1. EPIRETINAL MEMBRANE
(also known as macular pucker, premacular fibrosis or cellophane maculopathy)
An epiretinal membrane is a thin sheet of fibrous tissue that can grow over the surface of the retina. The retina is like the film in a camera. In some cases the epiretinal membrane remains mild and does not significantly alter the vision however when an epiretinal membrane grows it may damage the macula and cause the vision to become distorted and blurred. The macula is the most important part of the retina and gives us sharp central vision for reading. If the membrane continues to progress, permanent damage to the central vision may occur.
(Fig 1. OCT scan of a normal retina)
(Fig 2. OCT view of an epiretinal membrane)
WHAT CAUSES AN EPIRETINAL MEMBRANE?
In most cases an epiretinal membrane occurs as a result of age changes in the vitreous jelly which cause it to separate from the retina. These changes occur in everyone and are normal, but for unknown reasons, some people develop scarring or membrane formation. Occasionally an epiretinal membrane will develop in an eye as a result of retinal tears, detachment, trauma, inflammatory disease, blood vessel abnormalities, or other pathological conditions and it is important to see an experienced Vitreoretinal surgeon to evaluate for these.
WHAT IS THE TREATMENT FOR AN EPIRETINAL MEMBRANE?
If an epiretinal membrane is mild and not interfering with your vision, no treatment is required. An annual review and OCT scan to monitor for progression are important. Once a membrane develops, it will never go away on its own. Once the membrane begins to affect your vision, it can be removed surgically.
WHAT IS EPIRETINAL MEMBRANE SURGERY LIKE?
Modern surgery allows us to very successfully remove the epiretinal membrane. The surgical procedure is called a Vitrectomy. This is performed using very fine microsurgical “keyhole” instruments to gently peel the membrane from the retina. The surgery usually takes less than one hour, and is usually performed under “twilight” sedation using local anesthetic and is not painful. It is day surgery and you do not need to stay in hospital over night. As long as you do not have a retinal detachment you will NOT need to position face down after surgery.
WHAT IS THE CHANCE OF MY VISION IMPROVING?
In 90% of cases, once the membrane is removed, the distortion and the vision should improve. How much vision is restored depends on your general health, the health of your eye and the length of time that the membrane has been present. In general, most people regain around 50 % of the vision they have lost, however some will gain more and some less. In general the milder the membrane and less time it has been growing, the better the prognosis. Your vision will continue to improve slowly for up to one year.
WHAT HAPPENS AFTER THE SURGERY?
Following surgery, the vision will be mildly blurred for the first week due to mild swelling. For the first 24 hours it is best to rest at home. Computer work and watching television are fine.
A protective shield is recommended for sleeping, for the first week after the surgery and you will be required to have eye drops for one month. You can resume light activities a few days after surgery. Depending on your type of work, some people return to work within a few days, others may require a week or longer off for heavy physical activity.
2. Vitreous Floaters
Symptoms
Floaters are spots in front of your vision, and just like clouds, they come in all shapes and sizes. They are seen best when looking at a white wall or blue sky. They may variously be described as spots, dots, cobwebs, worms, rings, or specks. They are more visible with eye movements which make them swirl around in front of your vision
Causes
We all have some floaters and some floaters are often normal. The sudden onset of new floaters though can often indicate a serious retinal problem like a retinal tear or bleeding in the eye and require urgent examination by a retinal specialist. In many cases the cause may be a simple age related vitreous detachment, in which case no intervention is required. Without a dilated retinal examination though it is impossible to rule out a vison threatening retinal tear or detachment and new floaters requires an urgent examination preferably either that day with your local optometrist if possible, who will help determine the urgency with thich to arrange a referral to a retina specialist.
Other common causes of floaters are bleeding in the eye, due to diabetes or retinal vein occlusions for example and ocular inflammatory disorders. All of these require urgent evaluation.
Complications
Floaters range in severity from mild and completely asymptomatic, to severe, causing significant difficulties with reading, driving and working.
Floaters by themselves do not damage the eye, but like clouds, they may cause shadowing of the retina beneath them, which can impair your vision. The underlying cause of the floaters however, if untreated can cause severe and potentially permanent damage, underlining the importance of a good ocular exam to evaluate for the cause of your floaters
Treatment
If your doctor confirms your retina is normal and the floaters are not bothering you, then no treatment is required.
If your floaters are bothering you a lot and interfering with your vision, then it is certainly possible to remove them. It is always worth giving things time to settle first though, because after a few months, floaters can become less annoying and clear a little or move out of your central vision.
If your floaters have been present for a long time, with no improvement, then fortunately modern surgery can remove them with a 99% chance of success. The surgical technology to remove floaters has improved dramatically over the past ten years and many people who were told years ago that nothing could be done can now be helped. Modern vitrectomy has a 99% chance of successfully removing the floaters and less than a 1% chance of the floaters returning but like any surgery there are risks and you should discuss these with your doctor prior to considering surgery.
