Macular Hole Surgery Without Face Down Positioning

by Paul E. Tornambe, M.D.

La Jolla, California

 
 

The purpose of this website is to inform you about macular holes, macular hole surgery, post operative care with and without face down posturing, and make you aware of a retina specialist in your area who performs macular hole surgery and, under usual circumstances, does not mandate face down positioning. I receive several calls a month from patients who for one reason or another are unable to be placed face down and ask for a doctor in their area who does not require face down positioning. I’m not sure why many retina physicians are so adamantly in favor of face down posturing, for the recent literature abounds with numerous papers verifying that face down positioning is not necessary (See Bibliography). Old habits are hard to break! The retina doctors listed on this website are all formally fellowship trained (one year or more for all US and Canadian doctors) and have indicated that they usually perform macular hole surgery without face down positioning. These surgeons may not advise exactly the same approach as mine, but they all believe that post operative face down positioning is usually not necessary to treat a macular hole. The following is my opinion regarding macular holes and how I manage a patient with a macular hole.

We published the first paper in Retina in the mid 1990’s advocating both no face down positioning and cataract surgery prior to or at the time of macular hole repair.   Since then I position no one older than 50 years old face down for any period of time. Why age 50? Well, almost every patient over the age of 50 who has a vitrectomy for any reason (macular hole, macular pucker, retinal detachment, diabetic retinopathy, etc.) will develop a cataract  (clouding of the lens in the front portion of the eye) within a few months to years of the vitrectomy. So if you are over 50 and need a vitrectomy, cataract surgery is in your near future. Furthermore, it is easier for the cataract surgeon to remove the cataract before the vitreous is removed, and it is easier for the retinal surgeon to perform vitrectomy surgery after the human lens has been removed. The main reason face down positioning was advocated in the early days of macular hole surgery was to prevent the gas bubble from touching the human lens, which causes an immediate cataract. If the cataract is removed and replaced with a plastic intra-ocular lens, then the gas bubble may touch the plastic lens without doing any harm, thus eliminating one reason to be placed face down.

Let’s back up for a moment to discuss the anatomy of the eye,  what a macular hole is, why a macular hole forms, how it is repaired, and why face down positioning is not important. A macular hole happens because of two factors, you picked the wrong parents (genetic) and you’ve had a lot of birthdays (aging)! 

Anatomy Lesson

The eye is like a camera, light enters the front of the eye, is focused by the cornea and the lens (with age the lens gradually becomes cloudy and is called a ‘cataract’). The focused rays of light pass through the middle fluid of the eye called the vitreous which has a jelly like consistency and then onto the retina, which like the  film in the camera takes the picture. The retina lines the back of the eye (like a rubber bladder in a basket ball)  takes the picture and then sends the image to the brain via a cable we call the optic nerve. The very center of the retina is a small circular area called the macula, which is the most sensitive part of the retina and is responsible for reading and color vision. The rest of the retina is needed for night vision and peripheral vision.










If a hole develops in the macula, central vision is reduced. A macular hole usually starts as a small defect and enlarges with time. The earlier these holes are repaired the better the chances for better post operative vision. It is rare that ‘perfect’ vision returns with surgery, but it is common for the operation to improve vision significantly and more than 50% of patients will regain enough vision to read and drive. Today, the only way to repair a macular hole is with an operation called a vitrectomy. Drugs are being developed which may cure many holes in the future with just an injection of the drug into the eye. Ocriplasmin (microplasmin) with the brand name of Jetrea has recently been approved by the FDA  and is available. One injection of this drug resulted in 40% closure of macular holes which had vitreomacular traction. If there is no traction on the hole the drug is not useful. The most successful candidates are patients less than 65 years old with a vitreomacular adhesion less than 1500 microns with no epiretinal membrane and no prior cataract surgery. In this ‘ideal group‘ the success rate may be as high as 60%. Jetrea is approved for only one injection and the cost of the drug is about $4000.  Recently, Duker reported that patients with a macular hole in one eye and no separation of the vitreous from the macula in the fellow eye had a 40% risk of developing a hole. Jetrea might be considered in these fellow eyes prone to develop a macular hole as a preventative measure.

                         Macular Hole Surgery

What is a macular hole?

