At all stages of your treatment pathway, you will receive my direct access telephone number. This will negate the need to go via any third party, such as a secretary or the hospital, in order to obtain any routine or urgent advice. I will be available 7 days a week for you in this regard. This is a very important aspect to the service I pride myself in providing, giving you the reassurance and confidence to make your journey through this difficult time as smooth and anxiety-free as possible.
This and all other aspects of the service I provide have resulted in very high satisfaction levels from my former patients, rating my service an average of 4.9/ 5 on Trustpilot.
It is safe to perform light exercise after surgery. I will individualise the advice relating to more vigorous exercise when I review you at your post-operative visits.
You can shower and wash your hair from the day after your procedure, however, it is advisable not to allow water to enter the eye for approximately 2 weeks following surgery. This can be avoided with simple measures including wearing swimming goggles during showering or washing your hair backwards in a sink similar to hairdressers.
Drops are prescribed to be used for several weeks following the procedure. Additional drops will be prescribed if the pressure in your eye is found to be excessively high at any point.
There may be some discomfort initially which generally becomes less on a day-by-day basis. Simple oral analgesia such as paracetamol for a few days is usually sufficient, if required. It is common to experience mild itching for 1-2 weeks following surgery.
If left alone, there is only up to 1 in 10 chance that a FTMH will spontaneously close with improvement in vision. The vast majority of FTMHs will progress gradually over time to a level where you many not even be able to read the largest print on a standard vision chart. Your peripheral vision will not be affected, however. We know that over time, FTMHs will typically enlarge, and that the larger and more established the hole, the worse the prognosis for vision improvement.
There are no known treatments including drops that can prevent the development of full-thickness macular holes
The risks of severe complications are very low. Complications include:
- Retinal detachment. The risk of this is less than 1% but if it occurs, further surgery will be required to prevent visual loss
- Cataract development. This is where the natural lens in the eye becomes cloudy, and is required in majority of patients within 2 years of initial vitrectomy surgery. When cataract surgery is performed, this does also provide an opportunity for correcting any pre-existing refractive error such as short- or long-sightedness or astigmatism.
- Blindness in the affected eye due to post-operative infection or bleeding during the operation. The risk of this is extremely low (< 1 in 1000 cases)
- High or low eye pressure after the operation. This is usually temporary
- Temporary inflammation in the eye which is usually readily treated with drops
- Temporary bruising and swelling around the eyelids
- Lid drooping which may very rarely persist
- Possible allergy to drops
- Double vision which is usually very temporary
- Non-closure of the FTMH (< 5%) which may warrant further surgery
There may be some discomfort initially which generally becomes less on a day-by-day basis. Scleral buckling surgery tends to produce slightly more discomfort than vitrectomy surgery. Simple oral analgesia such as paracetamol for a few days is usually sufficient. It is common to experience mild itching for 1-2 weeks following surgery.
Drops are prescribed to be used for several weeks following the procedure. Additional drops will be prescribed if the pressure in your eye is found to be excessively high at any point. If oil is used, I generally require you to use a few drops a day until the oil bubble is removed.
I will arrange to see you 1-2 days following the procedure, then again at 1-2 weeks and 2-3 months. If additional visits are advisable, for example, to check or control your eye pressure, then I will arrange as many visits as required in order to maximise the safety of your eye and to achieve the best final result.
I generally employ modern sutureless microincision techniques for performing vitrectomy surgery, which does not usually require the use of stitches. |Sometimes stitches are required, however, and always so if a scleral buckle procedure is performed. These may take anywhere between 2-5 weeks to completely dissolve.
Generally, it is inadvisable to drive whilst there is gas in the eye due to the sudden loss of vision in one eye, and the often distracting nature of a partially absorbed moving gas bubble within the eye (see gas section above). It will be safe to drive once the gas bubble has completely absorbed, and if there is sufficiently good vision overall using both eyes to satisfy current DVLA visual criteria. If oil is used, you will be able to drive if the vision in your other eye meets DVLA criteria. In all instances, you must feel safe to drive. You will be advised whether you need to contact DVLA at your follow up appointments.
You must not fly at any point if there is any residual gas in your eye. Once the gas has fully absorbed, then may fly. It is safe to fly if you receive an oil bubble to reattach your retina. It is not advisable, however, to schedule any foreign travel for immediately after eye surgery, in particular retinal detachment surgery.