3. MACULAR HOLE
A macular hole is a retinal problem whereby a hole develops in the macular region. The macula is the part of the eye that gives you your central vision. A macular hole therefore causes distortion in the central vision and sometimes a dark spot is noticed in the centre of the vision. The underlying cause is thought to be due to a fine membrane around the macula which undergoes outwards traction which pulls the hole open. This is something that happens with age, and is not related to genetics, diet, exercise or due to anything you have done to your eye.
WHAT CAN BE DONE TO TREAT A MACULAR HOLE?
Modern surgery is now very successful in closing the macular hole and improving vision. Surgery involves vitreoretinal microsurgery where very fine microsurgical instruments are inserted inside the eye and the vitreous jelly removed. The membrane which causes the macular hole is also removed. A special gas bubble is left in the eye which is absorbed over two to four weeks and replaced with the eye’s own natural fluids. The success rate of closure of a standard macular hole is 99 %. Rare atypical, long standing or post-traumatic holes may require further surgery if the initial surgery is not successful in closing the hole.
Very rarely some holes, particularly those holes which have been present for a long period of time, may not be able to be closed, but this is much less than 1%.
WHAT IS THE CHANCE OF MY VISION IMPROVING?
Once the hole is closed, the distortion in vision should improve and the level of vision should also improve in 90% of cases. The degree to which this occurs depends on the individual person and your general health, the length of time that the hole has been present, how well you perform the face down positioning and the success of the surgery.
WHAT WILL I HAPPEN IF I DO NOT HAVE THE SURGERY?
If the hole is not treated it will almost always cause further deterioration in vision and enlarge with time leaving a larger size dark spot in the centre of vision. Some very small, partially developed macular holes may close spontaneously without treatment and these are therefore simply observed. This will require regular follow-up by your eye doctor. Spontaneous closure is rare however, less than 1% for a Stage 3 hole. Once the macular hole begins to enlarge and your vision decreases, the chance of spontaneous closure is extremely low, and surgery should be considered to close the hole.
WHAT WILL HAPPEN AFTER THE SURGERY?
Following surgery, the vision will be blurred for approximately two to four weeks, due to the gas bubble and the dilating eye drops. As the bubble gets smaller with time, you will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal.
For the first 24 hours following surgery you need to keep your face down with your nose parallel to the floor for at least 50-55 minutes in the hour, the other 5-10 minutes may be used to perform normal duties. You need to sleep with your head face down as much as possible. The face down position can be maintained whilst sitting in a chair and keeping one’s head down or if this isn’t possible you may lie on your side with your nose facing over the edge of the bed down to the ground. You must not sleep on your back while the gas bubble is in your eye.
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery by the nurse or surgical assistant. Following this, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first few days after the surgery.
EYE DROPS
Eye drops need to be used for one to two months following surgery.
These commence the day after surgery, after you have seen your surgeon.
GLASSES
New spectacles may need to be obtained a few months following surgery.
INTRAOCULAR GAS
It is extremely important to understand the following warnings about an intraocular gas bubble:
While the bubble is present, you MUST NOT FLY in an airplane under any circumstances. Doing so could result in blindness as the bubble expands with altitude. If you have air travel plans within the first two months after your surgery, mention this to your doctor.
If you need to travel over the Great Dividing Range, you must discuss this with your doctor first. The increased altitude can cause severe, vision threatening pressure rises. It is usually best to stay at sea level for 1 week before going back over the range. This depends on the type of bubble, so ask your doctor.
If you require surgery of any kind over the following two months you MUST TELL THE ANAESTHETIST ABOUT THE GAS BUBBLE, as nitrous gas anaesthetics will cause the bubble to expand and cause severe vision threatening pressure rises. This includes dental procedures.
FACE DOWN POSITIONING AIDS
These are not essential, and most patients do not need them, however for those with back or neck problems, this equipment can be useful. There are companies that hire out equipment to help you maintain the face down posture reducing the strain on your neck and back.
4. Retinal Detachment
The retina functions like the film in a camera. It converts light energy into electrical signals for transmission to the brain. The retina is a thin film of tissue that lines the inside of the eye like wallpaper. A retinal detachment is like the wallpaper peeling off the walls inside the eye.
The retina is held in position partially by a suction force. If a hole develops in the retina, then the suction force is lost and the fluid that normally fills the inside of the eye passes through the hole and enters the space underneath the retina. As more fluid passes under the retina, the retina gradually detaches from the inner wall of the eye. When the retina is detached the cells do not receive enough oxygen and glucose and it is not able to function properly. If the retina remains detached, it will slowly deteriorate and lose function permanently. If the retina can be reattached with surgery quickly enough, it is possible to recover some function.
