This page aims to give you some general information about the treatment and aftercare of this condition. Please feel free to discuss any specific concerns with Mr Prasad.
The retina is the light sensitive layer at the back of the eye (film) which transmits the messages of the light rays along the optic nerve to the brain. Light rays enter the eye through the transparent (clear) cornea then pass through the pupil in the centre of the iris (coloured part of the eye). Light must pass through the lens and vitreous (a jelly-like substance) before reaching the retina.
The macula is the central part of the retina which is capable of the detailed vision necessary for tasks such as reading. 
Formation of a macular hole
The central portion of the eye is filled with a jelly-like substance known as the vitreous. As a person ages, the vitreous jell begins to shrink, being replaced by liquid. As the vitreous shrinks, it pulls away from the surface of the retina. In most cases, this pulling away or vitreous separation occurs without any negative effect. A patient may notice floaters but no significant visual damage occurs. In a small number of cases shrinkage and movement of the vitreous can result in the formation of a hole in the macular region, known as a macular hole. This process results in a defect or dark spot in the central vision with distortion and central visual loss.
Symptoms
These include: decreased central vision for both distance and reading activities, distortion in central vision, a defect in the central vision where letters may disappear.
Treatment
It is possible to offer a surgical procedure with the potential for visual improvement. This procedure is known as a vitrectomy, and involves the microscopic removal of the vitreous gel from the centre of the eye. Particular attention is paid to removing any of the vitreous attachments from the macula, thus releasing the traction (pulling) on the retina which caused the macular hole initially. This permits settling of the retina against the wall of the eye.
To assist in this process, a large gas bubble is placed within the eye, which, when it comes into contact with the retina, presses it against the wall of the eye, sealing the macular hole. This process acts much like a hand holding wall paper against the wall permitting it to stick and remain in position as the "wallpaper glue" dries.
In order to be effective, the bubble must apply continued upward pressure against the retinal surface in the area of the macula. Because the macula is located in the back part of the eye, you must remain in a "face-down" position to allow the bubble to rise toward the back of the eye and exert this pressure. You must maintain this face-down position for three days after surgery in order to achieve successful closure of the macular hole and maximize the chances for vision improvement. This face-down positioning is the single most critical portion of the procedure for closing macular holes.
The gas bubble may take anywhere from 6-8 weeks following surgery to completely disappear. The bubble is gradually resorbed by the body, and the vitreous cavity is then filled with liquid produced by the eye.
The surgery is performed typically under general anaesthesia, with an overnight stay in hospital. It may be done with a local anaesthetic for some patients. Additional stay of 1 to 2 nights may be needed sometimes. You will need to use several eye drops applied over the course of several weeks following the surgery. Full visual recovery may not occur until as late as three months after the surgical procedure.
Tests before surgery
You may have tests (such as urine test, blood tests and an electrocardiograph ECG) to check your suitability to receive general anaesthesia.
General Questions
Q. Is a macular hole the same as macular degeneration?
No, macular holes and macular degeneration are two separate and distinct conditions. Macular degeneration is a condition affecting the tissues lying under the retina, while a macular hole involves damage from within the eye, at the junction between the vitreous and the retina itself.
Q. What happens if I choose not to have surgery?
Your central vision will usually deteriorate, but you will not loose peripheral vision because of the macular hole. The eye will not go blind because of this condition.
Q. If I have a macular hole in one eye, does it happen in the other?
There may be risk of developing a macular hole in the other eye. The doctor evaluating you can determine the status of the vitreous gel and its degree of traction on the retinal surface in the uninvolved eye, and can help to better define the risks to this eye. It is very important to contact your ophthalmologist if you notice any distortion in the other eye (specially, if you notice that straight lines have a ‘break’ or a ‘bump’ in them) as this may signify the development of a macular hole on that side.
Q. Is there anything that caused the macular hole, or is there anything that can be done to prevent a macular hole from developing in the other eye?
In the majority of cases, however, macular holes develop spontaneously. In rare instances, trauma or other conditions lead to the development of a macular hole. As a result, there is no known way to prevent their development, nor is there any way to know who is at risk for developing a hole prior to its appearance in one or both eyes.
Q. Does it matter how long I have had the macular hole if I am interested in having surgery done?
Macular holes present for less than six months have a better chance of repair and visual recovery than those present for more than six months. Surgery is not usually recommended for macular holes which have been present for more than one year as the success rate is low. If a macular hole exists in one eye, it is very important to monitor for any vision changes in the second eye, and report these vision changes to your ophthalmologist immediately.
Q. If I have surgery, what type of vision improvement can be expected?
Typically, for macular holes less than six months in duration, a vision improvement of approximately three lines on the eye chart (or 50% improvement) can be achieved. Obviously, this is an "average" visual improvement. Vision recovery varies on a patient-by-patient basis. Some patients achieve only a small amount of vision recovery, while others achieve a more significant improvement.
Q. How important is it really to maintain the face-down position?
Face-down positioning is crucial to the success of the operation. If you are not able to maintain face-down positioning, it is unlikely that the operation will succeed. Therefore, if you think that you will not be able to maintain this posture for three days, it is very important to discuss this with the surgeon, before the operation.
Q. When will I get my vision back?
While the gas bubble is present in the eye, the eye is unable to focus light properly, and therefore vision is very blurred. You may only be able to see shapes, shadows or hand movements in front of your eyes while the bubble is large. As the bubble begins to shrink, vision begins to return. Final vision recovery is often not achieved for 6-12 weeks following the operation. If you have not had cataract surgery, the vision may begin to exhibit gradual deterioration approximately 6-12 months after the operation as a cataract develops. Cataract surgery will then be needed.
Q. Am I able to travel after macular hole surgery?
You should not travel by air while the gas bubble is still present – this period lasts upto 2 weeks. The depressurisation will cause the gas bubble to expand and your eye to become very painful.
Q. Are there any complications
As with any major surgery, there is a risk of complications. However it is important to realise that these are generally infrequent. Any one of these complications can result in failure of the operations, loss of some or all vision, and, in very rare situations, even loss of the eye.
These include a small percentage of patients who develop retinal tears or detachments during the surgical procedure itself, or in the immediate postoperative period. These problems are usually repairable by further surgery.
In patients who have not already undergone cataract surgery, the development of a cataract occurs in almost all individuals within six months to two years. Surgical removal of the cataract and placement of an intraocular lens is then required.
General risks of any operation in the eye include a risk of bleeding or infection. There is a very rare (1 in 1000) chance of developing an inflammation in the fellow eye (unoperated eye) after such a procedure, this is called sympathetic ophthalmitis.
Q. Don't you have to spend two weeks lying flat on your front after the operation?
No. This used to be the case and many surgeons still recommend it. Newer surgical techniques achieve the same result with 3 days of face down posturing,of which the first 24 hours is most critical. This minimal posturing regime makes a macular hole operation very patient friendly.
Please discuss any concerns you may have with your surgeon before the operation.
You may find it useful to write down any questions you may have, to ensure you have discussed them before surgery.
Further reading
From the National Eye Institute (USA)
