 Central Florida Retina Institute, Specializing
in diseases and surgery of the retina, macula, and vitreous,
 877-245-2020
Retina FAQs | Glossary
of Ophthalmologic Terms | Description
of a Retina | Diabetic
Retinopathy | Epiretinal
Membranes | Flashers &
Floaters | Macular Degeneration
| Macular Holes | Retinal
Detachment | Retinopathy
Of Prematurity | Clinical Trials
Q: Description of the macula
A: The macula is the center
of the retina. It is responsible for central vision (straight
ahead vision), your best vision, and most color vision. The center
of the macula is called the fovea.
Q: Description of a macular hole
A: A macular hole is a defect
in the macula.
Q: Symptoms of a macular hole
A: They are decreased or complete
loss of central vision. Other eye problems can cause similar
symptoms; the presence of a macular hole can only be determined
by a dilated eye exam.
Q: Can macular holes cause total blindness?
A: No, they can only cause loss
of central vision.
Q: Are there different types of macular
holes?
A: Yes, they fall into the following
categories:
• Classic macular holes:
also called idiopathic or degenerative macular holes, these are
much more common than other types. These are of the type that
will likely benefit most from surgery, if certain criteria are
met.
• Traumatic macular holes: these usually occur with direct
impact occurring on the eye or head. Some of the traumatic cases
spontaneously heal ("close" or "seal"). Surgery
is less successful in this group but can be performed if the
doctor thinks the retina and underlying retinal pigment epithelium
are functioning well.
• Macular holes caused by long-standing macular edema (swelling),
which can be caused by diabetic retinopathy, branch vein occlusion,
pars planitis, or other inflammatory eye disease. Patients with
holes of this type should not be treated with surgery.
Q: How common are classic macular holes?
A: Classic macular holes are
a moderately common cause of irreversible central visual loss
in people over age fifty. They are three times as common in women
as in men, for unknown reasons.
Q: What is the cause of classic macular
holes?
A: Most classic macular holes
are apparently related to posterior vitreous separation. Residual
vitreous humor remaining on the retinal surface after this event
probably contracts, pulling on the macula and fovea in an outward
direction.
Some macular holes are caused
by a thin layer of tissue known as an epiretinal membrane. These
holes typically have no cuff of fluid around them and are associated
with retinal "wrinkles".
Q: Does hardening of the arteries cause
macular holes?
A: No, circulation problems
have not been shown to have any relationship to macular holes.
Q: Are eye strain, nutrition, general health,
smoking or emotional stress related to macular holes?
A: No, there is no known relationship
between macular holes and any of these problems.
Q: If one eye develops a macular hole,
will the other eye develop one?
A: Usually not; most patients
develop holes in one eye only. The odds are about 6% of developing
a hole in the second eye.
Q: What is the treatment for macular holes?
A: Vitreous surgery, placement
of a gas bubble inside the eye, tissue peeling using forceps
(FORM), and head down positioning for several weeks after surgery
are required to repair macular holes.
Vitreous surgery consists of
removing the vitreous to enable injection of a large gas bubble
and, in many instances, peeling of tissue from the retinal surface
to stimulate hole closure.
The tissue on the retinal surface
may be residual vitreous, epiretinal membrane, or ILM. Most but
not all surgeons peel ("strip") this tissue away from
the retinal surface during vitreous surgery.
Dr. Charles developed forceps
membrane peeling techniques in the early 1980s. This technique
has been improved by using an inside out, circular motion and
special forceps that conform to the retina surface. This method
we call FORM, developed by Dr. Steve Charles, is more precise
than the FILMS method.
A decreasing number of surgeons
place blood products such as serum, clotted blood, or platelet
concentrate on the retinal surface. Our doctors do not use these
substances because there is no scientific evidence of their benefit,
there is potential risk, and many experienced surgeons no longer
use these agents.
Q: I've heard that ICG dye is sometimes
used in this type of surgery. Do you use it?
A: ICG dye is not used by our
surgeons for two reasons:
• Our surgeons are experienced
enough that they do not need the dye in order to see the ILM,
which is the dye's purpose.
• Toxicity of the dye has been reported by others.
Q: Is there a medication for the treatment
of macular holes?
A: No: there is no medicine,
eye drop, vitamin, herb, or diet that is beneficial to macular
hole patients.
