The macular hole and its operation
A macular hole is a tear in the surface of the eye's surface that forms in the center of vision, on the macula. When the hole first appears, images in the center of vision are blurred or centered on a black spot. As the hole enlarges, a dark spot or blind spot (scotoma) appears in your central vision. The condition is caused by an abnormal detachment of the vitreous humor, which remains too firmly attached to the macula. A macular hole does not affect your peripheral (side) vision. Treatment is exclusively surgical and allows the hole to close. The operation is called a vitrectomy: the vitreous humor is detached from the retina, suctioned out, and then the edges of the hole are softened (peeled). Finally, a gas is injected into the eye to press on the edges of the hole and help it close.
Definition
The macular hole is a tear in the center of the macula: the fovea. This is the most important area of the retina, as it is at the center of the visual field and is responsible for precise vision.
In a macular hole, a defect is present in the center of the retina. This condition causes a loss of central vision.
What are the causes of a macular hole?
Age is the most common cause of macular holes. Indeed, with age, the gel present in the eye's cavity, called the vitreous humor, begins to liquefy and detach from the retina.
Generally, the vitreous humor detaches without any problem. But sometimes, the vitreous humor can adhere to the retina. In this case, it pulls on the macula, creating a hole.
Less commonly, a macular hole is secondary to eye trauma or retinal detachment.
Symptoms
A macular hole indicates the presence of a hole in the center of the macula, the portion of the retina used for precise vision.
The main symptoms are therefore a decrease in vision and the appearance of a scotoma (a fixed dark spot in the center of vision).
Some patients complain of line distortion (metamorphopsia), because the edges of the hole are raised.
Diagnosis
Your ophthalmologist will put drops in your eye to dilate (widen) your pupil. This allows them to look inside your eye through a lens: the fundus.
He will then take pictures of your eye using optical coherence tomography (OCT). With OCT, the machine scans the back of your eye. It provides very detailed images of the retina and macula.
Your ophthalmologist will note the presence of the hole in the macula and will be able to measure it in order to assess the prognostic factors for surgery.
Treatment – Vitrectomy surgery
Surgery is the only way to treat a macular hole. The technique used is called vitrectomy.
Before the operation
Before surgery, you will be asked to consult with the anesthesiologist to determine the most appropriate type of anesthesia. For this surgery, a regional anesthetic, also known as peribulbar anesthesia, is most often recommended.
For this consultation, remember to gather your medical records and documents available: list of treatments, medical history, medical examinations, medical reports which will help the anesthesiologist to draw up a complete medical assessment.
The day of the operation
Il vous sera demandé de vous rendre A JEUN depuis 6 heures à l’heure indiquée sur la convocation. Attention, ne consommer ni café ou thé, ni aliment solide, liquide ou cigarettes !
La durée de cette opération est d’environ une heure. Par la suite, si la chirurgie a été effectuée dans le cadre de l’ambulatoire (cas le plus fréquent) il vous sera possible de regagner votre domicile en présence de votre accompagnant.
Anesthesia
Vitrectomy for a macular hole is performed under peribulbar anesthesia. The anesthesiologist will first sedate you and then inject an anesthetic around your eye. Within 10 minutes, your eye will be painless and immobile. This is known as regional anesthesia.
In case of anxiety during the operation, additional sedation will be administered.
The operation
The procedure takes place in the operating room, with the patient lying on their back. It lasts approximately 30 minutes. The steps are as follows:
Vitrectomy – The vitreous gel responsible for the macular hole is detached from the retina and aspirated.
The peeling – The edges of the hole are softened by removing the outermost layer of the retina, called the “limiting” layer.
Packing – The macular hole is filled with sterile gas to help it close. The gas will disappear on its own in 3 to 5 weeks.
Post-operative and convalescence
Your eye may be sore after the operation. Your surgeon will ask you to take medication to relieve the pain.
You must wear an eye patch for a short period. You must also put drops in your eye.
You should keep your face facing the ground as much as possible for a week, or even longer. This helps maintain pressure from the gas bubble on the edges of the hole. Ask your ophthalmologist when you can resume your daily activities.
You cannot fly, climb mountains, or go scuba diving until the gas bubble has disappeared. Rapid ascents can increase intraocular pressure due to the expansion of the bubble.
If you need to undergo another type of surgery, be sure to inform your doctor before the operation that you have a gas bubble in your eye.
Your vision will improve as the macular hole closes. It may take several months for the hole to fully heal. The degree of vision recovery depends on the size of the hole and how quickly it is treated.
Postoperative positioning
After vitrectomy, it is helpful to keep the macula under gas as much pressure as possible. To achieve this, it is recommended to keep the face facing downwards for one week. However, analyses of the scientific literature question the usefulness of this strict positioning.
Complications
At the onset of symptoms, it may be tempting to accept the current vision and forgo surgery. However, this situation is not sustainable and may lead to the following complications:
Enlargement of the hole leading to a worsening of visual loss and an increased rate of surgical failure.
Retinal detachment due to lifting of the edges of the macular hole.
Except in exceptional circumstances, every macular hole must be operated on in an attempt to close it.
Risks of the operation
Like any surgical procedure, vitrectomy carries risks. The most notable are the following:
The hole's failure to close
Eye infection
A bleeding in the eye
A retinal detachment
Glaucoma – Caused by a surge in intraocular pressure related to gas
A cataract – Caused by clouding of the lens upon contact with gas
Your ophthalmologist will discuss these risks with you and how vitrectomy can help you.
What should be done if the macular hole fails to close?
Sometimes the first operation fails to close the macular hole. In these cases, a second operation is necessary. It is sometimes required to place a thin membrane (amniotic membrane) in the hole to guide its closure.
Recovery and prognosis
Visual recovery after macular hole surgery is often satisfactory but partial.
1/4 of patients will have a full visual recovery without any after-effects.
Half of the patients will have a recovery between 6 and 9/10 with persistence of some loss of sensitivity in the center of vision.
1/4 of patients will retain a sensation of scotoma (spot) or metamorphopsia (distortions) significantly hindering their vision.
Note that residual visual disturbances cannot be corrected with glasses, as the macular hole is an anomaly of the eye's sensor and not of the focus.
Visual recovery is better in patients with a small macular hole (< 200 microns), which has been present for a maximum of a few weeks and has a satisfactory preoperative visual acuity (> 6/10).
Frequently Asked Questions
What are the causes of a macular hole?
A macular hole is most often caused by an abnormal posterior vitreous detachment. More rarely, its origin may be traumatic.
How to treat a macular hole?
Spontaneous closure of macular holes is extremely rare. Therefore, treatment for a macular hole is exclusively surgical. The procedure is called a vitrectomy. The eye socket is emptied and then filled with gas to apply pressure to the hole and help it close.
How to sleep and position yourself after macular hole surgery
Après une vitrectomie pour trou maculaire, il faut maintenir un positionnement visage parallèle au sol. Cela siginifie qu’il faut dormir sur le ventre pendant 7 jours.