What are the symptoms of a retinal detachment? Some patients have no symptoms at all. Others may notice flashing lights in their eyes prior to the retina detaching.
Most commonly, people will notice a sudden or dramatic increase in floaters, little black spots or lines within their visual field.
A dark black curtain is usually noted covering part of your visual field.
What happens if I do nothing?
If a retinal detachment is not treated, it will usually progress until the entire retina is detached. The retina will gradually lose function, and the eye will become blind.
How is a retinal detachment treated?
There are 3 ways to treat a retinal detachment.
1. Scleral Buckle – in this procedure, a tiny silicone band is placed around the eye like a belt. This pushes the outer wall of the eye inwards and helps close the hole in the retina. The retina is fixed back in position with Cryotherapy, or freezing treatment. Sometimes a gas bubble is also injected into the eye.
2. Vitrectomy – this is a microsurgical “keyhole” operation using 3 tiny instruments which remove the jelly from inside the eye and any scar tissue which has developed. The retina is fixed in position using laser treatment. The eye is then filled with a bubble of a special gas, heavy liquid or silicone oil. After this procedure you will need to keep your head down, to allow the bubble to close the hole. The bubble is designed to hold the edges of the retina together so it heals, just like a plaster cast holds the edges of a broken bone together.
3. Pneumatic Retinopexy – for selected types of small detachments with holes in the upper retina, the retina can be reattached with a combination of a gas bubble and either laser or Cryotherapy. This may avoid a larger surgical procedure, however the chances of success are smaller than the success with a vitrectomy or scleral buckle.
What is retinal detachment surgery like?
The surgery takes approximately one to two hours, and is not painful. Your anaesthetist will give you intravenous medication to make you very relaxed and sleepy and an anaesthetic injection to prevent any pain. It is performed in a day surgery, and you do not need to stay in hospital over night. During the surgery you do not feel any pain at all.
What is the chance of success? Modern surgery is now very successful in reattaching the retina. In the early part of the 20th Century, the chances of successfully reattaching the retina was less than 10 %, but now with modern techniques the chance of reattaching the retina with one operation is around 99 %. There is however around 10 % chance that the retina will re-detach, either due to new holes or scar tissue formation. These people will need a second operation. Of these cases, the majority will be fixed with the second operation, however a small percentage of people may require additional procedures if the scar tissue continues to re-grow. You can minimize the chances of requiring a second operation by
- having the retinal detachment fixed as soon as possible
- resting as much as possible in the first few days after the surgery
- keeping your head in the correct position, which will be detailed by your surgeon after the surgery
- using the eye drops as directed after the surgery
What is the chance of my vision improving?
The amount of vision that returns depends mostly on how much vision was lost pre-operatively and how long the retina was detached for. If the central vision was still intact prior to the surgery, it will remain intact unless scar tissue or another detachment develop post-operatively which can reduce the vision. If the central vision was lost prior to the surgery, unfortunately the vision will never be as good as it was before the retina detached. If the retina has been detached for many weeks or months, the amount of vision that returns will be less than if it were only detached for a few days. It is important to understand that any improvement occurs very slowly, as the retinal cells remodel, and the vision may continue to improve slowly for up to one year. Some patients who are still very blurred at the 3 month mark, will be satisfied by the improvement noted after 6 or even 12 months.
What happens after the surgery?
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery when you come to the office. After that, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first week after the surgery.
Following surgery, the vision will be very blurred due to swelling and the dilating eye drops. Some patients who have a gas bubble will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal and will go away completely when the bubble is reabsorbed.
For the first one to two weeks following surgery you need to take it easy. Eye drops need to be used for one to two months following surgery. These should commence the day after surgery, after your have seen your surgeon.
New spectacles will usually need to be obtained three to four months following surgery.
What if I have a gas bubble
Your surgeon will tell you if you have a gas bubble placed during surgery. If so, you will need to keep your face down for at least 50-55 minutes in the hour, the other 5-10 minutes may be used to perform normal duties. You need to sleep with your head face down as much as possible. The face down position can be maintained whilst sitting in a chair and keeping one’s head down.
It is extremely important that you do not fly in an airplane or go to high altitudes (eg Great Dividing Range) until the gas bubble as gone. Doing so will risk extreme increases in intraocular pressure and potential blindness.
By two weeks after the day of surgery, you do not need to be so strict with the face down positioning. It is very important not to sleep on your back, or lie on your back looking up for any extended periods, as in this position, the gas bubble will rub on your lens, which should be avoided.
Is there a risk to my other eye?
