Vitrectomy: What to Expect With Macular Pucker Surgery and Recovery
Some surgical procedures are still so new that it is difficult to find enough information on the Internet about them. Such is the case with the macular pucker peel procedure, which has been performed only since about the mid-1990s. I have just had this procedure done on my left eye, and I hope that what I write will help others who are contemplating the surgery.
A macular pucker, also known as an epiretinal membrane, often occurs as part of the aging process, but sometimes it can be caused by previous trauma, retinal detachment, diabetes, or post-vitreous detachment (PVD). The epiretinal membrane is scar tissue that forms over the macula, the area of the retina responsible for central vision. The membrane creates traction on the retina, resulting in distortion, blurriness, or both. For some people, the distortion makes straight lines look wavy or crooked, and for others, the vision has a patchy quality.
What is the Goal?
The visual impairment created by a macular pucker typically stops at the 20/60 level, but sometimes it can progress beyond that. If aided vision cannot be corrected to better than 20/40, surgery may be a possibility. The goal is to improve visual acuity, reduce some of the distortion, and possibly prevent permanent damage to the macula.
If you already have a cataract formed in the eye with the epiretinal membrane, you need to be aware that the ERM peel surgery will very likely cause a worsening of your cataract.
However, if your cataract is already pretty advanced, you may consider very strongly having the cataract removed before any retinal surgery. Your retinal surgeon has to look directly through your natural lens in order to do the surgery, and a cataract is cloudy and yellow enough to obstruct his view.
In my case, it made better sense for me to have the cataract removed first, followed three months later by the ERM peel. If you take the same route, expect that your retinal specialist will have definite opinions on the type of intraocular lens you select to replace your natural lens. Some IOL’s will make the retinal surgeon’s field of view more uncertain and distorted.
What is Surgery Like?
At the time of surgery, the patient is anesthetized, their eye dilated, and the surgeon inserts trochars and infusion cannulas directly into the eyeball. First the surgeon performs a vitrectomy, which is the removal of the vitreous humor from the eye. The vitreous is later replaced by a saline solution. Next, the surgeon places a special contact lense over the surface of the eye, giving him a window that he can look through in order to see the retina. With the aid of a high-powered microscope and special lighting, the surgeon takes tiny forceps and peels the epiretinal membrane from the macula. This usually takes about 30 minutes, but can take over an hour depending on the texture of the membrane.
What Kind of Anesthesia?
Most frequently, this surgery is performed using a topical anesthetic and light sedation. Some surgeons, like mine, will prefer to put the patient under general anesthesia. This eliminates the possibility of the patient moving during the delicate procedure. Do not assume that your procedure will go exactly the same as what you've read about on a retina surgeon's web site. When in doubt, ask your surgeon what his routine is. If your pre-operative screening involves doing blood work, an EKG, and a chest X-ray, you are most certainly going to be put under all the way. If you are under general anesthesia, most likely the surgical team will give you a nerve block as well.
Video of ERM Surgery
What Kind of Surgical Instruments?
I had state-of-the-art surgery, using either 23 or 25-gauge needles. This means that my surgery was sutureless, and my incisions healed within a week. Within 7 days, all the redness, swelling, and bloodshot quality was gone from my eye, and you would never guess that I had surgery.
If your surgeon is not using the most modern sutureless equipment, I would ask why not, and get a second opinion. If there are no sutures, there is no post-operative pain, and the incisions heal much faster. But with sutures, you are likely to experience some pain, irritation, and grittiness for a while. It does take considerable skill to use the finest needles. Think about the difference to your recovery and healing.
Dyes Used in Surgery?
There should be no need for your surgeon to inject a dye to stain the epiretinal membrane. Some of them might do it so they can see the membrane better, but there is always the possibility that such a dye could be toxic. When in doubt, ask.
Possible Gas Fluid Exchange
On your surgical consent form, you will see listed the possible use of a gas bubble in the patient’s eye.
The most common reason this would occur is that the patient’s retina detached or tore during the procedure, which happens about 2% of the time. You need to know that a retinal detachment is one of the risks of this, or any, eye surgery. Very serious, but hopefully, it won’t happen to you.
