Part Four: After Face-Down Positioning Is No Longer Required: What to Expect After Macular Hole Surgery

By Joy R. Efron, Ed.D.

This is the fourth of a five-part series, Surviving Recovery from Macular Hole Surgery. This section covers the period after face-down positioning is complete and the longer-term recovery process begins.

A “Jiggling” Feeling

When face-down positioning is over, the remaining gas bubble jiggles and it may feel as if part of your face is underwater. People who can’t close one eye (the operated eye) can wear a patch over the operated eye to keep from feeling woozy.

Sleeping Position

Even when I was no longer required to be face-down, I didn’t sleep on my back until the gas bubble was completely gone. The way I understand it is that while you’re on your back, the gas bubble comes in contact with the lens and accelerates the development of a cataract.

[Editor’s note: The most common risk following macular hole surgery is the development of a cataract in those who have not already undergone cataract surgery. The chance of developing a cataract is over 80% and is related to the surgery and gas bubble. In order to achieve the best possible vision, cataract surgery is typically performed after the gas bubble has gone away.]

If you do develop a cataract, your doctor will probably want to delay cataract surgery as long as possible following macular hole surgery. Of course, if you’ve had cataract surgery prior to macular hole surgery, these issues won’t be of concern.

What to Expect from Recovery

My own personal experience is that macular hole surgery recovery consists of four phases over a period of a year:

Phase One: Face-down positioning
Phase Two: a slow, gradual improvement in vision
Phase Three: a deterioration of vision due to the development of a cataract.
Phase Four: a dramatic improvement in vision following cataract surgery.

My Phases in Progress Explained

Everyone will have different milestones. The information below represents a summary of material from a journal I used to monitor my personal visual progress.

Phase One

During face-down positioning, my vision improved from light perception, to color recognition, to shape recognition, to finger counting, to central vision a few inches from the operated eye. With good lighting, I was able to read newspaper headlines and a few sentences of an article for a short period of time. Both eyes tired easily.

Phase Two

After face-down positioning was completed and the gas bubble had been absorbed, I experienced a slow, gradual improvement in vision.

Three months after surgery, my visual acuity had incrementally improved to almost 20/200 and the distortion had become less significant. Very good lighting was essential.
With new glasses, my visual acuity in the operated eye measured 20/60, but that was not a functional measurement. I was unable to coordinate the very different images in the two eyes and could only use the glasses during seated activities, such as watching television.
Although I “read” the newspaper, it was very different than my previous meticulous reading. It took several sessions, due to my eyes tiring, and consisted only of the beginning of articles of interest.
Reading outside in the sunlight was helpful. Large print books, available from most public libraries, were much easier to read and could be read for a longer period of time.

Phase Three

Five months after surgery, my visual acuity had deteriorated to the extent that I was only able to count fingers a few inches in front of my eyes.
Excellent lighting became even more critically important than in Phase Two. In dim lighting conditions, especially at night, vision in my operated eye was reduced to shape recognition with no details.
I was still unable to wear the glasses for more than a few minutes due to problems trying to reconcile the very different images from each eye. The glasses became less and less helpful. My functional vision was dependent upon the eye that had not been operated on, which tired easily.
Reading had become more of a struggle, regardless of print size.
I was unable to walk confidently wearing the new glasses, because my depth perception was erroneous enough to present safety hazards.
Finally, I gave up on the new glasses for any kind of activity that involved movement, though I continued to use them for seated activities.
For any activity involving movement, I used my old (pre-macular hole) glasses, with one lens (the old lens for the operated eye) removed. Thus, I was using monocular [one-eyed] vision with my old glasses, and depending exclusively on the unoperated eye.

Phase Four

My cataract surgery was performed seven months after the macular hole surgery. Cataract surgery usually results in a dramatic improvement in visual acuity.

The day after my surgery, my visual acuity was measured at 20/40. This continued to improve for a few months.
At eleven months post-macular hole surgery, my visual acuity had improved to 20/25 and distortion was nearly non-existent.
With good lighting, I could read regular sized print. Glasses enable me to read small print comfortably.

Cataract Surgery

Cataract surgery is almost always required within a year following surgery for a macular hole. Ask your surgeon if your vitrectomy poses any particular risks or challenges and what kind of visual improvement you are likely to achieve.

Important Advice

Most retinal surgeons measure the length of the eye prior to macular hole surgery in case they cannot see well enough through the lens to operate, thereby necessitating simultaneous macular hole and cataract surgery.

[Editor’s note: The length of the eye, also called the “axial length,” is a measurement of the distance between the front (cornea) and rear (back of the sclera) surfaces of the eye.]

Surgeons typically perform these two operations at the same time only if absolutely necessary. After the macular hole closes, however, the length of the eye may be shorter by the depth of the macular hole. Ask your doctor if you should be measured again prior to cataract surgery, as the depth of the macular hole may affect the choice of lens implanted during cataract surgery.

Other Concerns

Glaucoma

Steroids are commonly given to minimize post-operative inflammation. In about 15% of cases, patients react to steroids with high intraocular (within the eye) pressure (glaucoma).

In my case, the pressure was very high and it took two different types of glaucoma medications to lower the pressure to a normal range. I was insistent on monitoring the pressure on a regular basis to make sure it didn’t damage the eye.

Monitor the Other Eye

People who have a macular hole in one eye seem to have a higher chance of getting one in the other eye. It’s important to have frequent, periodic checks of the second eye. Monitor that eye for distortion and other vision problems.

One way to monitor visual distortion is by using an Amsler Grid. The first image below shows an Amsler Grid as seen with unimpaired vision. The next image gives an example of an abnormal Amsler Grid, as seen by a person with eye disease.

[Editor’s note: These images are much smaller than actual Amsler Grids. If you have been diagnosed with eye disease, ask your eye care professional for a regular-sized Amsler Grid you can use at home.]

Amsler Grid as seen with normal vision
As seen with normal vision

Amsler grid as seen by person with eye disease
An example of an abnormal
Amsler Grid

Look at the Amsler Grid weekly to make sure that all vertical and horizontal lines appear to be free from distortion, i.e., straight and parallel. At the first sign of distortion, make an appointment with your retinal specialist.

Face-down positioning, which is usually required for successful recovery from macular hole surgery, can be challenging and uncomfortable, but the results are worth the effort. With determination and innovation you can get through your post-operative period successfully.