By
Jonathan Yoken, MD
MACULAR
HOLE
What is
a macular hole?
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Macular
Hole
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The macula
is the thinnest and most delicate portion of the retina. In some
individuals, over time, a cellophane-like film may build up on
the surface of the macula (this is referred to as an epiretinal
membrane or pre-retinal fibrosis). For reasons that are not completely
understood, this filmy buildup may slowly distort and stretch
the underlying tissue. These stretching forces may become so strong
that the retina will eventually form a hole at the macula. The
macular hole is tiny-usually a fraction of a millimeter-but can
result in severe blurring, distortion, and loss of detail vision.
There is no
accepted therapy for preventing a macular hole from forming. Early
macular holes-where some stretching is seen but no actual hole
has developed-may in some cases stabilize or even regress over
time. Once a true hole has developed, however, vision is markedly
blurred and rarely improves spontaneously. Up until ten to fifteen
years ago, no effective treatment was available for this condition,
and the visual loss from macular holes was permanent.
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Retina
with Macular Hole
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Normal
Retina
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How are
macular holes repaired?
Currently,
the most effective treatment for macular holes is surgery. The
procedure, called a vitrectomy, involves inserting tiny instruments
into the anesthetized eye to remove the vitreous gel, allowing
access to the macula. Delicate forceps are then used to peel away
the epiretinal membrane, which allows the macula hole to close.
Why must
I position my head down after surgery?
The most important
part of the surgery occurs after the procedure is done.
At the end of surgery, the eye is carefully filled with a special
gas that gently pushes against the macula to keep the hole closed
while the eye heals. In order for this gas to properly support
the macula, the patient must follow very special instructions
during the postoperative period.
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Gas
Bubble
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As bubbles
rise to the surface of water, the gas bubble floats to the top
of the liquid that normally fills our eyes. As the macula is in
the back of the eye, the head must be positioned so that the bubble
will float to the back. This is accomplished by maintaining face-down
positioning-the patient's face is tilted toward the floor. This
posture must be maintained 20-22 hours per day during the first
week after surgery, or the likelihood of success will be dramatically
reduced.
While staying
face down virtually all day is not a pleasant prospect, there
are several strategies that make this possible. It is possible
to rent special chairs which are designed for massages, which
support the body while leaning forward and which have a padded
opening to support the head in a face down position. Alternatively,
a pillow can be placed on the surface of any table, and the forehead
placed on the pillow for support. While in bed, the face should
be against the pillow, but can be turned slightly toward one side
to assure easy breathing. The most important thing is to maintain
face down position all the time! (Even when a passenger in
a vehicle on the way to follow-up at your doctor's office). During
meals or trips to the bathroom, steadily looking downward will
help keep the gas bubble in contact with the macula. We strongly
discourage patients from simply sitting face down with out any
support for the neck, as neck strain will set in quickly and will
make any further positioning uncomfortable.