If you have had a retinal detachment in one eye, then there is a small risk of developing one in the other eye. You should have new symptoms such as flashing lights or floaters evaluated as soon as possible. Extremely rarely, the vision in the other eye can be affected by a condition called sympathetic ophthalmitis, however the incidence of this is less than 1 in 14 000
5. Vitreous Haemorrhage
A vitreous haemorrhage is a collection of blood within the eye, in the space between the retina and the lens. Normally the vitreous cavity is filled with clear, transparent jelly. Light passes through the vitreous uninterrupted, and is focused on the retina. When bleeding occurs into the vitreous jelly, the light path is blocked and vision is impaired.
What causes a vitreous haemorrhage?
A vitreous haemorrhage is usually due to a blood vessel within the retina breaking, and bleeding into the vitreous cavity. Common causes of bleeding are a result of the development of fragile new blood vessels on the retina due to either diabetes or blockages in the retinal veins (Retinal Vein Occlusions).
Another common cause of vitreous haemorrhage is a “Posterior Vitreous Detachment”. This occurs as a result of age changes in the vitreous jelly and results in the jelly peeling off and separating from the retina. As the jelly separates, it can tear the retina or small blood vessels on the surface of the retina.
Other common causes of bleeding are retinal tears and detachments, penetrating or blunt injuries to the eye or inflammatory diseases of the eye
How does a vitreous haemorrhage affect vision?
A vitreous haemorrhage can be severe and result in legal blindness, or it may be mild and result only in annoying black floaters. The severity of visual loss is related to the density of the haemorrhage and the underlying cause for the bleeding.
It is important to understand that a vitreous haemorrhage itself usually does not damage the eye or permanently affect the vision. It is the underlying condition, eg diabetes, or vein occlusion which can permanently damage the vision.
What is the treatment for a vitreous haemorrhage?
The most important first step is to identify the cause of the vitreous haemorrhage and treat that.
If a vitreous haemorrhage is mild and not affecting your vision, no treatment is required. The floaters may be annoying, but if they are mild it is best to ignore them, and wait for them to decrease with time. In some people with mild haemorrhages, the blood may clear within a few weeks. In people with more severe haemorrhages, the blood may take many months to clear or may not clear at all.
If the blood is not clearing quickly enough, it can be removed surgically. However it is important to weigh up the risks versus benefits carefully, and only proceed if the blood is causing noticeable problems with your vision, or interfering with your day to day activities.
What is the chance of my vision improving after surgery?
There is usually a greater than 90% chance that the vision will improve after surgery. The final amount of visual improvement after surgery depends entirely on the health of the underlying retina. Once the blood is removed, if the underlying retina is normal, the vision should return to the level it was before the bleeding occurred. If the retina has been damaged by diabetes, retinal detachment, macular degeneration or a retinal vein occlusion, the vision may not improve.
What will happen if I do not have surgery?
If the blood is not removed, it will usually not damage the eye itself. There are exceptions however, where delaying surgery can be detrimental. For example diabetes in the eye can get worse and remain undetected and untreated behind the blood. A retinal detachment can develop and result in permanent visual impairment
What happens after the surgery?
Following surgery, the vision will be blurred for a few weeks due to mild swelling and the dilating eye drops. Some patients who have a gas bubble will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal and will go away completely when the bubble is reabsorbed.
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery when you come to the office. After that, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first week after the surgery.
For the first one to two weeks following surgery you need to take it easy. Eye drops need to be used for one to two months following surgery. These should commence the day after surgery, after your have seen your surgeon.
New spectacles may need to be obtained three to four months following surgery.
6. WHAT ARE THE RISKS OF VITREORETINAL SURGERY?
Although Vitrectomy surgery is a very successful procedure, one should be aware that all surgery has risks, and occasionally problems can arise following surgery.
A cataract may develop earlier than would be expected during the normal aging process.
The eye may develop increased pressure (glaucoma) and medication may be required.
Retinal tears or detachment of the retina may develop during surgery, or following surgery, and may require further surgery. correct these.
Infection and haemorrhage are very rare risks which may occur with any surgery. If you notice pain or decreased vision following surgery, contact our consulting rooms or your surgeon’s mobile as soon as possible. Infections often treatable if detected early. A severe infection or severe bleeding however can result in permanent blindness, but this is very rare, much less than 0.1%.
INTRAOCULAR GAS
This is used for retinal detachments, macular holes and less commonly for other retinal conditions. If you have a gas bubble it is very important not to sleep on your back, or lie on your back for extended periods, as in this position the gas bubble will rub on your lens
While a bubble is present, you MUST NOT FLY in an airplane. This could result in blindness as the bubble expands with altitude.
If you need to travel over the Great Dividing Range please mention this to your doctor. It is not possible to travel over the range for at least one week, longer in some cases
If you require surgery of any other kind over the following two months you must tell the anesthetist about the gas bubble as nitrous gas anaesthetics will cause the bubble to expand and cause severe vision threatening pressure rises.
