Macular Hole
What is a Macular Hole?
A Macular Hole is a small microscopic break in the macula which is located in the back of the eye. Patients with a Macular Hole will have reduced vision in that eye however it may go unnoticed as the healthy eye will compensate for the poor vision of the affected eye. In order to see clearly, light from an object has to be focused by the optical elements of the eye onto the light-sensitive tissue called the retina. The macula is the small part at the centre of the retina which provides the sharp, central vision we need for reading, driving, and seeing fine detail.
Age is a contributing factor in the development of a Macular Hole as it increases in patients over 60 years of age, and is more common in women. Patients with a Macular Hole have a 10% – 15% chance of developing a hole in the other eye.
The size of the hole and its location on the retina determine how much it will affect a person’s vision. When a large Macular Hole develops, most central and detailed vision can be lost. If left untreated, a Macular Hole may lead to long term blindness and occasionally a retinal detachment, a sight-threatening condition that requires immediate medical attention.
As you can see in the image below, the macula lifts up leaving an opening. It resembles a drawbridge opened. No part of the macula is actually missing and with surgery these two sides are pressed down causing the opening to close; as you would see when a drawbridge is lowered.
Most of the eye’s interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. It consists of 99% of a watery substance constantly produced by the Ciliary body and the other 1% contains millions of fine fibers that are attached to the surface of the retina. They are extremely springy/ elastic and give full expanse within the eye. They give the vitreous fluid the gelatinous form in the posterior chamber of the eye. As we age the vitreous slowly shrinks and pulls away from the retinal surface. Natural fluids will fill the area where the vitreous has contracted, which is normal. However, if the vitreous is firmly attached to the retina when it pulls away, it can cause a small tear on the macula. Once the vitreous has pulled away from the surface of the macula, some of the fibers can remain attached and can contract. This increases tension and can lead to a Macular Hole.
Macular Holes can also occur from eye disorders, such as high myopia (nearsightedness), macular pucker, and retinal detachment; eye disease, such diabetic retinopathy and Best’s Disease; and injury to the eye.
Symptoms
The common symptoms are blurring and distortion. Distortion of vision can mean that straight lines such as a picture frame become bent or kinked when viewed with the affected eye.
Management
Although some Macular Holes can seal themselves and require no treatment, surgery is the only form of treatment and is necessary in many cases to help improve vision; however without surgery a macular hole will not cause blindness.
The surgical treatment is known as a ‘Vitrectomy’ where the vitreous humour is removed from the posterior chamber of the eye to prevent it pulling further on the eye and it is replaced by a bubble which containing a mixture of air and gas. The bubble acts as an internal, temporary bandage that holds the edge of the Macula Hole in place as it heals.
Following surgery, patients must undertake post operative posturing in a face-down position, normally for 5 days but further posturing may be advised. This position allows the bubble to press against the macula and be gradually reabsorbed by the eye, sealing the hole. As the bubble is reabsorbed, the vitreous cavity refills with natural eye fluids produced by the Ciliary body. However the fibres that were previously in the vitreous humour will not reproduce as they only develop in the embryonic stage of our life and do not move or change.
Maintaining a face-down position is crucial to the success of the surgery. Because this position can be difficult for many people, it is important to plan for post operative posturing prior to your surgery. You are also unable to travel by air, nor ascend to altitudes higher than 400 metres on land whilst the bubble is in the eye as the change in pressure and altitude may cause problems to the eye. Your Ophthalmologist will advise when you are able to safely travel by air.
Post surgery
The eye may feel gritty and uncomfortable following surgery. Staying in a face down position after surgery is required to ensure the gas bubble inserted during surgery is positioned against the part of the retina that needs to be held in position. The gas in your eye forms a bubble and floats upwards towards the ceiling. It can take up to 14 days before the bubble is absorbed by the body and during this period you are required to maintain a face down position for 50 minutes of every hour during the day. This will ensure that your retina has the best chance to be successfully treated and repair correctly.
*Additional information regarding the face-down posturing position is provided at the time of booking surgery.
POST OPERATIVE POSTURING
Posturing is necessary to ensure the gas bubble inserted during vitrectomy surgery is positioned against the part of the retina (lining of the eye) that needs to be held in position. The gas in your eye forms a bubble and floats upwards towards the ceiling.
The purpose of the gas bubble is to block the hole in the retina, stopping fluid leaking in again until the scar reaction has taken place. This can take up to 14 days.
The only way of getting the bubble to press against the macula is to look vertically down to the floor. If you do not participate with the “face down posture” technique the bubble does not press against the Macular Hole, which is at the back of the eye.
This is most easily achieved if you tilt your head forwards with your face and eyes pointing downwards. Posturing post operatively will give your retina the best chance to be successfully treated.
Preparing for posturing
Posturing is hard work, however your hard work and commitment makes a big difference to the outcome of your surgery. Making some preparations prior to your surgery will help you.
- Call on family and friends for support during this time
- Consider booking equipment to help you posture. Many patients find that getting their equipment a few days before the surgery helps them adequately prepare
- Prepare meals prior to your surgery. Remember that you only have 10 minutes in each hour to prepare and eat your meals
- Go shopping for all your essential requirements prior to your surgery
How long do I need to posture for?
- Some patients are only required to posture for a few days, others are required to posture for up to 10 days
- Your surgeon will advise what is required prior to your discharge
- You must posture for 50 minutes out of every hour
- During your 10 minute break you can move around freely with your head up
During the day
- Your face and eyes must be looking down as though you are reading a book resting on your lap
- Try sitting in a chair, leaning over a table and resting your forehead on your arms or pillow
- If you have good vision in your other eye you may read a book on your lap
- You may watch a TV by placing the TV on the floor by your feet and putting a mirror in front of it
During the night
- You may be required to be face down during the night, if so your surgeon will advise you of this
- If you are required to posture with either left or right check to the pillow, cushions or pillows behind your back will assist in stopping you from rolling onto your back
- Travelling
- If you have a long car journey some patients find it helpful to have a couple of pillows to lean over
- If a gas bubble has been inserted you cannot travel by air until this has dissolved, this may take several weeks
Posturing evices
There are some devices that are available to hire, patients who are required to posture for several days may find these useful. You may obtain further information about these devices by visiting Summit Support. Please be advised that these devices are not necessary for successful posturing.