charles developed forceps membrane peeling techniques in the early 1980s. This technique has been improved by using an inside out, circular motion and special forceps that conform to the retina surface. This method we call FORM, developed by Dr. Steve Charles, is more precise than the FILMS method.
A decreasing number of surgeons place blood products such as serum, clotted blood, or platelet concentrate on the retinal surface. Our doctors do not use these substances because there is no scientific evidence of their benefit, there is potential risk, and many experienced surgeons no longer use these agents.
Q: I've heard that ICG dye is sometimes used in this type of surgery. Do you use it?
A: ICG dye is not used by our surgeons for two reasons:
Our surgeons are experienced enough that they do not need the dye in order to see the ILM, which is the dye's purpose.
Toxicity of the dye has been reported by others.
Q: Is there a medication for the treatment of macular holes?
A: No: there is no medicine, eye drop, vitamin, herb, or diet that is beneficial to macular hole patients.
Q: Is there a laser treatment for macular holes?
A: No, only surgery can repair a macular hole.
Q: Do holes ever disappear without surgery?
A: It depends largely upon the amount of separation of the vitreous from the retina present in the macular hole. A staging system is used to describe this amount of separation. Stage 1 is a macular hole of partial thickness separation of the retina; that is, it does not extend all the way through the retina and is not a true hole. Patients with a Stage 1 macular hole typically have little or no visual loss. Approximately 50% of Stage 1 macular holes disappear without surgery.
Stages 2, 3, and 4 represent, respectively, formation of a true hole, enlargements of the macular hole, and separation of the vitreous from the retina. These will not spontaneously disappear.
Q: What is the purpose of the gas bubble?
A: It acts like a bandage to help cells and associated tissue to grow across the hole, eliminating the defect in the retina.
Q: Why is it necessary to be face down when a gas bubble is in the eye?
A: The bubble floats and is only in contact with the macula when the face is pointed toward the floor.
Q: How many hours per day should the patient be face down?
A: Our doctors recommend that the strict head down position is kept at all times for 7-10 days after surgery. Patients can sleep and nap face down, read with the book or papers in their lap, watch television by placing a small set on the floor, and walk for exercise while looking down without much difficulty. Some occupations are compatible with this approach while others are not. Driving should limited to emergencies. Limited compliance with head positioning decreases the chances of success of the surgery and increases the chances of cataract formation.
Q: What drops should be used after vitreous surgery for macular holes?
A: We do not recommend the use of steroid drops. We use only an antibiotic and a dilating drop for a few days after surgery.
Q: How long does the surgery take?
A: The procedures usually take our doctors less than 30 minutes.
Q: Is the surgery performed on an inpatient or outpatient basis?
A: The surgery is performed on an outpatient basis in all cases unless there is a medical reason to be in the hospital.
Q: Can I fly with a gas bubble in my eye?
A: No. The bubble can expand, causing pressure increase, excruciating pain, and even blindness in the eye. Airplane travel, mountain climbing or travel in or to or through the mountains, scuba diving, and travel to higher elevations by any mode of transportation are to be avoided while the gas bubble is present in the eye. These activities can generally be resumed once the bubble has completely resorbed.
Q: What is the success rate of the vitreous surgery?
A: The rate of closure of the macular hole after successful surgery is about 90%, but the rate of visual improvement varies considerably. Most patients experience some improvement in vision after successful surgery. The final improvement in vision may not be achieved for many months after surgery. All of the factors affecting the degree of improvement are not yet understood, but include:
the size of the hole.
the quality of the surgical technique.
the ability of the patient to remain for 7-10 days in a face down position.
Q: Are there any complications?
A: Often, there is a significant instance of cataract progression after vitreous surgery. Some doctors believe that patients with an absolutely clear lens develop cataracts as a result of vitreous surgery, but our doctors disagree. The vast majority of patients requiring vitreous surgery for macular hole have nuclear sclerotic cataracts (yellowing of the center of the lens), which can worsen after vitreous surgery. Surgeons differ widely on the percentage of patients that suffer cataract progression due to vitreous surgery. Our doctors believe that the progression rate is about 10%.
Retinal detachment can occur after vitreous surgery performed for any reason, including macular hole repair. Opinions vary widely on the frequency of retinal detachment after macular hole surgery, ranging from 1.5% to 30%. Our doctors believe that the incidence is less than 5%.
A small number of patients (about 1%) will experience reopening of the hole after initial success.
Q: If the hole reopens, should surgery be repeated?
A: If the surgery fails because it was a large hole, it should not be repeated in most instances. If surgery fails because the patient failed to remain face down the first time and will definitely remain face down the second time, surgery may be considered.