Another possible reason for a gas bubble is to insure against any damage which might have occurred during the surgery. Unexpectedly, my surgeon put a short-acting gas bubble in my eye. He made an on-the-spot decision to peel the ILM (inner limiting membrane) as well as the ERM. Based on what he saw, he could not be sure he did not leave a true macular hole, so he inserted the gas bubble as a precaution. Fortunately, after surgery, we found out that everything was OK.
Face-Down Positioning, or Sleeping on Your Stomach
Don't worry. This probably won't be necessary.
The vast majority of patients get up, walk away, and have someone drive them home. That is the extent of what they do, and they take it easy for a couple of days. They can usually lie on their back, prepare meals, and drive a car after the first 24-hour follow-up visit.
But those few patients with a gas bubble need to stay in the face-down position 90% of the time until the doctor says it’s OK to be upright. Since I had a gas bubble, I had to assume face-down positioning for 3 days only. The purpose of this is to exert just the right amount of pressure against your macula, which is located at the back of the eye. When the doctor determines that your macula is all right, he will give you your “get out of jail card.” It is dangerous NOT to do what he says, and you cannot fly in an airplane while you have the gas bubble. With a retinal detachment, the face-down positioning will be more strict, and might have to last for two weeks.
Your vision with a gas bubble in your eye is like looking through a goldfish bowl. When you move, the liquid sloshes around in your eye, but in a matter of days, it goes down, and you can see over the bubble. Gradually it disappears (in my case, it took 10 days to go away).
It’s good to be prepared for anything to happen. I was prepared, so I knew where to rent vitrectomy recovery equipment, and that such equipment may be covered by medical insurance. Try to be aware of any possibility, even if it seems unlikely to happen. Question your surgeon in detail about all of the inherent risks.
Read more about what is involved with face-down recovery.
What Are the Results?
There is not one standard outcome to be expected from this surgery. How much visual improvement you can expect depends on your healing capacity and the length of time the macular pucker has been present in your eye.
This surgery is not like cataract or Lasik or PRK surgery, where the surgeon plugs numbers into a formula, trying to hit a refractive target for your vision. Everyone’s retina heals differently, and some retinas are more damaged than others. However, as a general rule, 85% of the people undergoing this procedure will get some improvement, typically about 2 lines on the eye chart. Another rule of thumb is that he/she will get back 50% of the vision that was lost. Some fortunate patients improve even beyond that and go back to 20/20 vision.
My visual improvement was documented about 2.5 weeks after surgery. Before the surgery, my best corrected vision in my left eye was 20/40. At the 2.5 week point, it was 20/30. About 5 months after surgery, I could see 20/25 out of that eye.
I do have some residual distortion. That's fairly typical. With a successful ERM peel, you will be seeing better through your visual distortion. I know that sounds strange, and none of your explanations will make sense to you or anyone else. Just accept that it's something of a paradox. I had one correspondent who had this surgery, and she said that, although she still has quite a bit of distortion, she can see better because "the central blurriness disappeared as well as the huge floaters and faded spots."
After the surgery, there will be some lasting damage to your macula, however slight. Two months after surgery, one of my ophthalmologists took a picture of the back of my eye, and let me have a look. The macula is supposed to be very regular and spherical. Mine looks like a spinach leaf that an insect decided to nibble on, and not finding it tasty, moved on to the next vegetable.
I’ve begun to refer to the ERM peel surgery as “Peel and Hope.” Because that is all you can do. With a competent surgeon, you stand an excellent chance of an improvement in visual acuity. And having the surgery just might mean the difference between being able to pass the eye test at the Department of Motor Vehicles, and failing it. I am glad that I had the surgery.
It takes 3 to 6 months for full healing to take place after an ERM peel. I believe the 20/25 aided vision I have now with my left eye is about as good as could be expected.
The information in this article is not meant to diagnose or treat any disease. If you have any of the symptoms mentioned, consult your personal physician.
Reference Articles on PubMed
- Macular function and ultrastructure of the internal limiting membrane removed during surgery for idiopathic epiretinal membrane.
- Combined phacoemulsification and sutureless 23-gauge pars plana vitrectomy for complex vitreoretinal diseases.
- Diffractive multifocal intraocular lens interferes with intraoperative view
- Outcomes of idiopathic macular epiretinal membrane removal with and without internal limiting membrane peeling: a comparative study.
- 23-gauge transconjunctival sutureless vitrectomy: a retrospective study of 164 consecutive cases