Patients who have a macular hole, have a defect, or hole in the center of the macula. This hole is located at the very back portion of the eye (see above figure).  They note that parts of words are blurred, missing, or are distorted. Macular holes are caused by a vitreous membrane (called the posterior hyaloid membrane) which exerts traction on the macula and creates a defect in the inner retina (see photos 1,2,3 in the right column). The liquid vitreous then goes through the hole and swells the retina like a sponge  The edges of the hole elevate, like a drawer bridge. Macular holes are treated by removing this membrane (see ‘4’ in the right column) and another adjacent membrane which lies on the surface of the macula called the internal limiting membrane (ILM). To allow the retinal defect or hole to heal, a gas bubble is used to cover the hole (see 5), much like a band-aid. The bubble simply isolates the hole from the liquid vitreous. The deeper retina contains cells (Retinal Pigment Epithelial Cells) which pumps the fluid out, the swelling resolves and the draw bridge closes. The bubble keeps fluid from re-entering the hole while it heals. A type of ‘scab’ forms over the hole which permanently seals the defect. If the gas bubble does not cover the hole, fluid continues to enter the macula which remains swollen, a scab cannot form, and the hole edges will remain elevated. If a SMALL gas bubble is inserted into the central cavity of the eye, in order to put the ‘bubble on the trouble’ the patient must lie face down so the bubble covers the macular hole. However, if the bubble is LARGE and completely fills the eye, the bubble will press on the hole regardless of body position (except face UP). THE BUOYANCY OF THE BUBBLE PLAYS NO PART IN HOLE CLOSURE, ALL THE BUBBLE DOES IS KEEP VITREOUS FLUID FROM ENTERING THE MIDDLE OF THE RETINA AND ALLOWS THE ‘SCAB’ TO FORM. THEREFORE FACE DOWN POSITIONING IS NOT NECESSARY IF THE BUBBLE IS LARGE, THAT IS IF 95% OF THE VITREOUS CAVITY IS FILLED WITH A GAS BUBBLE, THE HOLE WILL BE COVERED REGARDLESS OF THE HEAD POSITION. See figure #6; a CAT scan showing that when patient lies on the left side the bubble is still large enough to cover the macula and  the photo beneath it (#7) which shows a shrinking gas bubble, 8 days after insertion, which is still large enough to cover the hole with the patient in an upright position.


What will happen if nothing is done?

Macular holes almost always only affect the very center of your vision, and do not affect peripheral (side) vision. They almost never cause a retinal detachment. A small hole can enlarge and reduce vision to the level that you will not be able to read or see the big ‘E’ on the eye chart, but peripheral vision is usually not affected even if the hole is not treated. One in 100 eyes will spontaneously improve without surgery, 99% don’t close on their own. The literature states that the chances of getting a second hole in your other fellow eye is between 10 and 50%.  Our personal experience is that it’s closer to 10% than 50%.


Must the hole be repaired immediately?

The best results are obtained when surgery is performed within 6 months after the hole has developed. THIS IS BECAUSE THE HOLE USUALLY GETS LARGER WITH TIME.There are reports of vision returning to the 20/50 level (reading vision) as long as ten years after the hole was noted, but the odds of getting better vision drop with length of time the hole has been present. Best chances of visual recovery occur when the hole is small, when pre operative vision is better than 20/200 and if the hole has been present for less than one year.


What is involved to repair the hole?

The operation is usually done as an outpatient. You are asked to arrive at the hospital an hour or two before the operation to dilate your pupil and prepare you for surgery. 

The operation is done in the operating room (hospital or out patient facility), usually as an outpatient. Medical clearance may be necessary from your personal physician to O.K. you for surgery. We will usually require a recent physical exam, CBC, EKG, and electrolytes. Do not take aspirin or blood thinners within 2 weeks of surgery unless your doctor says that the medications are crucial. If you take insulin check with your doctor to determine the appropriate dose on the day of surgery.


The operation usually takes about 1 to 1.5 hours to perform. The procedure can be done under local or general anesthesia.  The procedure requires that the vitreous jelly inside your eye be removed as well as the membranes which cause the hole. We usually stain the membrane with a dye so it can be seen well and completely removed (see figure 4) . The eye is then filled completely with a gas bubble which lasts about two weeks, and resorbs spontaneously. If your lens is not removed, you will have to maintain a face down position for one week to keep the bubble away from the lens or a cataract will develop.  You may get up to eat or go to the bathroom, otherwise you must remain face down. If you do not position face down, the hole will close but a dense cataract will form immediately and usually will have to be removed within a month to restore vision. 


In eyes that the lens is removed and an implant inserted (cataract surgery) prior to the macular hole operation, face down positioning is not necessary for the bubble does not affect the plastic intra-ocular lens implant. We will frequently recommend the cataract be removed a few weeks before or at the same time of the macular hole operation, even if the cataract is not ripe.  Our studies have shown that face down posturing is not necessary for success, and our success rates with no positioning are very similar if not the same as those who position patients face down.


