Part One: Introduction to Surviving Recovery From Macular Hole Surgery

Joy R. EfronJoy R. Efron, Ed.D.

This is the first of a five-part series, Surviving Recovery From Macular Hole Surgery. This section contains a brief description of the author's experience, plus introductory information about macular holes, macular hole surgery, and recovery.



Introduction

The purpose of this article is to offer hints and tips to assist in "surviving" the difficult post-operative period following macular hole surgery. The suggestions presented here were very beneficial to me during my post-operative phase.

Joy in the face-down position

Joy using face-down
equipment to keep
necessary items within
reach

With adaptation for individual needs, I hope that many of these ideas may be of value to anyone who is preparing for macular hole surgery. The required face-down positioning following surgery was extremely uncomfortable and challenging for me. However, maintaining that position was, I believe, one of the main reasons that my recovery was successful.

Remaining face-down for six weeks would not have been possible for me without the assistance of others, face-down positioning equipment, mentoring and encouragement by others who have gone through macular hole surgery, and support of family and friends.

The information provided here is based on my own experience and research, and the advice of my doctors and former patients. You should always seek out and follow the advice and guidance of your own doctors.

Throughout the article, various products and equipment are mentioned; the Resources section provides additional information about these items. Since I live in Southern California, some of these resources are specific to that region of the country.

My Story

Following 42 years as an educator of blind and visually impaired children, it was a great surprise to me to suddenly experience a visual impairment on a first-hand basis. While driving in January 2009, I became aware that the painted highway lane markers appeared to be extremely wavy when viewed through my left eye. Everything (whether near or far) was blurry. A visit to the ophthalmologist determined that I had a full thickness macular hole (through all layers of the retina).

During the two months between diagnosis and surgery (in March 2009), my vision continued to deteriorate. Every horizontal and vertical line appeared to have at least five "S" curves. The city looked devastated, with buildings at eccentric angles. At times, while I was looking at a person, it would suddenly appear as if his or her head had shrunk to a minuscule globe. Items appeared smaller with my left eye than with my right eye.

Scanning became extremely difficult, e.g., while walking in a grocery store, items on shelves appeared to be jumbled together. While trying to read, letters were skewed and wavy. Letters became smaller while reading across a line of print. My best-corrected visual acuity had deteriorated from normal to less than 20/200. All visual tasks had become fatiguing and additional lighting had become critically important.

What is a Macular Hole?

The eye is filled with a gel-like substance called vitreous, which helps maintain the shape of the eye. As people age, the vitreous starts to shrink and pull away from the retina. This usually causes no problems. In isolated cases (about three per 1,000 people over the age of 60), some resilient fibers refuse to let go of the retina. Essentially, a tug-of-war takes place, with the body of the vitreous shrinking while the "stubborn" fibers hold tight to the retina.

This tug-of-war can cause a hole in the macula, the area of clearest central vision in the retina. Once a hole is formed, the body's defenses create scar tissue on the retina. The hole and the scar tissue cause blurriness and visual distortion. A macular hole should not be confused with macular degeneration or a retinal detachment.

Symptoms of a Macular Hole

Macular holes often begin gradually. According to the National Eye Institute, in the early stages of macular hole development, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult.

What Takes Place During Surgery for a Macular Hole?

Surgery consists of a vitrectomy (removal of the vitreous), peeling of the retinal scar tissue, and insertion of a gas bubble in place of the vitreous. Usually, those who have had macular hole surgery will also need cataract surgery within a year.

What Makes Recovery Challenging?

Over several weeks, the pressure of the gas bubble causes the hole to close. Since gas rises and the macula is located at the back of the eye, the patient must be face-down following surgery for the gas bubble to be properly positioned to exert the necessary pressure on the macula. It is extremely important to your doctor's recommendations for face-down positioning during recovery.

I could find no definitive research relative to either the number of hours per day or the total number of days a patient must be face-down. Some doctors suggest two to three days; others suggest longer periods, or until the gas bubble dissipates. Through networking with friends and professionals, I spoke with individuals, from Massachusetts to Hawaii, who had gone through macular hole surgery. Based on their informal reports, there appeared to be a dramatic correlation between visual outcome and the number of hours per day and the total number of days spent face-down.

Based on my doctor's recommendations at the time of my surgery (2009) and my own research, I was face-down for six weeks following surgery. For the first 29 days, this meant face-down positioning 24 hours per day, with the only exceptions being four brief periods per day when I rolled onto my back for eye drops. For the last 14 days, I was face-down at night and during most of the day; face-up periods were brief.

The face-down period was extremely unpleasant, but I was goal-directed and determined to do everything in my power to contribute to the best possible visual results following surgery. Patience, perseverance, and determination paid off.

[Editor's note: Since this article was written, many ophthalmologists now use a shorter face-down period, which has proven to be successful. See the information below to learn about Dr. Antonio Capone's pioneering work in macular hole surgery.]

Meet Antonio Capone, Jr., MD, and His Pioneering Work in Face-Down Positioning after Macular Hole Surgery

Antonio Capone, Jr., MD

Antonio Capone, Jr., M.D. is a board-certified ophthalmologist whose special interests include pediatric vitreoretinal diseases, complicated retinal detachment, ocular oncology, and macular disease. He is an internationally recognized clinician, surgeon, and educator who has authored or co-authored over 200 publications in peer-reviewed medical journals, book chapters, and publications from clinical trials. Read about Dr. Capone's pioneering research in macular hole surgery, which indicates that face-down positioning is not always required for a successful outcome.

Please note: Always consult with your retinal specialist before following any advice about face-down positioning. Your retinal specialist may not agree with this course of action or may feel it is contraindicated for your condition.

Says Dr. Capone, "In the early 1990s, some surgeons asked patients to lie face down for up to a month after surgery. Little by little, as my success rate in macular hole closure improved, I started to whittle away at the duration of face-down positioning. This was the aspect of surgery that many people hated the most and I became less and less convinced that it was imperative for success. Over the years, I went from a week of face-down positioning, to three days of face-down positioning, to overnight positioning. Currently, I don't require face-down positioning at all for typical macular holes."

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What Outcomes Can You Anticipate?

According to the literature, most patients get some visual improvement following surgery, but outcomes vary greatly among patients. It can take a year before maximum visual improvement is achieved.

One year post-surgery, my visual functioning has far surpassed expectations. Visual acuity in my post-surgery eye is 20/25, with very minimal (insignificant) distortion, and image size is essentially the same with both eyes.

Copyright © 2010, Joy R. Efron, Ed.D.

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