Introduction  

Macular hole repair is treatment that aims to close a gap that develops in the macula, i.e., the central area of the retina, the light-sensitive spot of the eye. The gap or hole occurs when the vitreous humor/the vitreous, the gel-like substance at the back of the eye, becomes more liquid and shrinks due to aging. The vitreous is connected to the retina by tiny strands, and at times, it pulls on the retina as it shrinks, tearing off a piece of the macula. The missing part is known as a macular hole, and the vitreous can seep into it, causing distorted or blurred vision. A dark spot can also appear in the middle of the patient's visual field, and straight lines may seem wavy.

Macular holes usually affect people over age 60 and are more common in women than men. The disorder may also occur due to:

  • Eye injury
     
  • Best's disease
     
  • Macular pucker
     
  • A detached retina
     
  • Diabetic eye disease
     
  • A high degree of nearsightedness
     
  • Vitreous shrinkage or separation
     

Sometimes a macular hole can heal without intervention, but most need treatment to prevent permanent vision loss. The eye surgeon can treat macular holes to varying degrees, but for the best outcomes, the anomaly must be monitored or treated before it progresses.

The most common treatment for the condition is vitrectomy, where the surgeon removes the vitreous to stop it from tugging on the retina.
 

Before the Procedure

The surgeon will take detailed patient medical and surgical history. The patient must disclose any medical conditions they have and all the medication they are taking, including prescription medicines, over the counter drugs and dietary supplements. The surgeon will perform a complete eye evaluation, including visual acuity test and imaging tests such as ultrasound and optical coherence tomography (OCT) scans.

Treatment depends on the size and location of the hole. If it doesn't have a significant effect on vision, the doctor may only need to monitor its progression through regular eye exams.

The surgeon will give the patient instructions on how to prepare for the surgery. For example, the patient may be asked to stop taking some medications because they can cause complications and avoid all food and water for at least eight hours before the procedure. Patients should take a few days off work and come with someone or arrange for transport home after the surgery.
 

Procedure

Vitrectomy is an outpatient procedure that is performed under local anesthetic. The surgeon sedates and numbs the patient's eyes to prevent discomfort, and may also give the patient medicine to help them relax. S/he then cuts the sclera, the white part of the eye, and removes the vitreous with a microscopic cutting instrument.

S/he will make any other repairs needed, such as removing any debris or scar tissue and filling the eye with a saline solution and a gas bubble. In most cases, the surgeon doesn't need to stitch up the cuts, s/he will apply antibiotic ointment on the eye and cover it with a patch. Over time, body fluids will gradually replace the saline solution and the gas bubble.
 

Risks & Complications

Cataract formation is the most common risk related to the procedure. Other risks are rare and include:

  • Swelling
     
  • Bleeding
     
  • Infection
     
  • Glaucoma
     
  • Vision loss
     
  • Lens damage
     
  • Double vision
     
  • Change in refractive error
     
  • Loss of depth perception or night vision
     

The patient may experience some soreness and blurred vision for a day or two after the treatment.

Complications can occasionally occur, especially in patients with a history of eye surgery or eye conditions and immune-compromised individuals. The complications may include:

  • Retinal detachment
     
  • Problems with eye movement
     
  • A repeat surgery due to an unsatisfactory outcome
     
  • Over-reaction or allergic reaction to anesthesia may increase the risk for pneumonia, stroke, or heart attack

 

After Care & Recovery

The surgeon will prescribe antibiotic eye drops to help prevent infection and provide aftercare instructions. S/he will see the patient the day after the procedure to assess the outcome, check for any complications, and schedule follow-up visits. The patient may need to wear an eye patch to protect the eye for a day or two. For proper healing, the patient must follow the specific instructions given by the doctor. For example, if a gas bubble is used, the patient must remain in a facedown or other specified position for some days. It helps to maintain the bubble in place until it's absorbed.

The patient should call the doctor immediately if they experience:

  • Vision loss
     
  • Eye discharge
     
  • Floaters or flashes of light
     
  • Severe pain, redness, or swelling around the eye
     

The full recovery process may take between four weeks and several months. During that period, the patient must avoid activities such as reading, exercise, driving, scuba diving, mountain climbing, air travel, etc.
 

Outcome

American Society of Retina Specialists reports indicate that over 90 percent of the surgeries are successful, and the patient's vision improves as the macular hole heals.