Q: Is there a laser treatment for macular
holes?
A: No, only surgery can repair
a macular hole.
Q: Do holes ever disappear without surgery?
A: It depends largely upon the
amount of separation of the vitreous from the retina present
in the macular hole. A staging system is used to describe this
amount of separation. Stage 1 is a macular hole of partial thickness
separation of the retina; that is, it does not extend all the
way through the retina and is not a true hole. Patients with
a Stage 1 macular hole typically have little or no visual loss.
Approximately 50% of Stage 1 macular holes disappear without
surgery.
Stages 2, 3, and 4 represent,
respectively, formation of a true hole, enlargements of the macular
hole, and separation of the vitreous from the retina. These will
not spontaneously disappear.
Q: What is the purpose of the gas bubble?
A: It acts like a bandage to
help cells and associated tissue to grow across the hole, eliminating
the defect in the retina.
Q: Why is it necessary to be face down
when a gas bubble is in the eye?
A: The bubble floats and is
only in contact with the macula when the face is pointed toward
the floor.
Q: How many hours per day should the patient
be face down?
A: Our doctors recommend that
the strict head down position is kept at all times for 3 weeks
after surgery. Patients can sleep and nap face down, read with
the book or papers in their lap, watch television by placing
a small set on the floor, and walk for exercise while looking
down without much difficulty. Some occupations are compatible
with this approach while others are not. Driving should limited
to emergencies. Limited compliance with head positioning decreases
the chances of success of the surgery and increases the chances
of cataract formation.
Q: What drops should be used after vitreous
surgery for macular holes?
A: We do not recommend the use
of steroid drops. We use only an antibiotic and a dilating drop
for a few days after surgery.
Q: How long does the surgery take?
A: The procedures usually take
our doctors less than 30 minutes.
Q: Is the surgery performed on an inpatient
or outpatient basis?
A: The surgery is performed
on an outpatient basis in all cases unless there is a medical
reason to be in the hospital.
Q: Does the two-week gas bubble (SF6) result
in the same success rate as the three-week bubble (C3F8)?
A: Most data indicates that
the three-week bubble is more effective than the two-week bubble.
Q: Can I fly with a gas bubble in my eye?
A: No. The bubble can expand,
causing pressure increase, excruciating pain, and even blindness
in the eye. Airplane travel, mountain climbing or travel in or
to or through the mountains, scuba diving, and travel to higher
elevations by any mode of transportation are to be avoided while
the gas bubble is present in the eye. These activities can generally
be resumed once the bubble has completely resorbed.
Q: What is the success rate of the vitreous
surgery?
A: The rate of closure of the
macular hole after successful surgery is about 90%, but the rate
of visual improvement varies considerably. Most patients experience
some improvement in vision after successful surgery. The final
improvement in vision may not be achieved for many months after
surgery. All of the factors affecting the degree of improvement
are not yet understood, but include:
• the size of the hole.
• the quality of the surgical technique.
• the ability of the patient to remain for three weeks in
a face down position.
Q: Are there any complications?
A: Often, there is a significant
instance of cataract progression after vitreous surgery. Some
doctors believe that patients with an absolutely clear lens develop
cataracts as a result of vitreous surgery, but our doctors disagree.
The vast majority of patients requiring vitreous surgery for
macular hole have nuclear sclerotic cataracts (yellowing of the
center of the lens), which can worsen after vitreous surgery.
Surgeons differ widely on the percentage of patients that suffer
cataract progression due to vitreous surgery. Our doctors believe
that the progression rate is about 10%.
Retinal detachment can occur
after vitreous surgery performed for any reason, including macular
hole repair. Opinions vary widely on the frequency of retinal
detachment after macular hole surgery, ranging from 1.5% to 30%.
Our doctors believe that the incidence is less than 5%.
A small number of patients (about
1%) will experience reopening of the hole after initial success.
Q: If the hole reopens, should surgery
be repeated?
A: If the surgery fails because
it was a large hole, it should not be repeated in most instances.
If surgery fails because the patient failed to remain face down
the first time and will definitely remain face down the second
time, surgery may be considered.
If you have
any further questions about the service provided by Central Florida
Retina Institute or if you would like to make an appointment,
please call (863) 682-7474 or call toll-free at 877-245-2020.
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