Advances in Macular Hole Treatment and Recovery
I am aware of the following changes since my own macular hole vitrectomy surgery in 2009. One of the biggest changes is that there is now more information available online. However, this information is still limited and most is not written in terms that are easily understood by the general public.
A Major Change: Face-Down Positioning Time Requirement
In many cases, the face-down period has been shortened tremendously. I was face-down for six weeks. Most people now report one to two weeks. It does not take as long for the hole to close as previously thought. Some doctors now feel that face-down time is unnecessary to close macular holes. If people are face-down for only a few days, there is no statistically significant difference in the percentage of holes that reopen. However, there is no consensus among retinal surgeons.
The National Eye Institute still recommends face-down positioning, with length based on the doctor’s guidance. It’s important to note, however, that although many studies indicate similar rates of successful hole closure with or without face-down positioning, there is little research-based information about the correlation of visual recovery following face-down positioning vs. visual recovery without face-down positioning.
The American Academy of Ophthalmology (AAO) Retina/Vitreous Panel has issued Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole 2014, Updated 2017. The report states that “…there is no clear consensus regarding duration of facedown positioning to seal macular holes following vitrectomy surgery, but longer positioning may be required for holes larger than 400 [micrometers] or those with inadequate tamponade.”
[Editor’s note: “Tamponade” refers to a treatment that closes or blocks a wound or opening – in this case, a macular hole – by pressing on, or plugging, it.]
Most patients with gas tamponade are generally instructed to remain prone, face-down during the immediate postoperative period, but the length of that period is determined individually. AAO has also issued Face-Down Recovery After Retinal Surgery (PDF).
I believe the reduced amount of time for the face-down period is due to four factors:
- Retinal surgeons are using a different gas than in 2009. The gas is quicker acting and dissipates more quickly than in the past.
- Peeling of the internal limiting membrane (ILM) of the retina has become a standard procedure. ILM peeling seems to improve hole closure results. [Editor’s note: The internal limiting membrane is the thin membrane that overlays the innermost layer of the sensory retina.]
- Many patients, due to neck and back degeneration, are unable to remain face-down. In these cases, silicone oil is often used, which does not require face-down positioning. This, however, requires a second surgery to remove the silicone oil. Since it is a foreign material, there are some small risks of complications from the oil.
- Many surgeons measure success based on anatomical success (hole closure as well as concern with hole reopening) rather than functional success (the amount of vision recovered post-surgery).
Timeline for Surgery
In Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole 2014, Updated 2017, AAO summarizes many studies as follows:
In case series, many authors have reported better closure rates and better final visual acuities when the duration of symptoms is less than 6 months. Findings from case series indicate that a macular hole that has been present for more than 2 to 3 years may be closed, yet the success rate is lower (63%) and visual acuity outcomes are worse than for a macular hole of shorter duration.
Despite this recommendation (concerning better visual results with patients who have had the surgery within six months), many retinal surgeons have a large patient load and may be unable to schedule surgery within that time period. See Important Issues Raised by Macular Hole Patients for suggestions on advocating for a more timely surgical appointment.
Selection of Tamponade
In general, there is no consensus about the best choice of tamponade agent: air, type of gas, or silicone oil. Silicone oil may be used for patients who are unable to be face-down. This requires a second operation to remove the oil and the surgical results are not usually as good as with gas. While surgeons have learned that the hole closes much faster than they had thought previously, there have been no studies comparing vision recovery with respect to a slow-acting gas (long face-down period) versus a fast-acting gas (shorter face-down positioning time).
Some health insurance groups are now paying for the rental equipment for face-down positioning. As most do not, it is still necessary to advocate strongly for patient needs and, in many cases, to appeal the ruling of the insurance company. Medicare has never provided this equipment, regarding it as “comfort” rather than “medically necessary.”
See Insurance Coverage and Reimbursement Issues for more information about coverage for face-down equipment and financial resources for medication.
There is a lack of studies concerning face-down positioning and functional visual recovery, including visual acuity and any distortion of vision. However, my correspondence with people throughout the world clearly supports a close correlation between the strict regimen of face-down positioning and functional visual recovery. Face-down instructions vary greatly.
Some surgeons instruct their patients to be face-down the entire time with exceptions only for inserting eye drops. Others tell their patients to be face-down for a certain number of minutes of each hour or for a certain number of hours per day. Other variables, such as surgical skill, size of the macular hole, age of the hole, and the presence of pre-existing eye conditions are critically important to the outcome.
Ocriplasmin (trade name Jetrea) is a drug used by some retinal specialists to treat vitreal-macular adhesions. This drug was approved by the FDA in 2012 to separate adhesions of the vitreous from the macula. Injection of this drug causes liquefaction of the vitreous and helps dissolve the biological “glue” holding the vitreous onto the retina. This drug shows potential to become the first way to treat vitreal-macular adhesions pharmacologically, including macular holes.
For small macular holes, 40% received closure with this drug, as compared with a 90% closure rate with vitrectomy. If the procedure is not successful, vitrectomy remains an option. There are benefits, risks and complications of both intravitreal ocriplasmin and vitrectomy.
Certain types of macular holes have a higher rate of closure with ocriplasmin, including those in people who have not yet had cataract surgery; have small macular holes; have focal [i.e., attached at one point] rather than broad attachment of the vitreous; and do not have associated epiretinal membrane, which is abnormal tissue on the surface of the retina which can contribute to the macular hole and which the drug has no effect on.
The longer-term effects of ocriplasmin injections and complications have not been studied. Ask questions and discuss various options with your retinal surgeon.
Decision to Perform a Vitrectomy
Vitrectomy may be indicated depending on the amount of damage to the macula caused by pathologic changes in the vitreous. Typically, due to risks and possible complications of surgery, a vitrectomy is not performed unless, and until, there has been a significant deterioration of vision. This may result from a macular hole, a pseudohole, a macular pucker or epiretinal membrane, or other causes. If you have one of these conditions and it has not yet affected your vision, monitor it carefully and consult your ophthalmologist if or when there are changes.
Updates in Macular Hole Treatment and Recovery
- My Personal Journey and Vision Recovery from Macular Hole Surgery
- Macular Hole Statistics
- Macular Hole Surgery Recovery Techniques and Suggestions from Readers
- Insurance Coverage and Reimbursement Issues for Macular Hole Surgery
- Important Issues Raised by Macular Hole Patients
- My Suggestions for Patients Having Macular Hole Surgery
Also see Suggested Resources for more information about helpful products and organizations, as well as the author’s contact information.
I was an educator of blind and visually impaired children for 42 years. Although I have read and researched a great deal and have had extensive discussions with retinal specialists, I am not an ophthalmologist or a medical doctor.
Reviewed and edited by Mrinali Patel Gupta, M.D., VisionAware Medical Consultant