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Providing eye surgery in Cheshire, Manchester, Lancashire and all surrounding areas.

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Macular Hole:

What is macular hole?

Macular HoleMacular hole is a condition affecting patients in their 60s and 70s, usually female, where a tiny hole develops in the very centre of the retina (the macula) not associated with any other eye problem. There is initial central distortion of vision, and then gradual loss of reading vision.

Occasionally macular holes can develop after trauma, in very short-sighted people or those who have had retinal detachment.

Is this macular degeneration?

No, a macular hole is a different condition from age-related macular degeneration (AMD).

Do I need any tests?

Usually the diagnosis can be made by clinical examination. However the macular hole may be tiny (less than 0.4mm across) and Mr Charles may arrange an OCT (optical coherence tomography) scan to confirm the condition:

OCT Scan showing Macular Hole in cross section

How can it be treated?

Treatment is by surgery. A pars plana vitrectomy is performed. 3 tiny holes are made in the sclera (white of the eye) and the vitreous jelly is removed, together with a very thin membrane (the ILM or inner limiting membrane) is removed with placement of a gas bubble in the eye. This gas bubble is absorbed over 4 weeks or so after surgery. In the past, patients were positioned face down for 10 days or so, and tended to require cataract surgery within 6 months of surgery. For the past 8 years I have been treating patients with combined cataract surgery at the same time and a single night of face down positioning after surgery, with excellent results. This is much more convenient for patients and gives them a much quicker long term visual improvement. Patients must not fly or drive while they have a gas bubble in the eye.

Do I need a general anaesthetic for surgery?

No. Mr Charles has performed this sort of surgery under local anaesthetic for many years and is very happy with the technique. However, everyone is different and some patients may prefer to have a general anaesthetic. Therefore the decision as to what kind of anaesthetic you would like is made at the time of your assessment, also bearing in mind your general health.

What is it like to have a gas bubble in the eye?

The vision is blurred if there is a gas bubble in the eye, a sensation rather like having your eyes open under water. As the gas bubble gets smaller, patients notice it's edge as wobbly line in the upper field of vision. This will then drop across the field of vision, the bubble then being seen as a round blob before it disappears, as painted by one of our patients:

Patient Drawing

What happens if my macular hole is not treated?

The central vision will slowly get worse, reducing your ability for fine tasks in that eye (ie: read, or recognise faces). The peripheral part of the vision will remain unaffected. Therefore, although the vision will become very blurred in the centre, the eye will never become totally blind. However it is the macula that gives the central, most important part of vision. Therefore we encourage patients to undergo macular hole surgery.

Can I develop a hole in my other eye?

15% patients can develop a hole in the other eye. However sometimes, after clinical examination of the jelly of the eye, we may be able to say this is unlikely.

Stephen Charles has extensive experience of performing macular hole surgery, and teaching the technique to trainee vitreoretinal surgeons. He has helped refine the surgical technique and published on macular hole surgery without prolonged post-operative positioning.

Is there an alternative to vitrectomy surgery in the treatment of macular holes?

Yes.  A new treatment by intravitreal injection of the enzyme JETREA (Ocriplasmin) has recently been approved (October 2013) by the National Institute of Clinical Excellence (NICE) in treatment of small macular holes (ideally less than 250 microns). An intravitreal injection of JETREA is a simple outpatient procedure, without need for a gas bubble or any face down positioning. However vitrectomy surgery may still be required if the intravitreal JETREA injection is not successful at closing the macular hole (40 to 60% of patients depending on size of hole). Also see Section on Vitreomacular Traction (VMT).

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