(also known as macular pucker, premacular fibrosis or cellophane maculopathy)
An epiretinal membrane is a thin sheet of fibrous tissue that can grow over the surface of the retina. The retina is like the film in a camera. In some cases the epiretinal membrane remains mild and does not significantly alter the vision however when an epiretinal membrane grows it may damage the macula and cause the vision to become distorted and blurred. The macula is the most important part of the retina and gives us sharp central vision for reading. If the membrane continues to progress, permanent damage to the central vision may occur.
(Fig 1. OCT scan of a normal retina)
(Fig 2. OCT view of an epiretinal membrane)
WHAT CAUSES AN EPIRETINAL MEMBRANE?
In most cases an epiretinal membrane occurs as a result of age changes in the vitreous jelly which cause it to separate from the retina. These changes occur in everyone and are normal, but for unknown reasons, some people develop scarring or membrane formation. Occasionally an epiretinal membrane will develop in an eye as a result of retinal tears, detachment, trauma, inflammatory disease, blood vessel abnormalities, or other pathological conditions and it is important to see an experienced Vitreoretinal surgeon to evaluate for these.
WHAT IS THE TREATMENT FOR AN EPIRETINAL MEMBRANE?
If an epiretinal membrane is mild and not interfering with your vision, no treatment is required. An annual review and OCT scan to monitor for progression are important. Once a membrane develops, it will never go away on its own. Once the membrane begins to affect your vision, it can be removed surgically.
WHAT IS EPIRETINAL MEMBRANE SURGERY LIKE?
Modern surgery allows us to very successfully remove the epiretinal membrane. The surgical procedure is called a Vitrectomy. This is performed using very fine microsurgical “keyhole” instruments to gently peel the membrane from the retina. The surgery usually takes less than one hour, and is usually performed under “twilight” sedation using local anesthetic and is not painful. It is day surgery and you do not need to stay in hospital over night. As long as you do not have a retinal detachment you will NOT need to position face down after surgery.
WHAT IS THE CHANCE OF MY VISION IMPROVING?
In 90% of cases, once the membrane is removed, the distortion and the vision should improve. How much vision is restored depends on your general health, the health of your eye and the length of time that the membrane has been present. In general, most people regain around 50 % of the vision they have lost, however some will gain more and some less. In general the milder the membrane and less time it has been growing, the better the prognosis. Your vision will continue to improve slowly for up to one year.
WHAT HAPPENS AFTER THE SURGERY?
Following surgery, the vision will be mildly blurred for the first week due to mild swelling. For the first 24 hours it is best to rest at home. Computer work and watching television are fine.
A protective shield is recommended for sleeping, for the first week after the surgery and you will be required to have eye drops for one month. You can resume light activities a few days after surgery. Depending on your type of work, some people return to work within a few days, others may require a week or longer off for heavy physical activity.
2. Vitreous Floaters
Symptoms
Floaters are spots in front of your vision, and just like clouds, they come in all shapes and sizes. They are seen best when looking at a white wall or blue sky. They may variously be described as spots, dots, cobwebs, worms, rings, or specks. They are more visible with eye movements which make them swirl around in front of your vision
Causes
We all have some floaters and some floaters are often normal. The sudden onset of new floaters though can often indicate a serious retinal problem like a retinal tear or bleeding in the eye and require urgent examination by a retinal specialist. In many cases the cause may be a simple age related vitreous detachment, in which case no intervention is required. Without a dilated retinal examination though it is impossible to rule out a vison threatening retinal tear or detachment and new floaters requires an urgent examination preferably either that day with your local optometrist if possible, who will help determine the urgency with thich to arrange a referral to a retina specialist.
Other common causes of floaters are bleeding in the eye, due to diabetes or retinal vein occlusions for example and ocular inflammatory disorders. All of these require urgent evaluation.
Complications
Floaters range in severity from mild and completely asymptomatic, to severe, causing significant difficulties with reading, driving and working.
Floaters by themselves do not damage the eye, but like clouds, they may cause shadowing of the retina beneath them, which can impair your vision. The underlying cause of the floaters however, if untreated can cause severe and potentially permanent damage, underlining the importance of a good ocular exam to evaluate for the cause of your floaters
Treatment
If your doctor confirms your retina is normal and the floaters are not bothering you, then no treatment is required.
If your floaters are bothering you a lot and interfering with your vision, then it is certainly possible to remove them. It is always worth giving things time to settle first though, because after a few months, floaters can become less annoying and clear a little or move out of your central vision.
If your floaters have been present for a long time, with no improvement, then fortunately modern surgery can remove them with a 99% chance of success. The surgical technology to remove floaters has improved dramatically over the past ten years and many people who were told years ago that nothing could be done can now be helped. Modern vitrectomy has a 99% chance of successfully removing the floaters and less than a 1% chance of the floaters returning but like any surgery there are risks and you should discuss these with your doctor prior to considering surgery.
