Advances in Macular Hole Treatment and Recovery

I am aware of the following changes since my macular hole vitrectomy surgery in 2009. One of the most significant changes is that more information is available online. However, this information is still limited, and most is not written in terms easily understood by the general public.

A Major Change: Face-Down Positioning Time Requirement

In many cases, the face-down period has been shortened tremendously. I was face-down for six weeks. Most people now report one to two weeks. It does not take as long for the hole to close as previously thought. Some doctors now feel that face-down time is unnecessary to close macular holes. If people are face-down for only a few days, there is no statistically significant difference in the percentage of holes that reopen. However, there is no consensus among retinal surgeons.

The National Eye Institute still recommends face-down positioning, with length based on the doctor’s guidance. However, it’s important to note that although many studies indicate similar rates of successful hole closure with or without face-down positioning, there is little research-based information about the correlation of visual recovery following face-down positioning vs. visual recovery without face-down positioning.

I believe the reduced amount of time for the face-down period is due to four factors:

Retinal surgeons are using a different gas than in 2009. The gas is quicker acting and dissipates more quickly than in the past.
Peeling of the internal limiting membrane (ILM) of the retina has become a standard procedure. ILM peeling seems to improve hole closure results. [Editor’s note: The internal limiting membrane is the thin membrane that overlays the innermost layer of the sensory retina.]
Due to neck and back degeneration, many patients cannot remain face-down. In these cases, silicone oil is often used, not requiring face-down positioning. This, however, requires a second surgery to remove the silicone oil. Since it is a foreign material, there are some small risks of complications from the oil.
Many surgeons measure success based on anatomical success (hole closure as well as concern with hole reopening) rather than functional success (the amount of vision recovered post-surgery).

American Academy of Ophthalmology Preferred Practice Guidelines

The American Academy of Ophthalmology (AAO) Retina/Vitreous Panel has issued Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole 2014, Updated 2019. The report states, “…there is no clear consensus regarding duration of facedown positioning to seal macular holes following vitrectomy surgery, but longer positioning may be required for holes larger than 400 [micrometers] or those with inadequate tamponade.”

[Editor’s note: “Tamponade” refers to a treatment that closes or blocks a wound or opening – in this case, a macular hole – by pressing on, or plugging, it.]

Most patients with a gas tamponade are generally instructed to remain prone, face-down during the immediate postoperative period, but the length of that period is determined individually. AAO has also issued Face-Down Recovery After Retinal Surgery (PDF).

My Take on the Preferred Practice Guidelines

I am not a medical doctor but remain concerned that “success” seems to still be concentrated on whether the hole closes and whether it remains closed. Obviously, these are very important factors, but i would like to see a greater emphasis on the extent of functional visual recovery. While the relationship between face-down positioning and visual acuity recovery is still not a settled issue, my logic (not my medical knowledge) still favors staying face-down to the extent possible until the gas dissipates. My layman’s interpretation remains that gas rises, and the pressure of the gas causes the hole to close. Therefore, face-down position is important until the gas dissipates. Of the dozens of macular hole patients with whom I have communicated during the years, it seems that best visual acuity results are achieved by those who have been face-down until the gas dissipates.

Timeline for Surgery

In Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole 2014, Updated 2017, AAO summarizes many studies as follows:

In case series, many authors have reported better closure rates and better final visual acuities when the duration of symptoms is less than 6 months. Findings from case series indicate that a macular hole that has been present for more than 2 to 3 years may be closed, yet the success rate is lower (63%) and visual acuity outcomes are worse than for a macular hole of shorter duration.

Despite this recommendation (concerning better visual results with patients who have had the surgery within six months), many retinal surgeons have a large patient load. They may be unable to schedule surgery within that time period. See Important Issues Raised by Macular Hole Patients for suggestions on advocating for a more timely surgical appointment.

Selection of Tamponade

There is no consensus about the best choice of tamponade agent: air, type of gas, or silicone oil. Silicone oil may be used for patients who are unable to be face-down. This requires a second operation to remove the oil, and the surgical results are not usually as good as with gas. While surgeons have learned that the hole closes much faster than they had thought previously, no studies have compared vision recovery with respect to a slow-acting gas (long face-down period) versus a fast-acting gas (shorter face-down positioning time).

Equipment Rental

Some health insurance groups now pay for the rental equipment for face-down positioning. As most do not, it is still necessary to advocate strongly for patient needs and, in many cases, to appeal the insurance company’s ruling. Medicare has never provided this equipment, regarding it as “comfort” rather than “medically necessary.”

See Insurance Coverage and Reimbursement Issues for more information about coverage for face-down equipment and financial resources for medication.

Visual Recovery

There is a lack of studies concerning face-down positioning and functional visual recovery, including visual acuity and any distortion of vision. However, my correspondence with people worldwide clearly supports a close correlation between the strict regimen of face-down positioning and functional visual recovery. Face-down instructions vary greatly.

Some surgeons instruct their patients to be face-down the entire time, with exceptions only for inserting eye drops. Others tell their patients to be face-down for a certain number of minutes of each hour or for a certain number of hours per day. Other variables, such as surgical skill, size of the macular hole, age of the hole, and pre-existing eye conditions, are critically important to the outcome.

Intravitreal Injection

Ocriplasmin (trade name Jetrea) is a drug used by some retinal specialists to treat vitreomacular adhesions. This drug was approved by the FDA in 2012 to separate the vitreous adhesions from the macula. Injection of this drug causes vitreous liquefaction and helps dissolve the biological “glue” holding the vitreous onto the retina. This drug shows the potential to become the first way to treat vitreomacular adhesions pharmacologically, including macular holes.

For small macular holes, 40% received closure with this drug compared to a 90% closure rate with vitrectomy. If the procedure is not successful, vitrectomy remains an option. There are benefits, risks and complications of both intravitreal ocriplasmin and vitrectomy.

Certain types of macular holes have a higher rate of closure with ocriplasmin, including those in people who have not yet had cataract surgery; have small macular holes; have focal [i.e., attached at one point] rather than broad attachment of the vitreous; and do not have associated epiretinal membrane, which is abnormal tissue on the surface of the retina which can contribute to the macular hole and which the drug has no effect on.

The longer-term effects of ocriplasmin injections and complications have not been studied. Ask questions and discuss various options with your retinal surgeon.

Decision to Perform a Vitrectomy

Vitrectomy may be indicated depending on the amount of damage to the macula caused by pathologic changes in the vitreous. Typically, due to risks and possible complications of surgery, a vitrectomy is not performed unless, and until, there has been a significant deterioration of vision. This may result from a macular hole, a pseudohole, a macular pucker or epiretinal membrane, or other causes. If you have one of these conditions and it has not yet affected your vision, monitor it carefully and consult your ophthalmologist if or when there are changes.

Updates in Macular Hole Treatment and Recovery

Also see Suggested Resources for more information about helpful products and organizations, as well as the author’s contact information.

A Disclaimer

I was an educator of blind and low-vision children for 42 years. Although I have read and researched extensively and have had extensive discussions with retinal specialists, I am not an ophthalmologist or a medical doctor.

Reviewed and edited by Mrinali Patel Gupta, M.D., VisionAware Medical Consultant. Updated by author August 2023.