Following the operation, you will spend about one hour after surgery in the recovery room. At this point a nurse will go over your postoperative instructions. YOU ARE NOT PERMITTED TO FLY OR ASCEND IN ALTITUDE MORE THAN 2000 FEET BY CAR FOR ABOUT TWO WEEKS AFTER THE OPERATION. IF YOU DO NOT FOLLOW THESE INSTRUCTION THE EYE PRESSURE DURING ASCENT MAY RISE AND CHOKE OFF THE CIRCULATION TO THE OPTIC NERVE RESULTING IN SEVERE PERMANENT VISUAL LOSS. YOUR DOCTOR WILL TELL YOU WHEN IT IS SAFE TO REMOVE THESE RESTRICTIONS. IF YOU HAVE TO HAVE GENERAL ANESTHESIA WITHIN A FEW WEEKS OF THE EYE SURGERY FOR SOME REASON, YOU MUST LET THE DOCTORS KNOW, ESPECIALLY THE ANESTHESIOLOGIST, THAT YOUR EYE CONTAINS A GAS BUBBLE.


Post operative care

Your operated eye will be patched for twenty-four hours. You will wear a protective shield for naps and bedtime for two weeks to protect the eye. Drops will be started the next day. Drops will be used to prevent infection, minimize inflammation, keep the eye pressure at a safe level, and relax the muscles inside the eye. The drops will be used for two to six weeks. You will receive a patient information sheet to inform you how to take care of your eye. Please read the patient post operative information sheet and feel free to ask YOUR DOCTOR if their are any questions. You may also receive a pill for eye pressure, and a pain pill. The pill for eye pressure (Diamox) is a sulfa compound, so don’t take it if you have a known allergy to sulfa. It should also not be taken if you have a history of kidney stones. If you develop flank (back, kidney) pain while taking the medicine, stop it immediately and call your doctor.


Diamox may also make your fingers and lips tingle, may cause loss of appetite, give diarrhea, may make carbonated beverages taste flat, and may make you feel depressed. Try to take the pill for at least two days or call your surgeon if you are having problems.


Pain

There is usually very little pain following this type of surgery. If you have severe pain, not adequately relieved by the pain medication prescribed, please call your doctor immediately. If you have a severe deep eye ache, eyebrow pain, or persistent nausea and/or vomiting, call immediately. It could mean that the pressure in the eye is elevated.


Restrictions

For two weeks following surgery no face down positioning is necessary. You may sleep in any position except ‘face up’ towards the ceiling. It is best to sleep on the side which places the operated eye uppermost (example, if surgery is done on the right eye, sleep on the LEFT side). You should avoid heavy lifting (>25lbs), bending or straining for 3 weeks. Avoid all unnecessary reading until the bubble has completely resorbed. Because the bubble will expand as you ascend in altitude and could significantly raise the pressure inside your eye, do not ascend to an altitude over 2,000 feet. Also, do not fly until the bubble resorbs. We suggest you  restrict your activity for 2-4 weeks. Some people can return to work a week or two after the operation, but this will depend upon their occupation. If a longer acting gas bubble is used you may have to restrict some activities up to eight weeks. We use the shorter lasting two week gas bubble 98% of the time.


Visual return

Your vision will be poor while the bubble is inside your eye.You will see light and movement but not much more. As the bubble resorbs your vision will improve. The top of your visual field will be the first vision to return. As the bubble resorbs, it may break-up into smaller bubbles. This is normal. Once the bubble has completely resorbed, you may or may not note an improvement in the blurring or distortion of central vision you noted prior to surgery. About 80% of what will return will occur by 4 months post operatively. 90% of visual recovery will return by one year, and usually all the vision that can return will return by 2 years.


Success rate

Over the years we have performed hundreds of macular hole operations and have tried to constantly improve our techniques. I reviewed (4/28/13) a consecutive series of macular holes I repaired with our latest techniques and instruments. The series included 70 never operated on before, non traumatic macular holes less than 750m in size. My surgical technique utilized small gauge (#23) vitrectomy instruments, ICG peeling of the ILM in all cases, 25% SF6 gas (lasts about two weeks) and NO FACE DOWN POSITIONING. All eyes had cataract surgery either prior to the vitrectomy operation or at the same time of the vitrectomy operation. In 97% of eyes the hole closed with one operation, and in 69% reading vision (ie., 20/40 or better) returned.  The retinal detachment rate was 4% (3 eyes).  Two of the 3 eyes with detachments were successfully repaired and the holes closed. In one eye scar tissue formed (PVR) and vision was lost.


