Vitrectomy

Alternatives

There is no non-surgical treatment for macular pucker.  Rather than having surgery right away, some patients choose: not to have surgery; to follow visual function and macular pucker for a few months and then decide; or to address other vision problems independent of the macular pucker then decide.

Benefits

After macular pucker surgery about 80 percent to 90 percent of patients have improved visual acuity.  The average improvement is about half way to normal.  Also, over 90 percent of patients notice improved visual function. Things like reading speed and stereovision are also improved in about 90 percent of patients.

Visual acuity improves in eighty percent to ninety percent of patients after vitrectomy for macular pucker. The average improvement is halfway to normal depending on the preoperative vision. So if the vision starts at 20/80, average improvement is 20/40. From 20/100 the average improvement is 20/50. Some people improve less than that and some improve more. The better the pre-operative visual acuity then the better the average post-operative visual acuity.

A few recent studies suggest that reading vision is affected more than visual acuity in patients with macular pucker.  The distortion and gaps in the vision make it difficult for patients to read even when they can pick out letters on a visual acuity chart. Reading vision improves (measured by reading speed) in about 90 percent of patients after macular pucker surgery.

Macular pucker can cause patients to see things larger than they actually are (macropsia). The difference in image size between the affected and unaffected eye (anisekonia) can reduce stereovision. Recent research has shown that macular pucker surgery can improve stereovision.

The vitrectomy that is done as a part of macular pucker surgery removes the vitreous from the eye.  It is not uncommon for patients with macular pucker to have significant vireous opacities (floaters). While removing the vitreous, most of the vitreous opacities are also removed and most patients do not see floaters or vitreous opacities after vitrectomy.

Procedure

Vitrectomy surgery is done in a surgical suite either in a surgicenter or hospital. The section briefly reviews the anesthesia, vitrectomy, membrane peel, post-operative discomfort, and post-operative vision.

Surgery is done in an operating suite under sterile conditions. Most surgery is done with regional anesthesia. The patient is sedated and then an injection is done behind the eye or next to the eye so the procedure is painless. Removing the vitreous gel is the first step in macular pucker surgery. Since the vitreous is sticky and attached to the peripheral retina, it is usually partially removed to allow instruments to be safely introduced into the eye to remove the macular pucker.  Removing the vitreous also removes any floaters the patient sees.  Recent studies suggest that the absence of the vitreous might be why patients who have had vitrectomy develop cataracts.  There is also a small (10%) 5 year risk of glaucoma in eyes that have had the vitreous removed. The macular pucker is grasped with a delicate forcepts and peeled from the surface of the retina, like a piece of tape is peeled from a piece of paper. For about a week, the patient should take it easy.  For the first 24 hours from surgery, because of the sedation, you are not allowed to drive.  Most patients have very little discomfort after macular pucker surgery. Usually the surgeon will see the patient a day after the surgery and then a week or two later, and then periodically for 3 to 12 months. Most complications occur in the first month after the surgery. Rarely a gas bubble is used after macular pucker surgery and in those cases, the patients is not allowed to fly until the bubble is absorbed. Most patients see worse after surgery for about a week or two.  Then, after a few weeks, the vision usually returns to about where it was before the surgery.  Subsequent visual acuity improvement occurs in 80% to 90% of patients VERY SLOWLY.  Most of the visual acuity and visual function improvement occurs during the first six months and then a little more improvement occurs over the next two years.  DISTORTION of vision improves more slowly than visual acuity.  Usually distortion is still present for 6 to 12 months and gradually becomes less bothersome with time. If the patient has not yet had cataract surgery, usually a visually significant cataract develops in the first 6 months so the vision can get worse from the cataract. Subsequently cataract surgery is necessary to achieve full visual potential.

Risks

Risks of vitrectomy for macular pucker include (but are not limited to), cataract, glaucoma, no vision improvement, retinal detachment, infection, bleeding, macular hole, vision loss, regrowth of pucker, macular trauma from surgical instruments, and macular damage from surgical light.