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Vitrectomy for Macular Hole

What Does The Surgery Involve?

Macular hole surgery consists of two parts: the operation itself (which involves a vitrectomy with the peeling of the inner limiting membrane and a gas injection), and the ‘posturing’ after the surgery (I explain this in more detail further down the page).

The procedure is completed using small 25 or 27 gauge instruments to ensure no stitches are required.

Will I Feel The Macular Hole Surgery?

No, you should not feel any part of the surgery due to it being performed under local anaesthetic. First, the anaesthetist will apply anaesthetic drops into your eye before sedating you with an injected drug in your vein. This sedation will help you remain unaware of the anaesthetic injection for your eye.

You should not feel any pain during the macular hole surgery itself, but you should inform me immediately if you experience any sensation. I recommend you do this without talking to avoid moving your head or eyes. Before the surgery begins, your anaesthetist will inform you of a method of signalling that is safe. I can then apply more anaesthetic right away to minimise discomfort.

How Long Is The Operation Take?

The time taken for a macular hole repair can range from 20 to 30 minutes. However, if your vitrectomy is being performed in conjunction with a cataract extraction (phacoemulsification), this can make your operation up to 15 minutes longer.

How Is The Macular Surgery Done?

After you have been given your local anaesthetic, you will be wheeled into the operating theatre and an iodine solution will be applied around your eye to clean the area and prevent infection. Next, a plastic drape will be placed over your eye and face in a way that will still allow you to breathe easily. After ensuring you’re getting enough oxygen and air, a hole will then be cut in the drape to provide access to your eye for the macular hole repair. A microscope will also be positioned above your eye for magnification, and a light will be switched on. You might see this light at first, but it will fade after several minutes.

During the vitrectomy for your macular hole, you will experience several different sensations. You will feel my hands resting gently on your forehead and sometimes on the bridge of your nose. Sometimes, you may feel a trickle of fluid down your face. While this may feel uncomfortable, it is nothing to worry about. You’ll also hear the theatre staff talking and various sounds produced by the vitrectomy machine.

Before the surgery commences, I will make three small holes (ports) in the white (sclera) of your eye. The first of these will have a constant flow of fluid passing through it for ‘infusion’, while the second is used to insert a fibre-optic ‘light pipe’ into your eye for adequate illumination. The third port is used for all other instruments that are required during the macular hole repair, including the ‘cutter’ for removal of the vitreous and forceps for removal of the membrane on the retina’s surface (otherwise known as the ILM).

The next stage of the macular surgery is to replace the fluid within your eye with air. While this is occurring, you might be able to hear a whistling sound. At the end of the operation, this air will be replaced with gas.

 

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What Happens After The Macular Hole Surgery?

When the operation is finished, your eye will be covered with a protective pad and shield, which will stay on until I examine your eye the next day.

Immediately after your macular hole repair surgery, you will enter a recovery area where nurses will check your pulse, blood pressure and other vitals. Despite the sedation, you should be fully awake by this stage and ready to have some food and drink.

When the nurses are satisfied you’re ready to leave, you’ll be escorted out of recovery to meet your friend/relative. Before you leave, you’ll also be provided with a prescription for drops. It’s recommended that you take this to the chemist to be filled as soon as possible, as you will need the drops during your examination the following day.

You will also be asked to posture for five days after the macular hole operation, commencing on the day of the operation.

 

What Is Posturing And Why Is It Necessary?

At the end of the macular hole repair operation, the air in your eye is replaced with gas. This gas forms a bubble in your eye and floats upwards, similar to a bubble in a carbonated drink. However, if you remain upright, this gas bubble won’t press against the macular hole at the back of your eye. Without this, the hole may not close, as vitrectomy for macular hole is not effective without the gas.

The only way to get the gas bubble to press against your macula is to look vertically down towards the floor. One of the easiest ways in which to do this is to tilt your head forwards and point your face down (known as face-down posturing). I usually request that posturing is done for 50 minutes out of every hour for five days, but not when you’re sleeping, when it is recommended to sleep on either side and not sleep on your back. One tip to help you avoid this is to place pillows behind you to prevent you from rolling onto your back during sleep.

While face-down posturing can cause back and neck pain and contribute to feelings of social isolation, there is specialised posturing equipment available that can help, such as RetinaRest (retinarest.com). This also is supplied with a mirror that is designed to let you look down while still seeing ahead of you.

 

How Can I Best Prepare Myself For Posturing?