3. MACULAR HOLE
A macular hole is a retinal problem whereby a hole develops in the macular region. The macula is the part of the eye that gives you your central vision. A macular hole therefore causes distortion in the central vision and sometimes a dark spot is noticed in the centre of the vision. The underlying cause is thought to be due to a fine membrane around the macula which undergoes outwards traction which pulls the hole open. This is something that happens with age, and is not related to genetics, diet, exercise or due to anything you have done to your eye.
WHAT CAN BE DONE TO TREAT A MACULAR HOLE?
Modern surgery is now very successful in closing the macular hole and improving vision. Surgery involves vitreoretinal microsurgery where very fine microsurgical instruments are inserted inside the eye and the vitreous jelly removed. The membrane which causes the macular hole is also removed. A special gas bubble is left in the eye which is absorbed over two to four weeks and replaced with the eye’s own natural fluids. The success rate of closure of a standard macular hole is 99 %. Rare atypical, long standing or post-traumatic holes may require further surgery if the initial surgery is not successful in closing the hole.
Very rarely some holes, particularly those holes which have been present for a long period of time, may not be able to be closed, but this is much less than 1%.
WHAT IS THE CHANCE OF MY VISION IMPROVING?
Once the hole is closed, the distortion in vision should improve and the level of vision should also improve in 90% of cases. The degree to which this occurs depends on the individual person and your general health, the length of time that the hole has been present, how well you perform the face down positioning and the success of the surgery.
WHAT WILL I HAPPEN IF I DO NOT HAVE THE SURGERY?
If the hole is not treated it will almost always cause further deterioration in vision and enlarge with time leaving a larger size dark spot in the centre of vision. Some very small, partially developed macular holes may close spontaneously without treatment and these are therefore simply observed. This will require regular follow-up by your eye doctor. Spontaneous closure is rare however, less than 1% for a Stage 3 hole. Once the macular hole begins to enlarge and your vision decreases, the chance of spontaneous closure is extremely low, and surgery should be considered to close the hole.
WHAT WILL HAPPEN AFTER THE SURGERY?
Following surgery, the vision will be blurred for approximately two to four weeks, due to the gas bubble and the dilating eye drops. As the bubble gets smaller with time, you will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal.
For the first 24 hours following surgery you need to keep your face down with your nose parallel to the floor for at least 50-55 minutes in the hour, the other 5-10 minutes may be used to perform normal duties. You need to sleep with your head face down as much as possible. The face down position can be maintained whilst sitting in a chair and keeping one’s head down or if this isn’t possible you may lie on your side with your nose facing over the edge of the bed down to the ground. You must not sleep on your back while the gas bubble is in your eye.
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery by the nurse or surgical assistant. Following this, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first few days after the surgery.
EYE DROPS
Eye drops need to be used for one to two months following surgery.
These commence the day after surgery, after you have seen your surgeon.
GLASSES
New spectacles may need to be obtained a few months following surgery.
INTRAOCULAR GAS
It is extremely important to understand the following warnings about an intraocular gas bubble:
While the bubble is present, you MUST NOT FLY in an airplane under any circumstances. Doing so could result in blindness as the bubble expands with altitude. If you have air travel plans within the first two months after your surgery, mention this to your doctor.
If you need to travel over the Great Dividing Range, you must discuss this with your doctor first. The increased altitude can cause severe, vision threatening pressure rises. It is usually best to stay at sea level for 1 week before going back over the range. This depends on the type of bubble, so ask your doctor.
If you require surgery of any kind over the following two months you MUST TELL THE ANAESTHETIST ABOUT THE GAS BUBBLE, as nitrous gas anaesthetics will cause the bubble to expand and cause severe vision threatening pressure rises. This includes dental procedures.
FACE DOWN POSITIONING AIDS
These are not essential, and most patients do not need them, however for those with back or neck problems, this equipment can be useful. There are companies that hire out equipment to help you maintain the face down posture reducing the strain on your neck and back.
4. Retinal Detachment
The retina functions like the film in a camera. It converts light energy into electrical signals for transmission to the brain. The retina is a thin film of tissue that lines the inside of the eye like wallpaper. A retinal detachment is like the wallpaper peeling off the walls inside the eye.
The retina is held in position partially by a suction force. If a hole develops in the retina, then the suction force is lost and the fluid that normally fills the inside of the eye passes through the hole and enters the space underneath the retina. As more fluid passes under the retina, the retina gradually detaches from the inner wall of the eye. When the retina is detached the cells do not receive enough oxygen and glucose and it is not able to function properly. If the retina remains detached, it will slowly deteriorate and lose function permanently. If the retina can be reattached with surgery quickly enough, it is possible to recover some function.
What are the symptoms of a retinal detachment? Some patients have no symptoms at all. Others may notice flashing lights in their eyes prior to the retina detaching.
