Macular hole surgery is unusual in that the part that closes the hole happens after you leave the hospital, over the following weeks, with a bubble of gas doing the work.
That makes macular hole surgery recovery different from most operations. The gas sits in your eye for weeks, your vision stays poor while it is there, and how you hold your head during that time may matter.
Quick Overview
- Macular hole surgery is a vitrectomy: the vitreous gel is removed, a fine membrane is peeled from the retina, and gas is placed in the eye.
- The gas bubble holds the edges of the hole together while it heals, and vision stays blurred until the gas is absorbed.
- Face-down posturing is no longer required for everyone, and where it is needed, the posturing period is usually shorter than it once was.
- Vision improves gradually over months, and most macular holes close after a single operation.
The sections below cover the operation itself, the gas bubble, what posturing involves now, how vision returns, and the complications worth knowing about.
What happens during the macular hole operation
Macular hole repair is generally performed under local anaesthetic, though a general anaesthetic is used where that suits you better.
Your macula is the small central patch of retina, sitting beside the optic nerve, and it handles the fine detail you rely on for reading and recognising faces. Most of the vitreous jelly is removed from the eye, leaving a space. The inner limiting membrane, a fine layer across the surface of the retina around the hole, is normally peeled away to release the tension holding the hole open.
Gas is then inserted into that space to hold the hole closed while it heals. Removing the vitreous, peeling the membrane and using gas is the standard treatment for a macular hole, and the hole closes in 85 to 95 per cent of cases.
Most patients go home the same day.
The gas bubble and what it does to your vision
The gas bubble is the reason the hole closes. It floats upwards inside the eye and presses the edges of the hole together, holding them in the correct position while the retina heals.
It also blocks your sight. While the gas is in place, vision in that eye is poor. This is expected, and it is temporary.
The bubble shrinks as it absorbs, usually over two to six weeks depending on the gas used, and the space it leaves refills with the natural fluid the eye produces. Sight begins to improve as that happens.
Longer-acting gases hold the hole closed for longer and suit larger holes, at the cost of a longer stretch of poor vision and a higher chance of cataract.
One restriction is absolute until the gas has fully absorbed. Do not fly or travel to high altitude, because reduced air pressure expands the gas, causing pain and a sharp rise in eye pressure. Your surgeon will tell you when the bubble has gone, and flying is safe again.
What face-down positioning involves now
Face-down positioning has changed. It was once required of nearly everyone after macular hole surgery, and it is now decided case by case.
Posturing is becoming increasingly unnecessary, though there are still situations where it is needed, so check with your ophthalmologist whether it applies to you and for how long. Where it is required, shorter regimens of one to three days appear to give similar closure rates to a full week in selected cases, so strict compliance for weeks on end is no longer the default.
If posturing is needed, it usually means 50 minutes every hour with your head facing down. You do not have to lie flat. Sitting at a table with your head resting forward works, and posturing chairs can be hired. Time off is allowed for meals, the bathroom and eye drops. Keeping what you need easily accessible helps, and trying to watch TV with your head down does not work.
How vision recovers, and what affects it
Vision returns slowly, and it returns in stages. The first change is simply the bubble clearing.
For many patients, it takes several months for meaningful improvement to appear, and for some the main effect of surgery is to stop central vision from getting worse. Hole size, how long the hole was present before surgery and the state of the retina beforehand all influence the result, which is why outcomes are discussed individually instead of as a single success rate.
Straight lines looking wavy in the early stages, and a blank patch in the centre of vision later on, are the symptoms most patients notice beforehand, and both typically ease as the hole closes. It is uncommon for vision to be restored perfectly even after a hole closes, and peripheral vision is unaffected throughout.
Complications and follow-up appointments
Two things are worth knowing about in advance.
Cataract is considered a consequence of vitrectomy more than a complication of it. If the eye still has its natural lens, a cataract will almost certainly form in the months or years afterwards, and it can be removed when it starts to affect vision. Where a cataract is already forming, cataract surgery is often done at the same time.
Retinal detachment is less common. Removing the vitreous or peeling the membrane carries a small chance that the retina detaches, and it is dealt with promptly if it happens. Discuss these and any other problems that concern you beforehand.
Your eye drops matter throughout all of this. Drops are prescribed to prevent infection and reduce inflammation, and they are used on a set schedule for several weeks. Follow-up appointments check eye pressure, which can rise while gas is in the eye, and confirm the hole has closed.
Talk to Dr Edward Roufail about macular hole surgery
A macular hole distorts the centre of your vision while leaving everything around it intact, which is why many patients only notice it when they cover the other eye. Dr Edward Roufail is a vitreoretinal, cataract and refractive surgeon who assesses the macula with detailed imaging. He performs macular hole surgery and manages the recovery period afterwards, including whether posturing applies in your case. For more detail on this and related eye conditions, or to arrange an appointment, please call us on (03) 9071 0180.
Frequently Asked Questions
Can I read or use a screen while posturing after macular hole surgery?
Yes, within the position. A tablet or laptop propped low enough to read while your head is down works well, and audiobooks cover the rest. What does not work is anything that pulls your head up for long stretches.
Will I need someone at home with me after macular hole surgery?
For the first days, ideally. Preparing beforehand makes a real difference: meals cooked and frozen, bills paid, trip hazards cleared, and posturing equipment delivered before the operation, not after it.
What does the gas bubble look like as it absorbs?
Most patients describe a dark curved line that gradually falls through their vision as the bubble shrinks, sometimes breaking into smaller bubbles towards the end. Your surgeon will confirm at review whether it is clearing as expected.
Can a macular hole come back after it has closed?
Reopening is uncommon once a hole has closed and settled. If a hole does not close with the first operation, further surgery can be considered, and your surgeon will give you further information about what that involves for your eye.
Will I need macular hole surgery on my other eye?
Not usually, though it can happen. Macular holes typically affect one eye, and a hole developing in the other eye at some stage is possible, which is why any new distortion in the second eye is worth reporting. Contact the clinic if straight lines start to look wavy on that side.
Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.
References
https://my.clevelandclinic.org/health/diseases/14208-macular-hole
https://www.upmc.com/conditions/m/macular-hole