• Reference Number: HEY-179/2021
• Departments: Ophthalmology Department

Introduction

This leaflet has been produced to provide you with general information about your condition.  Most of your questions should be answered by this leaflet but it is not intended to replace the discussion between you and the healthcare team it may act as a starting point for discussion.   If after reading this leaflet you have any concerns or require any further explanations, please discuss this with a member of the healthcare team.

What is a macular hole?

The inner lining of the back of the eye is called the retina; it functions much like the film in a camera and transmits light signals to the brain. The most sensitive part of the retina is its centre and this is called the macula.

A macular hole is a hole or a tear in the central macular region of the retina, this can form when the vitreous (a clear, jelly like substance) inside the eye has shrunk.  As the vitreous has shrunk, it has pulled away from the retina, causing a hole or tear to form.

In the majority of people, if their vitreous shrinks, it does not cause any problems and there is no damage to their vision.  For patients who have developed a macular hole as a result of their vitreous shrinking, they may notice a number of symptoms.  You will be aware of a defect or dark spot in the centre of your vision and may also be aware of reduced near and distance vision.  You may also experience some distortion of straight lines and a loss of your central vision, where letters from a page of writing can seem to disappear.

It is important to realise that this condition is not the same as age related macular degeneration.

Do I need treatment?

You can chose not to have any treatment.  If you decide not to be treated you will most likely notice further loss of central vision. However you will retain your peripheral or side vision. There is a 1 in 10 risk of you having a macular hole develop in the other eye depending on the state of the vitreous jelly in the eye.

If you decide not have the operation you will not go blind as only the central vision is affected by this condition, however it is likely that your eye sight will deteriorate further.  You will need to have an annual eye check with your optician and they will be able to refer you back to us if your condition changes.

If the hole has been present for a long time, for example more than a year, then the outcome of surgery will not be as successful. Following the operation it can take several months for the full effect to be realised.

Surgery for macular hole

This involves making three small incisions about 1 mm in length in the white of the eye.  This will enable fine surgical instruments to enter the eye.  The vitreous gel inside the eye is then removed and replaced with a salty fluid. Then, very fine forceps are used to peel away the membrane from the surface of the retina. At this point you will be asked to keep very still. Once this, the main part of the operation is completed, the retina lining of the eye is examined for any weak areas.  If any areas of weakness are identified, you may need to have additional treatment, such as a freezing treatment (cryotherapy) or laser treatment, to those weak areas. This is in order to reduce the risk of a post operative complication called retinal detachment.

During the operation you may be aware of pressure sensations around the eye and some shadows and lights inside the eye. The amount of pressure and lights can vary due to the intensity of the local anaesthetic. Please be reassured that this is quite normal as the retina is still functioning. Following surgery, you will need to use eye drops for up to six weeks whilst your eye heals. You will be advised on how and when to use the eye drops before leaving hospital. The drops are to prevent infection and to reduce inflammation around the eye.

During the operation, a gas bubble will be inserted into your eye, this is in order to help the healing process; the bubble will act as an internal splint to support the retina as it heals. Gas can last from 2 weeks up to eight weeks, depending on the gas used. Your doctor will be able to confirm this with you when you are seen in outpatients. Blurred Vision after surgery: It is normal for your vision to be significantly blurred or poor after the operation and is due to the gas used to heal the macular hole. The gas will gradually absorb and you will notice a line in your vision that moves similar to a spirit level. You will start to see above the line, but under the line your vision will remain fuzzy or blurred. The gas will eventually disperse until it is only a small bubble in the bottom of your eye; the bubble will eventually disperse too.

It is very important that you do not fly in an aeroplane for up to eight weeks following your operation, depending on the type of gas used during operation.

Posturing after the surgery: In some cases following your operation you may be instructed not to sleep on your back for few days after the surgery. You may also be asked to keep your head in a specific position, in order to help the gas bubble do its job, you will be given a diagram and specific instructions on how to do this before you go home following the surgery.

If you require a general anaesthetic for another operation, during the eight weeks period following your operation; it is essential that you inform the anaesthetist that you have gas inside the eye.  This will be discussed with you before the operation and specific instructions will be given to you before you go home.

What are the complications or risks of surgery?

