Macular Pucker and Holes
What is a Macular Pucker?
Also called epiretinal membrane and cellophane maculopathy, macular pucker refers to the presence of a membrane over the surface of the macula. The macula is the central region of the retina. It is responsible for providing fine vision for such tasks as driving, reading, and watching television. The size of a pinhead, the macula is the part of the eye that is most responsible for detailed vision. Any pathology associated with this area will result in visual complications.
Macular pucker occurs as the normal vitreous gel breaks up as we age. It then separates from the retinal surface, causing irritation or damage to the retina. Its subsequent healing response by cells found within the retina tends to repair the area, forming a membrane. These conditions can occur in patients without any previous ocular history or can occur after surgery for other ocular procedure.
How is Macular Pucker Detected?
Pupil dilation is essential to diagnose macular pucker. As retinal specialists, our focus is to determine how much the macular pucker is contributing to your visual symptoms and what can be done to remedy the problem.
A fluorescein angiogram may be recommended to help evaluate whether there is leakage in the retina associated with the gliotic or scar tissue. Optical coherence tomography (OCT) is a state-of-the-art test that helps us actually visualize how much the pucker is pulling on the macula.
How is Macular Pucker Treated?
Treatment is not indicated unless the patient is bothered by symptoms. A small percentage of patients may have spontaneous resolution of this condition, as the membrane has been known to spontaneously retract from the retinal surface.
Surgery can be considered if the patient’s visual complaints are disturbing and create difficulty for them functioning. It also considered if there is significant leakage noted on fluorescein angiography, which would cause a risk to the patient’s vision over time.
Surgery is typically performed in an ambulatory setting under local anesthesia, although general anesthesia can be utilized. The surgical procedure includes that of a vitrectomy where the vitreous gel is removed from the eye. A light source is used to illuminate the eye while an instrument is used to remove the vitreous gel. Specialized instruments are then used to peel the scar tissue from the retinal surface.
It may take up to 2-3 months to gain back the majority of vision after the surgery. However, patients who have had macular puckers for extended periods of time or have significant leakage may take longer for recovery.
What is a Macular Hole?
A macular hole is a central defect in the retina. The macula is the central region of the retina, and is responsible for critical vision including reading, driving, and watching television.
A hole can develop as the vitreous gel ages. The vitreous gel goes through changes with age, which frequently results in floaters. Abnormal adherence of the vitreous to the macular region may result in traction or pulling, resulting in a macular hole.
How is a Macular Hole Detected?
There are 4 stages of a macular hole, all of which can result in some degree of symptoms. The most common symptom includes distortion and reduced vision for both near and distance. A macular hole is diagnosed by the ophthalmologist after dilated retinal examination. Optical coherence tomography (OCT) helps evaluate macular holes.
How are Macular Holes Treated?
Refinements in the surgical treatment of macular hole have steadily improved outcomes. The procedure involves the removal of the vitreous gel (vitrectomy), placement of a temporary gas bubble in the eye, and often removal of a membrane surrounding the hole.
Surgery is typically performed in an ambulatory setting under local anesthesia, although general anesthesia can be utilized. The gas bubble is put in the eye so the hole can close under a “dry” environment; the fluid in the eye can keep the hole open.
To keep fluid away from the hole while it closes, it is necessary for the patient to remain in a prone (face down) position anywhere from several days to 2 weeks. It may take up to 6 weeks for the air bubble to completely resolve from the eye.
Patients with macular holes may have varying degrees of visual loss. It is possible that, if not operated on, the condition may still remain stable with no further loss in vision. However, there also may be deterioration over time. This is impossible to predict.
Visual results after surgery depend on a number of factors including the presence of a cataract, the longevity of the hole, and any other associated macular conditions such as macular degeneration. Typically, it has been shown that if a hole is present for less than 6 months, at least a 3-line improvement in vision will occur with hole closure.
It can take anywhere from 2 to 3 months to regain vision after surgery. Vision is often diminished from cataract progression, and maximal vision improvement may require cataract surgery. Approximately 5-10% of macular holes are not closed successfully with surgery. Sometimes repeat surgery may lead to closure.