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Will The Macular Hole Increase In Size?
Question: I am a 72 year old Doctor of Oriental Medicine who was diagnosed with a moderate sized macular hole stage 4.
My right eye compensates for it and so driving and everyday work is not hindered by it. I am scheduled for a vitrectomy on XXXXXXX 30th. Recently I developed viral sinus infection that affected the eustachian tubbecase of the right ear.
I was treated with antibiotics and prednisone but the tinnitus remains. Several questions: 1.Should I reschedule the surgery due to the infection? 2. If the tinnitus remains will it cause problems with my being able to keep my head down for a week or several weeks ( continual sound annoyance?) 3. Since I have good vision at the moment with the glasses I use, can I wait some time till this issue with the sinuses improves. ? 4. Will the hole increase in size with time and what could happen if I don't have the surgery? I can certainly live with the condition the way it is. I understand that the tissue can harden if I don't have the surgery ASAP, is this this correct.? 5. Have you seen patients who can live a decent life with the hole and never have further problems? Thanks Dr. XXXXXXX
Brief Answer:
Stage4 macularhole usually shows no progression
Detailed Answer:
Hello Dr XXXXXXX
I am Dr. Dadapeer K, an Ophthalmologist and I answer health problems related to eye.
It seems from the history that you are having Grade 4 Macular hole affecting the retina.
I will answer your 4th question and 5th question first. Will the hole increase in size with time and what could happen if I don't have the surgery?
Have you seen patients who can live a decent life with the hole and never have further problems?
Macular hole is because of full thickness defect in the retinal tissue involving the macula, the central part of the retina. Hence it will give lead to loss of central vision without affecting the peripheral vision.
Naturally the macular hole will progress in 4 stages, and reach the last stage the 4th stage. Since you are already in 4th stage this will not progress further.
The vision will remain the same as your present vision and stabilize at this level itself.
Rarely macular hole can lead to complications like retinal detachment resulting in total loss of vision.
I have seen many patients who remain with a vision of 20/200 or 6/60 following macular hole for the rest of their life.
The chance of involvement of the other eye is about 10%, hence you require regular followup to look for complications in the affected eye and examination of the other normal eye.
The treatment suggested for macular hole in 4th stage is mainly surgical by vitrectomy. This surgery requires head down positioning in the post operative period for atleast 1 week. The surgery will lead to improvement in vision by atleast 2 lines. Hence surgery is indicated in almost all the patients.
Coming to your first three questions,
Since you have good vision you can obviously wait till the infection of your sinuses is cured. But you have to attend followup as advised by your treating doctor.
But do remember earlier the surgery better the chances of visual improvement.
Since the surgery is scheduled for 30th of January, I think by that time sinus infection will be cured by treatment. But if the tinnitus is causing problems for maintaining of the posture following surgery you can postpone the surgery for a short period.
Hope I have answered your questions.
Thank you
Above answer was peer-reviewed by :
Dr. Prasad
Thank you for your quick reply. I realize there are risks with this type of surgery such as Retinal detachment, infection, bleeding etc. I can assume all of these conditions can be treated. Generally, how long does it take for the bubble to decrease in pressure? Since I live about 6000ft in the mountains, I was told I would need to live at 3000ft. the level at which the surgery would take place? I guess each person is different, but is there an average time? My retinologist claims I can get 80-90% improvement. Will the "squeezing" factor of my vision be eliminated by removal of the epiretinal and limiting membranes?
This problem with my sinuses has been existing for over 8 weeks and is relentless.
Would it make any difference in the surgery if I were to wait a few months till it is completely cleared since the macular hole is confined? Do the tissues harden making it more difficult to do the surgery?
Brief Answer:
It is better to undergo surgery earlier.
Detailed Answer:
Hello Dr XXXXXXX
Thank you for the follow up query
Since you are diagnosed to have stage 4 macular hole, surgery is the treatment of choice. The surgery includes removal of the gel like structure from the eye called as vitrectomy and replacing the vitreous by a bubble to provide tamponade against the macula there by helping the macular hole to close.
The tamponade acts best in the head down position, hence this position is required to be maintained in the post operative period. This is required for first 10-14 days after surgery after which the bubble slowly decreases in size and disappears.
The chances of visual impairment depends varies and they are usually better than 75% as told by your doctor.
The squeezing may be because of refractive error or blurring of vision and if this is because of macular hole then it is likely to disappear after surgery.