Most commonly, people will notice a sudden or dramatic increase in floaters, little black spots or lines within their visual field.
A dark black curtain is usually noted covering part of your visual field.
What happens if I do nothing?
If a retinal detachment is not treated, it will usually progress until the entire retina is detached. The retina will gradually lose function, and the eye will become blind.
How is a retinal detachment treated?
There are 3 ways to treat a retinal detachment.
1. Scleral Buckle – in this procedure, a tiny silicone band is placed around the eye like a belt. This pushes the outer wall of the eye inwards and helps close the hole in the retina. The retina is fixed back in position with Cryotherapy, or freezing treatment. Sometimes a gas bubble is also injected into the eye.
2. Vitrectomy – this is a microsurgical “keyhole” operation using 3 tiny instruments which remove the jelly from inside the eye and any scar tissue which has developed. The retina is fixed in position using laser treatment. The eye is then filled with a bubble of a special gas, heavy liquid or silicone oil. After this procedure you will need to keep your head down, to allow the bubble to close the hole. The bubble is designed to hold the edges of the retina together so it heals, just like a plaster cast holds the edges of a broken bone together.
3. Pneumatic Retinopexy – for selected types of small detachments with holes in the upper retina, the retina can be reattached with a combination of a gas bubble and either laser or Cryotherapy. This may avoid a larger surgical procedure, however the chances of success are smaller than the success with a vitrectomy or scleral buckle.
What is retinal detachment surgery like?
The surgery takes approximately one to two hours, and is not painful. Your anaesthetist will give you intravenous medication to make you very relaxed and sleepy and an anaesthetic injection to prevent any pain. It is performed in a day surgery, and you do not need to stay in hospital over night. During the surgery you do not feel any pain at all.
What is the chance of success? Modern surgery is now very successful in reattaching the retina. In the early part of the 20th Century, the chances of successfully reattaching the retina was less than 10 %, but now with modern techniques the chance of reattaching the retina with one operation is around 99 %. There is however around 10 % chance that the retina will re-detach, either due to new holes or scar tissue formation. These people will need a second operation. Of these cases, the majority will be fixed with the second operation, however a small percentage of people may require additional procedures if the scar tissue continues to re-grow. You can minimize the chances of requiring a second operation by
- having the retinal detachment fixed as soon as possible
- resting as much as possible in the first few days after the surgery
- keeping your head in the correct position, which will be detailed by your surgeon after the surgery
- using the eye drops as directed after the surgery
What is the chance of my vision improving?
The amount of vision that returns depends mostly on how much vision was lost pre-operatively and how long the retina was detached for. If the central vision was still intact prior to the surgery, it will remain intact unless scar tissue or another detachment develop post-operatively which can reduce the vision. If the central vision was lost prior to the surgery, unfortunately the vision will never be as good as it was before the retina detached. If the retina has been detached for many weeks or months, the amount of vision that returns will be less than if it were only detached for a few days. It is important to understand that any improvement occurs very slowly, as the retinal cells remodel, and the vision may continue to improve slowly for up to one year. Some patients who are still very blurred at the 3 month mark, will be satisfied by the improvement noted after 6 or even 12 months.
What happens after the surgery?
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery when you come to the office. After that, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first week after the surgery.
Following surgery, the vision will be very blurred due to swelling and the dilating eye drops. Some patients who have a gas bubble will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal and will go away completely when the bubble is reabsorbed.
For the first one to two weeks following surgery you need to take it easy. Eye drops need to be used for one to two months following surgery. These should commence the day after surgery, after your have seen your surgeon.
New spectacles will usually need to be obtained three to four months following surgery.
What if I have a gas bubble
Your surgeon will tell you if you have a gas bubble placed during surgery. If so, you will need to keep your face down for at least 50-55 minutes in the hour, the other 5-10 minutes may be used to perform normal duties. You need to sleep with your head face down as much as possible. The face down position can be maintained whilst sitting in a chair and keeping one’s head down.
It is extremely important that you do not fly in an airplane or go to high altitudes (eg Great Dividing Range) until the gas bubble as gone. Doing so will risk extreme increases in intraocular pressure and potential blindness.
By two weeks after the day of surgery, you do not need to be so strict with the face down positioning. It is very important not to sleep on your back, or lie on your back looking up for any extended periods, as in this position, the gas bubble will rub on your lens, which should be avoided.
Is there a risk to my other eye?
If you have had a retinal detachment in one eye, then there is a small risk of developing one in the other eye. You should have new symptoms such as flashing lights or floaters evaluated as soon as possible. Extremely rarely, the vision in the other eye can be affected by a condition called sympathetic ophthalmitis, however the incidence of this is less than 1 in 14 000
5. Vitreous Haemorrhage
A vitreous haemorrhage is a collection of blood within the eye, in the space between the retina and the lens. Normally the vitreous cavity is filled with clear, transparent jelly. Light passes through the vitreous uninterrupted, and is focused on the retina. When bleeding occurs into the vitreous jelly, the light path is blocked and vision is impaired.
