Vitrectomy for Epiretinal Membrane (Macular Pucker Surgery)

What Happens After The Macular Pucker Surgery?

At the end of the operation, a pad and shield will be placed over your eye. This will stay on until the following day, when I will examine the eye. Immediately after the operation, you will be placed within a macular pucker surgery post op recovery area. Here, the nurses will check your pulse, blood pressure and other vital signs. Despite your sedation, it’s likely that you’ll be fully awake by this time and ready for a drink and snack.

Once the nurses are satisfied that you’re feeling fine and are in a fit condition to leave, you will be escorted out of the recovery area to meet your friend or relative who is taking you home. You will also be given a prescription for eye drops that you should have filled at the chemist straightaway, as you will need to bring the drops with you when you return to the clinic the next day.

What Does Macular Pucker Surgery Involve?

The surgery consists of a vitrectomy (the removal of vitreous gel) and the peeling of the epiretinal membrane. This is then followed by the peeling of the inner limiting membrane (ILM), with the entire procedure performed using small 25 (or 27) gauge implements to ensure no stitches are necessary.

Will I Feel The Operation?

No, you will not be able to feel the macular pucker surgery, as it is always performed under local anaesthetic. Before the anaesthetic drops are placed in your eye, you’ll also receive intravenous sedation with a drug injected into your vein. This will ensure you remain completely unaware of the anaesthetic injection around – but not into – your eye. You will also be comfortably lying on your back throughout the anaesthetic and surgery.

Is Macular Pucker Surgery Painful?

The surgery itself is not painful, but you should let me know if you feel any sensation or discomfort in the eye (this is rare). If there is any sensation, you should inform me without talking, as speaking can make your eyes move. Before the surgery begins, the anaesthetist will show you know how to signal in case this happens.

How Is The Operation Performed?

Once the anaesthetic has been administered, an iodine solution will be used to clean the area surrounding your eye, and your eye and face will be covered with a paper and plastic sheet (drape).

Next, myself and the anaesthetist will make sure that oxygen and air can freely flow under this sheet to enable you to breathe easily. A hole will next be cut into the drape to provide access to your eye. I will then sit down beside you and carefully position a microscope over your eye and switch a light on. This light may be bright at first, but it will appear to fade after a short period of time.

During the macular pucker surgery itself, you will feel my hands resting gently on your forehead and sometimes the bridge of your nose. You may also feel a trickle of fluid down your face, but this is not a cause of concern. In the background, you may hear various sounds, including the theatre staff talking, sounds made by the vitrectomy machine, and sometimes music.

The surgery 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, as well as forceps to remove the epiretinal membrane and the inner limiting membrane (ILM) on the retina’s surface.

The next step in the epiretinal membrane surgery is to replace the fluid in your eye with air. While this is happening, you may hear a soft whistling sound.

At the conclusion of the macular pucker surgery, I often inject a low dose of steroid into the eye. This has several advantages, including speeding up the healing rate and even potentially improving the surgery’s final result. However, it’s important to note that the injection has a risk of the pressure in the eye (intraocular pressure) rising afterwards. If this occurs, laser or drops may be needed for several months, while a very small percentage of patients may need further surgery to control the IOP.

How Long Is The Macular Pucker Surgery?

The operation time for an epiretinal membrane/macular pucker surgery usually ranges from 20 to 30 minutes, but this is not an indication of how well the operation has gone. If your surgery is combined with a cataract extraction, your surgery may take up to 15 minutes longer. Unlike cataract surgery on its own, your eye may take 6 or so weeks to settle, so you should refrain from visiting your optometrist until you’re told you can.

How Can I Avoid Macular Pucker Surgery Post Op Complications?

While any air remains in your eye after the operation (approximately one week), you must not go on an aeroplane or travel to any high altitude locations. If you do, this can make the bubble in your eye expand and cause the pressure in your eye to rise, leading to significant harm and pain. For similar reasons, if you require any general anaesthetic following your macular pucker surgery, it’s important to let the anaesthetist know that there may be air in your eye.

To avoid complications, it’s recommended you wear the shield you’re provided with while you sleep. This shield is specially designed to prevent pressure being placed on the eye, such as accidentally rubbing it while you are sleeping.

What Does Macular Pucker Surgery Recovery Involve?

While some surface irritation is normal, the operated eye should not be overly painful after the surgery. However, looking at bright lights may be uncomfortable, so wearing sunglasses in the sun is recommended.

Afterwards, your eye may also appear red, and you may notice a pinkish watery discharge on your bedding. It’s important to note that this is not a sign of any problem; it’s simply caused by tears mixing with blood on your eye’s surface.

Immediately after your epiretinal membrane surgery, and for several days following, you will not be able to see the bottom part of your visual field with the eye that was operated on. This is due to the bubble of air in your eye preventing light from focusing properly on the retina. However, once the air is slowly absorbed (within a week), you will start to notice your vision clear up, with a wobbly black or silver line at the top of the area that you can’t properly see. As time goes by, this line will decrease in size and you will find you’ll eventually only be able to see the bubble of air when looking downwards. Before the air completely disappears, you may see one or more circles in the bottom of your vision. The air takes roughly one week to be absorbed completely.

If you have a steroid injected into your eye at the end of the surgery, you may also see the steroid particles as black spots that float around above the bubble. These usually settle within a week.

How Long Does It Take To Recover From Vitrectomy Macular Pucker Surgery?

The macular pucker surgery recovery time can vary from between three to six months. Healing occurs gradually over this time, with most people regaining about half of the vision lost from a macular pucker.

What Should I Be Concerned About During My Macular Pucker Surgery Recovery?

If you experience any of the symptoms below, or if you become concerned about any other matter relating to your macular pucker surgery post op, you should get in touch with me as soon as possible.

• Pain, particularly when it’s a deep aching pain.
• Your eye has become more uncomfortable, worsening since I last saw you.
• Your vision has declined since your last appointment. In particular, if the top part of your vision gets worse, you should see me urgently.
• A pus-like discharge has developed after the surgery. Please note that this requires urgent attention
• You notice new floaters, flashes, or a shadow in your peripheral vision.

Not all problems can be described in a list like the one above. I urge you to call immediately with any questions or concerns you may have after your epiretinal membrane surgery, even if they seem minor or ‘silly’. After the surgery, you will also be given my mobile phone number. If I can’t see you, I will organise for you to be seen by another retinal specialist.

What Are The Risks Of Macular Pucker Surgery?

The risks of a vitrectomy surgery for epiretinal membrane 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.