After the anaesthetic is administered, your eye and face will be covered with a sterile drape. The whole vitrectomy operation will then be performed through 3 tiny incisions. You will hear vibrating noises throughout much of the procedure from the vitrectomy machine. You will not be able to see details of what is happening but may see only shapes or bright lights, or nothing at all. The operation will last from between 20-40 minutes. At the end of the procedure I routinely administer some antibiotics and antiseptic to minimise the chance of infection in your eye. I will then place a protective eye pad to shield your eye overnight. I will fully inform you of the posturing instructions and you will then be able to return to the eye clinic or ward.
You will be able to go home 1-2 hours after a local anaesthetic, and slightly longer after a general anaesthetic. The eye pad is removed the next day and you can start instilling your eye drops. There may be a small amount of discharge at this stage. Initially, your vision is likely to be worse than before the operation. This is perfectly normal and you must not feel alarmed about this. You will be reviewed 1-2 days following your operation for extra reassurance, to detect any immediate post-operative issues, and to answer any further questions you may have in detail. If any further drops are required at this stage, these will be prescribed. I will then check with you that you fully understand all instructions. There is usually some redness of the eye which disappears after just a few weeks, which is a benefit of the modern microincision equipment I use exclusively.
Injection of a bubble of gas is important in the healing process after surgery to repair the FTMH. The type of gas used will depend on several factors including the size and duration of your FTMH, and how much vision you have in your other eye. I will discuss my recommendations with you in detail during your initial consultation with me. Gases used in FTMH surgery include:
SF6 gas which can stay in your eye between 2-3 weeks before completely absorbing
C2F6 gas which can remain between 4-6 weeks before completely absorbing
C3F8 gas which can remain between 8-10 weeks before completely absorbing.
For up to half of this time, you will have very limited vision in the eye, being generally only able to see hand movements in the middle of your vision. As the gas bubble absorbs, your vision will become clearer, particularly in the top part of your vision. You will become aware of a line in your vision resembling a spirit level, and it may feel as though you are seeing “underwater”. The gas will progressively absorb until just a small bubble is noticeable in the bottom of your vision before it also completely disappears.
You may have read about the requirement for uncomfortable face-down posturing after surgery for FTMH. The latest evidence suggests that this provides no additional benefit for most FTMHs, but it may be of benefit in some large FTMHs, and may possibly result in better vision outcomes. I will tailor this advice to your eye and circumstances. If required to do so, then face down positioning by day for 3 days would normally be advised.
There is up to 5-15% risk of developing a FTMH in your other eye. I will individualise this risk to you during your consultation with me by reviewing your OCT scans in detail.
This will depend on multiple factors including your occupation, the level of vision in your other eye, and whether you must drive for a living. I will tailor this advice to your circumstances, but it is generally prudent to allow 2 weeks off from work. In most instances, it will be possible to then return to work or continue to work from home.
Further surgery with additional specialised measures can be performed in the unlikely event that your FTMH does not close and is often successful in closing the hole.
I perform most vitrectomy procedures under local anaesthesia, whereby a small amount of anaesthetic is administered around the eye to numb it and permit surgery to performed painlessly. Whilst you will need to be comfortable and lie still for the duration of the procedure, you can feel reassured that if you do need to move, you can simply inform me and I will then allow you to make yourself comfortable again. The advantages of this approach are that there will be no requirement to starve before the procedure, you can go home very soon after the procedure, and there will be no risk to your general health unlike with general anaesthesia. If you feel that you may be quite anxious during the operation, then mild sedation can be provided by an anaesthetist in addition to the local anaesthetic, which is an effective option in such cases, whilst still retaining the benefits of local anaesthesia. Some patients may still prefer general anaesthesia where you are put completely to sleep for the operation. You will be required to be nil by mouth prior to surgery and may require some pre-operative tests to ensure safe anaesthesia. I also provide supplemental local anaesthetic when general anaesthetic is given, as this significantly alleviates any immediate post-operative discomfort.
The eye is essentially a camera, and its camera film is known as the retina, a very specialised structure that senses and processes light. The central part of the retina is known as the macula, which is responsible for detailed central vision including reading and recognising faces. In most people the vitreous gel, which fills most of the eye, naturally and gently separates away from the retina with age. However in some people, it can be abnormally strongly attached to the macula causing pulling or traction (see vitreomacular traction). If the traction is sufficient it can cause a small full–thickness hole (FTMH) to form in the very centre of the macula. Because of this location, even a very small hole can cause symptoms. If the hole does not involve the full-thickness of the macula, we term it as a partial thickness or lamellar hole, and generally does not affect the vision as much as a FTMH.