Here are some top tips to help ready yourself for posturing:

  • Consider arranging hire of equipment that will assist you with posturing (e.g. retinarest.com 1300 66 80 59) as soon as you become aware of the date of your operation. If you choose to do so, it’s best to hire the equipment several days beforehand to help you prepare.
  • Work out how you are going to prepare and eat meals. Often, assistance from others will be necessary, as you will only have 10 minutes available out of each hour.
  • Make sure you do a shop for food, toiletries, entertainment and other essentials before your macular hole surgery. Audio books and CDs are highly recommended, as you can listen to these without moving your eyes. While you may not feel like reading within the first few days after surgery, large-print books and magazines are good to have on hand for later
  • DVDs can be watched as long as you keep your eyes in the correct position with the use of a RetinaRest mirror. This will enable you to watch TV, talk to friends, and look ahead of you.
  • Organise all of your toiletries and medications so they’re easily accessible without raising your eyes or head.
  • Make sure your kitchen appliances (e.g. kettle, toaster and coffee machine) are stored low so you can prepare foods and drinks without help.
  • Ensure you have straws on hand to help you sip cold drinks.
  • Prepare plenty of clean, comfortable clothing for the posturing period

FOR FURTHER INFORMATION REGARDING POSTURING AND PHYSIOTHERAPY, PLEASE CLICK BELOW TO DOWNLOAD A PRINTABLE INFORMATION SHEET:

RetinaDoctor – Post-operative Vitrectomy Care and Physiotherapy

How Can I Avoid Problems After Macular Hole Surgery?

While you have any gas remaining in your eye after your surgical macular hole treatment, you must not fly or travel to high altitude destinations, as this will expand the bubble in your eye. When the bubble expands, this can increase your eye pressure, causing pain and other negative effects. For similar reasons, you must let your anaesthetist know about the gas within your eye before you’re administered any general anaesthetic you may need afterwards. You will also be provided with a bracelet to wear on your wrist, warning anyone in case of an emergency that there is gas in your eye. You should wear this until all gas has disappeared.

Make sure to also wear the provided eye shield while you sleep. This will stop you from accidentally rubbing the eye when asleep.

When posturing with your arms positioned in front of you, make sure you don’t rest your elbow on unpadded areas for lengthy periods of time, as there are some who have caused injury to the nerve (known as the ‘funny bone’) by spending too much time leaning on it.

In the 10 minutes you have free each hour to look around, you should endeavour to stretch, walk, and even do gentle neck and shoulder rotations. I do not recommend going without these breaks, as sitting still for lengthy periods of time can lead to other problems, such as deep vein thrombosis, muscle stiffness, and difficulties posturing for the entire period.

 

What Should I Expect After The Surgical Macular Hole Treatment?

You should not experience much pain within the operated eye, but some surface irritation may be present (you may feel like something is stuck in your eye). Bright lights may also cause discomfort, so wearing sunglasses is often recommended when outdoors.

After the surgery, it is normal for the eye to be red and sometimes seep a pinkish watery discharge. This is nothing to worry about and is simply caused by tears mixing with blood.

Immediately after your vitrectomy for macular hole, and for the following five days, you won’t be able to see clearly with the operated eye; objects very close to the eye may be visible but anything further away will be very blurred . This is due to the gas in your eye preventing light from focusing on the retina. However, as the gas is slowly absorbed, the top of your vision will become clearer. You may also notice a wobbly black or silver line, and over time this will become more curved as the bubble of gas gets smaller before disappearing completely after a few weeks or so.

As the bubble is slowly absorbed by the eye, you will come to a point when you can see straight ahead over the top of the bubble. At this stage , if your central vision is better, the operation has probably worked. However, if you vision is not better, that does not mean that the surgery has failed; some people’s vision doesn’t improve straight away after surgery even when the hole is closed.

 

What Should I Be Concerned About After Surgery?

f you notice any of the below symptoms after your macular hole repair surgery in Melbourne, you should contact me as soon as possible.

  • If you experience pain within the operated eye – particularly if it’s a deep and aching pain.
  • If your eye is hurting more since the last time you saw me.
  • If your vision declines or worsens since your last appointment. If the top part of your vision gets worse, you should arrange to be seen as soon as possible.
  • If a pus-like discharge develops after your macular surgery.
  • If you become aware of any new vision issues, such as floaters, flashes of light, or shadows in your peripheral vision.
  • There are many other problems that haven’t been listed, but I urge you to call with any questions or concerns you may have, even if you think they may be minor or ‘silly’.

You can reach me by calling Vision Retinal Institute Eastern on (03) 9890 4333 during business hours. You will also be given my mobile number in case of emergency.

What Are The Risks Of Vitrectomy For Macular Hole?

The risks of a vitrectomy surgery for macular hole include:

  • Less than 1 in 1000 chance of blindness due to either infection or bleeding
  • Less than 1 in 200 lifetime risk of retinal detachment
  • 1 in 50 chance of reduced vision

I will discuss these risks and others with you before your surgery.