Three-day face-down positioning for macular hole surgery achieves high success rate
Scanning became extremely difficult, e. While trying to read, letters were skewed and wavy. Letters became smaller while reading across a line of print. All visual tasks had become fatiguing and additional lighting had become critically important. 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, 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.
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. 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.
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 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. See the information below to learn about Dr.
Macular Hole Progression
Antonio Capone's pioneering work in macular hole surgery. Antonio Capone, Jr. He is an internationally recognized clinician, surgeon, and educator who has authored or co-authored over 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.
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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 s, some surgeons asked patients to lie face down for up to a month after surgery. It can take weeks to months for vision to improve depending on various factors like degree of cataract after a successful surgery. There is also some risk that the surgery simply won't work, the hole will reopen or the retina will detach. This is uncommon, affecting only a small percentage of cases. But if a surgeon does procedures a year, Skondra points out, "that could mean some really unhappy and potentially visually disabled patients.
She got the idea for the new approach at an ophthalmology conference. Instead of jumping straight to surgery, he sometimes gave patients two types of eye drops to dehydrate the retina and decrease the swelling around the hole. As the fluid left and swelling decreased, the edges of the macular holes would sometimes creep back together, closing the hole.
He tried that on about ten patients and some of them recovered without needing surgery. Her first case was fairly convincing. The patient in Chicago had only one good eye, and that eye had a small macular hole with swelling around it. He was afraid to have surgery since it was his only good eye. So, Skondra explained the eye-drop approach, and the patient was on board.
Cataract surgery in people with age-related macular degeneration
She gave him two standard drugs: prednisolone, a steroid, and ketorolac, an anti-inflammatory. Then she added a third drug, an idea she got from a former mentor, Demetrios Vavvas, MD, PhD, an associate professor of ophthalmology at Harvard. That drug, brinzolamide , helps pump fluid out of the eye to lower pressures for patients with glaucoma.
All three were off-label uses, but they were unlikely to cause damage and "if the hole doesn't close," she reasoned, "we can still operate. After two weeks, patient No. Then, he went on vacation to Mexico and stopped using his eye drops. The hole promptly reopened. When he came back, Skondra put him back on the drops. Within a month, the hole was closed. The fact it got better with drops, worse after he stopped and then better after we restarted them is supporting the hypothesis that decreasing the swelling promotes hole closure as Dr Gentile's "hydration" theory suggested.
She didn't try it again for almost a year since she did not have a patient that seemed to be a good candidate. But in January , now at UChicago Medicine, a new patient, a hospital administrator, came into her clinic with a small but full-thickness macular hole.
They discussed surgical options at length, then Skondra mentioned the drops. The patient opted for drops and the hole closed. The third patient, who came to Skondra from another physician, had also a small macular hole. He responded to the drops at first, but his original doctor told him to stop taking them. The hole came back and required surgery. The fourth patient, however, a UChicago Medicine nurse, was what Skondra would think of as a textbook case. Marianne Strickland, RN, had just bought new glasses in March. She made an eye appointment in early May because her eyes felt strained and her central vision seemed "a little blurry.
The standard eye exam, however, revealed a small macular hole. Skondra explained the options: surgery, which is effective, or a less invasive but unproven option: eye drops.
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But it may save you from an operation on your eye. For Strickland, that was an easy choice. Her macular hole was small. There was some swelling around it as indicated by tiny cysts resembling the petals of a daisy. The hole had been there for at least three to four weeks probably longer, Skondra said.
Macular Hole Treatment - American Academy of Ophthalmology
She used the eye drops three or four times a day, about 10 minutes ibetween each set. As soon as I started using the drops, it started getting progressively better while it was the same or even getting worse for weeks before seeing Dr Skondra and starting the treatment. Skondra tells patients to continue to use the drops for a while, even after their vision returns to normal. She slowly withdraws the eye drops, one drug at a time after the first month.