Macular holes affect about 1 in 500 people, and effects women more than men. FTMHs are more common after the age of 60 and in slightly long-sighted and very short-sighted patients. It is not entirely clear why some people develop macular holes and why others don’t. Most FTMHs occur due to excessive pulling on the macula by the vitreous gel (see vitreomacular traction section). FTMHs may also develop due to eye trauma or inflammation, or if there is a history of previous eye surgery or retinal problems. Genetics, environmental factors, and systemic causes so not seem to be important in macular hole formation.
In the early stages of VMT, many patients will not have symptoms. However, by the time a full-thickness macular hole has developed, most patients will be aware of reduced central vision and distortion when looking at words or people’s faces. Straight lines may also appear crooked, and you may also be aware of a blind spot in the middle of your vision. Occasionally, some patients may only notice these symptoms when covering their good, unaffected eye or at routine review by their optometrist. Conversely, some patients are aware of symptoms even when both eyes are open together (interference).
No, they are very different conditions. This is a very important distinction to make as a FTMH is treated by intricate surgery by a vitreoretinal surgeon, where as wet macular degeneration requires simple injections of a drug into the eye.
Macular holes are often visible when your eye is examined by your optometrist or ophthalmologist doctor. Macular holes can also often be seen on photographs of your retina. Macular holes are however best detected and classified with the use of specialist retinal imaging equipment known as an OCT scanner. Your optometrist or ophthalmology doctor may already have performed this for you. This is important in differentiating full-thickness from partial thickness holes, as these are often treated differently. The OCT scan also helps to measure the size of the hole, which influences success rates and visual prognosis, and determines whether additional steps are advised during the operation to maximise chances of success.
If left alone, there is only up to 1 in 10 chance that a FTMH will spontaneously close with improvement in vision. The vast majority of FTMHs will progress gradually over time to a level where you many not even be able to read the largest print on a standard vision chart. Your peripheral vision will not be affected, however. We know that over time, FTMHs will typically enlarge, and that the larger and more established the hole, the worse the prognosis for vision improvement.
Although some very early FTMHs can occasionally just be monitored, surgery, which is the only treatment available, is advised for the vast majority of FTMHs and aims to improve your vision by closing the FTMH. It is well established that the chances of closing the FTMH and improving your symptoms of reduced vision and distortion are greater the smaller the FTMH, and the shorter the duration of symptoms. Therefore, prompt diagnosis and early surgery favour maximal gains in vision, and is generally considered gold-standard in the treatment of FTMHs. If left for a considerable time, the prognosis for visual improvement and hole closure are substantially reduced.
Macular hole surgery in my hands has over a 95% chance of closure with one procedure. Typically, most patients can expect their symptoms of distortion to improve or their vision to stabilise rather than progressively get worse. If operated on early enough, about 75% of patients can expect improvement in their vision by 2-3 lines of letters on the vision chart, and some may have even greater gain. Much of the improvement occurs within the first 2-3 months following surgery, but macular function can continue to improve for up to a year. Even if vision does not improve, it is much more likely to stabilise and not further deteriorate, and surgery will allow your two eyes to work better together without interference. For a small minority of people, vision could be worse and may require further surgery. It is important to appreciate that even with fully successful closer, your vision will not be as good as before you developed a macular hole. The vast majority of people who have undergone surgery are pleased that they did so.
Surgery for the repair of a FTMH is called vitrectomy. I exclusively use the latest generation micro-incisional keyhole surgical equipment to perform this operation. Through just 3 tiny incisions, each only approximately 0.5mm in length, the vitreous gel is delicately removed from the eye allowing access to the FTMH. Using very delicate (eg photo of instruments next to a coin etc?? ) forceps, a very fine retinal membrane which is only 1/400th of a millimetre thick is gently lifted and peeled from around the FTMH. This is the most critical and delicate part of the procedure. I then perform a very detailed and thorough search for any tears in your retina that can rarely form during the procedure and treat these as required. Following this, a gas bubble is injected into the eye which naturally absorbs over a period of a 2-8 weeks, depending on which gas was used in your operation (see gas in the eye FAQ). Removing the vitreous gel and retinal membrane, in combination with gas injection allow the FTMH to close. Because the incisions required using this specialised keyhole equipment are so small, sutures will not be required in most cases. Routine surgery is usually performed under local anaesthetic and can be performed in as little 20-40 minutes. If you feel you will be very anxious during the procedure, I have access to an excellent team of private anaesthetists who will be able to administer additional sedation or even general anaesthesia as required, in order to make the procedure as comfortable as possible for you. (See anaesthesia options FAQ)