Coming to your last part of question,
You can wait for the surgery, but the only risks are complications like retinal detachment, epiretinal membrane, macular pucker which if occur reduce the chance of visual recovery. Though these are relatively rare but their occurrence cannot be ruled out. Hence I advice you to undergo surgery as early as possible to reduce the risk of complications and to have good visual prognosis. You can postpone the surgery for a short time like 1-3 weeks but long time postponement is not advisable.
Hope I have answered your questions.
Thank you
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Dadapeer, The size of my macular hole is medium, stage 4, I do not know how long it has been there, but I suspect 6-8months or more. I go yearly for an eye exam. I noticed some ophthalmologists are stating that the hole can get bigger and cause more problems, if not addressed immediately. Yet they also say that the larger, deeper and older the hole the more difficult it is to repair. I am also glad to hear from you that there are patients who have the macular hole and live with it. Thus does not mean I will not have it repaired, but as I said in my last letter, I need to treat the chronic tinnitus that appeared last month. It may be a due to a clogged Eustachian tube or a hearing deficit ( which I do have.) I would like to prioritize my condition and work on the tinnitus first so I can can enjoy? having my head down for a week or more. As a Buddhist it will be an interesting practice. Dr. XXXXXXX
Brief Answer:
Stage 4 requires followup till you undergo surgery
Detailed Answer:
Hello
Dr. XXXXXXX
Stage 4 is the last stage in the macular hole and once the macular holes reach stage 4 thaey usually stabilize at this stage without progression. But the problem is associated complications as I mentioned in last answer like retinal detachment, epiretinal membrane and macular pucker, the occurrence of which will make the surgery complicate and reduce the chances of recovery of vision.
It is difficult to predict that who will develop these complications and who will not. Thats why early surgery is always better.
If your tinnitus is very bad requiring treatment, you can attend regular follow up with your ophthalmologist so that if at all any of the complications start you can undergo surgery immediately.
But my advice is do not delay it more by 2-3 months as you have mentioned it may be present for 6-8 months now.
Do discuss all these matter with your treating ophthalmologist once.
Hope I have answered your queries.
Thank you
With regards
Dr. Dadapeer K
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Dadapeer, In our dis cussions you had mentioned that you had seen many patients who have a macular hole, do not have surgery, and live for the rest of their lives with 20/200 vision. The hole is in my left eye about 200 microns in size and stage 4. Since my right eye is dominant I have decent vision with corrective lenses. I cannot with the left eye alone and faces appear squeezed ( macular hole). Recently, I've read about the negative aspects of the vitrectomy where because the size of the hole and stage 4, it does not close as expected. If it does close I cannot expect any form of normal vision. I've also read about patients losing total vision in the eye due to the surgery. I'm concerned about losing vision in the left eye since I can function the way things are now.
Can my good eye (R) weaken or lose visual acuity due to tyilithe stress placed upon it because of the defect in my(L) eye? The possibility of being blind in this eye makes me want to reconsider have the surgery, especially since the hole has reached it total size and probably will not increase. According to the information the retinologist sent, loss of vision is one of the risks of vitrectomy. Can you understand my concern?? Dr. XXXXXXX
Brief Answer:
Loss of vision following surgery is rare.
Detailed Answer:
Hello
Dr. XXXXXXX
I can definitely understand your concern and apprehension.
As you are worrying that the problem in left eye may put stress on the right eye and may affect vision in the right eye. This will not happen hence no need to worry.
Stage four macular holes are the ones which measure more than 400 microns in size and which have got complete posterior vitreous detachment.. More than size the presence of complete posterior vitreous detachment is important as because of complete detachment of the vitreous there is no associated traction on the macular hole and hence it will not progress further.
SInce you have mentioned the size as 200 microns please re confirm the stage of the macular hole with your doctor.
Coming to the complications of surgery, one of the common complication is anatomical closure of the macular hole without any improvement in vision. This occurs in long standing macular hole because of atrophy of the layers of the macula.
Loss of vision is very rare and can be because of surgically induced retinal detachment. All surgeries come with some iatrogenic complications and both patient and the treating doctor have to weigh the risks and decide regarding treatment.
Though stage 4 macular hole may not progress but there is a risk of loss of vision because of macular pucker, retinal detachment, epiretinal membrane.
Hence I personally feel seeing the risks and benefits I would like to operate on macular hole and I would like to operate early to prevent atrophy of the layers of the macula. Because early treatment is always better for visual prognosis.
Retinal surgeries are very delicate and no surgery can guarnatee complete vision recovery, but I feel trying is worth as a later date even if surgery is done no vision recovery may occur.
Hence I advice you to discuss with your surgeon and take second opinion if you require and take the discission.
Hope I have answered your query.
Thank you
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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