Complications and Risks

As with any surgery, there are risks which include but are not limited to bleeding, infection, retinal detachment, or a vascular occlusion of the eye. Fortunately, such an occurrence is uncommon. There are certain anesthetic risks including stroke and death. These too, are very rare. Every precaution is taken to prevent such complications. However, if they do happen, permanent damage can sometimes be minimized. For example, if a retinal detachment occurs, most can be repaired. You must, however, understand that sometime eyes lose all sight (central and peripheral vision) permanently as a direct complication of the operation. This is  major eye surgery and before you proceed with the operation you must carefully weigh the risks, alternatives, possible benefits and possible complications.


Macular Holes Surgery Without Face Down Posturing, what is done differently?


The  bottom line is that the retinal surgeon does exactly the same macular hole operation whether the patient lies face down or not! The key to no face down positioning success lies in (1) a large (>95%) gas fill of the vitreous cavity and (2) removal of the human lens prior to macular hole surgery. If the patient had cataract surgery in the past and the retinal surgeon performs a complete gas fill, positioning is not necessary. The surgeon does nothing else different!


This is how I perform macular hole surgery.


The eye first has the human lens removed and replaced with an intra-ocular lens. The cataract doctor should implant a mono-focal lens with a large optic and suture the wound. Next (either immediately following the cataract operation or no sooner than a week or two after the cataract surgery) the vitrectomy is performed. The vitreous jelly is removed and the posterior hyaloid membrane and internal limiting membranes are peeled off the surface of the macula (usually requires a dye to stain the transparent membrane). The peripheral retina is checked for retinal tears and treated if need be, then the fluid in the vitreous cavity is replaced with a 25% mixture of SF6 gas (lasts 2 weeks). If the hole is very large or has been present for a long period of time, C3F8 gas is used (lasts 8 weeks). With either gas it is important to get a 95% or greater fill of the vitreous cavity. If the cataract has been recently removed we use Pilocarpine 1% 3x per day for about ten days to keep the pupil small which prevents the gas bubble from pushing the lens forward. The patient may not fly or ascend over 2,000 feet until the bubble significantly shrinks or resolves completely. So, to re-state the point, the surgical technique is exactly the same, with or without face down positioning; the only difference is we don’t put the patient face down.


Summary

Macular hole surgery is a very effective and highly successful operation.  Without surgery, 99% of patients will have no improvement in vision. The operation is not perfect, and is not 100% successful but has a much better chance of restoring sight than doing nothing. The risks are relatively small, but if complications occur, all sight could be lost. Before deciding to go ahead with surgery you must determine how much this visual loss affects your life style. If you are doing all the things you like to do with minimal difficulty, we advise against surgery. If you feel that the quality of your life is significantly negatively affected, surgery should be considered.


Please note that although macular hole surgery is ‘routine’ surgery with a high success rate (>95%), it is still an operation and there is risk of infection, bleeding, retinal detachment, and even loss of all vision in the affected eye. There are also anesthetic risks which includes stroke and death. The chance of the above developing is rare but if it happens to you it is ‘100%’! There is no guarantee that vision will improve, but the odds are in your favor that better vision is likely with successful surgery.

The reader must understand that there are risks with any type of surgery, and that no guarantees are made. This web site does not guarantee a positive result nor certify any of the doctors listed.

 

Macular Hole Surgery Without Face Down Positioning

Full thickness macular hole

photo (left), OCT (above)

5-The gas bubble isolates the hole from the liquid vitreous, the retina pumps the fluid out, the hole (draw bridge) closes, and a ‘scab’ forms to keep the vitreous fluid from re entering the retina.

Macular Hole Formation

1-The Posterior Hyaloid Elevates the Inner Retina,

2-The liquid vitreous fluid enters the inner retina,

3-The swollen edges of the retina elevate like a drawer bridge forming a macular hole

4-During surgery the membranes are stained and then removed from the surface of the retina

6-CAT scan of a patient lying in the left side. The upper eye  contains an 80%gas bubble fill. Note that the bubble is large enough to cover most of the back portion of the eye.(Courtesy Wilson Heriot, MD)

7-Photo shows a 25% SF6 gas bubble at Day 8 following surgery. The bubble at Day 8 has shrunk 60% but still covers the macular hole with the patient in the upright position.