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Combined Surgery for Macular Hole

Combined Surgery MH_reduced


Both cataract surgery and vitrectomy surgery can be performed together as a ‘combined surgery’.

Technically, there are a few additional considerations during the surgery but this is now a commonplace operation performed by vitreoretinal surgeons who have also been trained fully in cataract surgery.

The advantages of having combined cataract and vitrectomy surgery make this increasingly the preferred choice for many patients:

  • If (even mild) cataract already exists at the time of vitrectomy surgery, this is very likely to become worse over quite a short time. One study showed that 4 out of 5 patients who had vitrectomy (even including those without any pre-existing cataract) developed a cataract in the operated eye within 2 years and then went on to have cataract surgery. Having combined surgery means that a second operation is not necessary.
  • If cataract surgery is performed after a vitrectomy it can be technically more difficult.
  • The risks of a single combined operation are likely to be lower than two separate operations.
  • Following a vitrectomy visual recovery can be slow. After the vision has begun to improve, the development of cataract later can be quite a disappointment for some, even if they have been warned. Combined surgery avoids this issue almost completely.

There are obviously circumstances when there are good reasons not to perform both operations together. Dr Chauhan will be happy to explain if this is the case.

Cataracts And Phakoemulsification

Cataracts4_0095_con_eye_conCAM02-nuclcatThe cataract operation component of the combined operation is used to treat cataracts. A cataract is formed when the lens inside the eye goes cloudy. This is usually a slow process that occurs naturally with age, but it commonly follows vitrectomy within a year or two.

There are many symptoms of cataract including reduced vision, blurring, glare from bright lights and increasing short-sightedness. Some of these symptoms can be treated in the short term by changing glasses and using dark glasses, but the only lasting and most effective treatment is cataract surgery.



Cataract surgery

What Does Combined Macular Hole Surgery Involve?

During a combined surgery, the cataract is removed first through a process called phakoemulsification. Phakoemulsification (phako for short) is the technique that has been used for several years as part of modern cataract surgery; Dr Chauhan has performed over 2500 phako operations since 1993.

Phako consists of making a small incision in the cornea (clear part of the front of the eye) and removing the cataract from within the lens capsule, a very thin bag in which the natural lens fits snugly. An artificial lens intraocular implant (or IOL) is then placed into the capsular bag, unfolding into place.

The second part of the 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 require

Will I Feel The Operation?

No. This surgery is almost always performed under local anaesthetic as a day case and the method is the same as that used for cataract or vitrectomy surgery. It involves some anaesthetic drops being put in your eye, followed by sedation with a drug injected into your vein. This will make you completely unaware of the anaesthetist giving you an injection of anaesthetic fluid around the outside of your eyeball.

The surgery is not painful but you should let the Dr Chauhan know if, as rarely occurs, you do feel any sensation in the eye. This is best done without talking as speaking makes your head (and eye) move.

Your anaesthetist will let you know how to signal this before the surgery. It is simple for more anaesthetic to be given straight away and this takes effect almost immediately. There is no need or benefit to being a martyr about this; the surgery is also easier if you are not in pain or discomfort. You will be lying on your back throughout the anaesthetic and surgery.

How Is The Operation Performed?

After the anaesthetic has been given, iodine solution will be used to clean around your eye. After this a plastic sheet (drape) will be used to cover your eye and face. Dr Chauhan and the anaesthetist will ensure that an oxygen and air mixture can flow freely under this sheet and that you can breathe easily. A hole will then be cut in the drape over your eye and a special clip used to hold it open. Dr Chauhan will then sit down and position a microscope above your eye and switch the light on. You may be able to see this light but it usually fades after a little while.

During the surgery itself, you will feel Dr Chauhan’s hands on your forehead and, occasionally, on the bridge of your nose. You may hear the theatre staff talking, as well various sounds made by the vitrectomy machine and possibly, music. You may feel a trickle of watery fluid down the side of your face but, whilst uncomfortable, this is not dangerous.

There are several steps to Phakoemulsification:

A tiny incision is made on one side of the cornea so that a second instrument can be used during the operation.

Corneal incision
The main incision is made in order to introduce the phako probe and other instruments into the eye.

A thick gel is injected into the eye both to protect the inside of the eye and open up space within the eye.

An opening is torn in the front of the lens capsule.

Fluid is squirted between the lens capsule and the lens itself, separating the two prior to cataract extraction.

Phakoemulsification of the lens is performed using a phako probe that vibrates at 40kHz. This sets up a shock wave that partly liquefies the cataract and also cuts through the lens, sucking it up as it goes. This is done using many different techniques; Dr Chauhan uses the ‘stop and chop’ method in which the cataract is removed piecemeal.

The remnants of the cataract are sucked up using another instrument.

IOL implantation
A folded-up lens is injected into the eye and opens up slowly within the capsular bag.

IOL rotation
If a toric lens is used this will be rotated to the point at which it helps correct the astigmatism.

Following the phakoemulsification, the vitrectomy component of the surgery is performed. This begins with the making of three tiny holes (ports) in the white (sclera) of the eye, allowing instruments to be introduced into your eye. One of these ports allows a constant flow of fluid to pass into your eye, providing ‘infusion’. Another port is solely used to insert a fibre-optic ‘light pipe’ to provide illumination from within, while the third port is used for all other instruments required throughout the surgery. These include the ‘cutter’ that is used to sever and remove the vitreous, and forceps for removal of the membrane on the retina’s surface (otherwise known as the ILM).

The next stage of the combined macular hole 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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How Long Is The Combined Surgery?

The operation time for a combined surgery usually ranges from 30 to 40 minutes, but this is not an indication of how well the operation has gone. Depending upon the condition being treated there may be additional components to the surgery, which would add time to the overall length of the operation.

What Happens After The Combined 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 combined 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 combined macular hole operation, commencing on the day of the operation.

What Is Posturing And Why Is It Necessary?

At the end of the combined 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 ( This also is supplied with a mirror that is designed to let you look down while still seeing ahead of you.


RetinaDoctor – Post-operative Vitrectomy Care and Physiotherapy

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. 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 combined 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.

How Can I Avoid Problems After Combined Macular Hole Surgery?

While you have any gas remaining in your eye after your combined macular hole surgery, 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 Combined Macular Hole Operation?

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 combined macular hole surgery, 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 The Surgery?

If you notice any of the below symptoms after your combined macular hole repair surgery in Melbourne, you should contact Dr Chauhan 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 combined macular hole 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 Dr Chauhan urges you to call with any questions or concerns you may have, even if you think they may be minor or ‘silly’.

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

What Are The Risks Of Combined Surgery 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

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