This type of surgery has similar risks to other types of eye surgery such as:

• Infection in the eye – this is called ‘Endophthalmitis’ and is very rare but can give rise to serious loss of sight.
• Bleeding inside the eye.
• Retinal detachment – this can happen at any time following the surgery, but most commonly in the first 2-3 months after surgery, and would require further surgery to seal the retinal holes and repair the detachment.
• Cataract – Almost all patients develop a cataract, (a cloudy lens which impairs vision) more rapidly than normal, following this type of surgery. This is because the internal fluid has been disturbed and also due to the presence of gas in the eye.  In some cases, the cataract may be removed during the operation, to enable a clearer view for the vitrectomy surgery to be performed. Cataracts can also be removed in a separate operation.  Your surgeon will discuss the best option for your eye condition.
• High pressure inside the eye – You may require additional eye drops to control the pressure, for a period of time, following the operation.
• Inflammation inside the eye.
• Bruising to the eyelids and eye – This will settle after a few weeks.
• Allergy to the medication used.

What happens before the operation?

Pre-operative Assessment

Before the surgery you will need to attend a pre-operative assessment.  At this visit you will be asked questions about your general health and blood tests and a recording of your heartbeat (sometimes referred to as an Electrocardiogram – ECG) are performed. These tests are to ensure that you are in good general health and well enough to undergo the surgery.  Measurements will also be taken of your eyes.  We will need to know what tablets and medicines you are currently taking and also if you are sensitive to anything else such as Elastoplast. It may be useful to write these down to bring to your assessment. At this visit, you will be advised on what pre-operative preparations you need to make, such as altering medications.

How do I prepare for the operation?

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination.

This is major eye surgery which is normally carried out under local anaesthetic however in exceptional circumstances a general anaesthetic is offered.

The operation is carried out as a day case and you will be instructed as to the time you are to attend the Eye Hospital in your appointment letter. You can expect to be in the hospital for most of the day.  In some cases, it may be necessary for you to remain in hospital overnight, but this is uncommon.

The following morning you will need to attend the ward for a quick eye check.

• Due to space restrictions if you want to bring anyone with you we request only one person accompanies you. We will request that they come back to collect you later in the day.
• Please bring a clean dressing gown and a pair of slippers with you along with overnight clothing and toiletries.
• If you use a hearing aid please also bring this with you.
• On the day of surgery take your usual medications as normal unless you have been advised to stop them prior to surgery.
• Also, please bring with you any medications that you may need to take whilst you are in hospital including inhalers and sprays.
• Please do not wear any make up nail varnish or jewellery, other than a wedding ring, as you will need to remove them before your operation.
• It is advisable not to bring valuables or money to the hospital the Trust will not accept responsibility for loss or theft.
• Please eat and drink normally before coming in to hospital unless you have been advised not to do so.
• On arrival in the ward a nurse will meet you and confirm the information that you gave at your pre-assessment appointment.
• We will give you eye drops before the operation. This is to dilate (widen) the pupil of the eye.
• You will be asked to get changed into a hospital gown and your dressing gown and slippers.
• Patients are offered drinks and light snacks free of charge.
• Visitors are asked to use the dining facilities in the Eye hospital café, main hospital or at the Women and Children’s hospital. A drinks machine is also available on the ground floor of the Eye Hospital.
• During your stay several checks are made, these are to ensure that you will be receiving the correct treatment.

What happens afterwards?

At this time you will be advised  when you need to come for a check up, how to look after your eye and told when to use the eye drops you need, to help the eye to heal.

Discharge Home

Upon your discharge home please contact the ward immediately if you experience any of the following problems:

• Excessive pain.
• Loss of vision.
• Increasing redness of the eye.
• Discharge from the eye.

Follow up appointments

• You will be reviewed in the Eye Clinic after two weeks and then at eight weeks following surgery.

Is there anything that I should avoid after the operation?

Important points to follow

Please remember the following points:

• You do not need to keep the eye covered once the anaesthetic has worn off.
• You should avoid heavy lifting and straining for the first week.
• You should avoid getting shampoo and soap into your eye for four weeks.
• You should avoid swimming for 12 weeks.
• You must not drive until you reach the minimum legal standard of vision.
• You should not drive until the anaesthetic has completely worn off and there is no double vision.
• It is normal for the eye to appear red and feel gritty this is due to the membrane covering the white of the eye being sutured after the operation, some of these effects last for up to four weeks. The stitches are dissolvable but take several weeks to completely dissolve.

If for any reason you are unable to attend for your appointments or need further advice, please do not hesitate to contact

Eye Clinic on telephone (01482) 816658 or 608788 (8.30am – 5.00pm) or

Out-of-Hours (01482) 604346 (Please listen to full voice message on how to access emergency out of hours service).

 Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Ophthalmology Department (01482) 816658 or (01482) 608788 (08:30am -17:00pm Monday-Friday)

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.