What causes a vitreous haemorrhage?
A vitreous haemorrhage is usually due to a blood vessel within the retina breaking, and bleeding into the vitreous cavity. Common causes of bleeding are a result of the development of fragile new blood vessels on the retina due to either diabetes or blockages in the retinal veins (Retinal Vein Occlusions).
Another common cause of vitreous haemorrhage is a “Posterior Vitreous Detachment”. This occurs as a result of age changes in the vitreous jelly and results in the jelly peeling off and separating from the retina. As the jelly separates, it can tear the retina or small blood vessels on the surface of the retina.
Other common causes of bleeding are retinal tears and detachments, penetrating or blunt injuries to the eye or inflammatory diseases of the eye
How does a vitreous haemorrhage affect vision?
A vitreous haemorrhage can be severe and result in legal blindness, or it may be mild and result only in annoying black floaters. The severity of visual loss is related to the density of the haemorrhage and the underlying cause for the bleeding.
It is important to understand that a vitreous haemorrhage itself usually does not damage the eye or permanently affect the vision. It is the underlying condition, eg diabetes, or vein occlusion which can permanently damage the vision.
What is the treatment for a vitreous haemorrhage?
The most important first step is to identify the cause of the vitreous haemorrhage and treat that.
If a vitreous haemorrhage is mild and not affecting your vision, no treatment is required. The floaters may be annoying, but if they are mild it is best to ignore them, and wait for them to decrease with time. In some people with mild haemorrhages, the blood may clear within a few weeks. In people with more severe haemorrhages, the blood may take many months to clear or may not clear at all.
If the blood is not clearing quickly enough, it can be removed surgically. However it is important to weigh up the risks versus benefits carefully, and only proceed if the blood is causing noticeable problems with your vision, or interfering with your day to day activities.
What is the chance of my vision improving after surgery?
There is usually a greater than 90% chance that the vision will improve after surgery. The final amount of visual improvement after surgery depends entirely on the health of the underlying retina. Once the blood is removed, if the underlying retina is normal, the vision should return to the level it was before the bleeding occurred. If the retina has been damaged by diabetes, retinal detachment, macular degeneration or a retinal vein occlusion, the vision may not improve.
What will happen if I do not have surgery?
If the blood is not removed, it will usually not damage the eye itself. There are exceptions however, where delaying surgery can be detrimental. For example diabetes in the eye can get worse and remain undetected and untreated behind the blood. A retinal detachment can develop and result in permanent visual impairment
What happens after the surgery?
Following surgery, the vision will be blurred for a few weeks due to mild swelling and the dilating eye drops. Some patients who have a gas bubble will see a black, wobbly, horizontal line which will slowly become lower and lower. This is the edge of the gas bubble, and is normal and will go away completely when the bubble is reabsorbed.
Immediately after the surgery, a patch will be placed on your eye with tape. This will be removed the morning after the surgery when you come to the office. After that, there is no need to wear a patch during the day. A protective shield is recommended for sleeping, for the first week after the surgery.
For the first one to two weeks following surgery you need to take it easy. Eye drops need to be used for one to two months following surgery. These should commence the day after surgery, after your have seen your surgeon.
New spectacles may need to be obtained three to four months following surgery.
6. WHAT ARE THE RISKS OF VITREORETINAL SURGERY?
Although Vitrectomy surgery is a very successful procedure, one should be aware that all surgery has risks, and occasionally problems can arise following surgery.
A cataract may develop earlier than would be expected during the normal aging process.
The eye may develop increased pressure (glaucoma) and medication may be required.
Retinal tears or detachment of the retina may develop during surgery, or following surgery, and may require further surgery. correct these.
Infection and haemorrhage are very rare risks which may occur with any surgery. If you notice pain or decreased vision following surgery, contact our consulting rooms or your surgeon’s mobile as soon as possible. Infections often treatable if detected early. A severe infection or severe bleeding however can result in permanent blindness, but this is very rare, much less than 0.1%.
INTRAOCULAR GAS
This is used for retinal detachments, macular holes and less commonly for other retinal conditions. If you have a gas bubble it is very important not to sleep on your back, or lie on your back for extended periods, as in this position the gas bubble will rub on your lens
While a bubble is present, you MUST NOT FLY in an airplane. This could result in blindness as the bubble expands with altitude.
If you need to travel over the Great Dividing Range please mention this to your doctor. It is not possible to travel over the range for at least one week, longer in some cases
If you require surgery of any other kind over the following two months you must tell the anesthetist about the gas bubble as nitrous gas anaesthetics will cause the bubble to expand and cause severe vision threatening pressure rises.