vitrectomy on 4th stage macular hole with history of previous old retinal detachment

[puppy900]

I am deeply conflicted about whether or not to follow my retinologist's advice to get a victrectomy on a fourth stage macular hole in an eye with an old retinal detachment. The retina in the left eye had become detached, so that the retina flapped down over the macula. The reattachment surgery was successful. The macula was creased in the middle but whole without further compromise. There was scar tissue from the surgery and swelling around the macula. When I looked just through the left eye there was a crease in the middle of my vision and a squashed image compared to the right eye. I was able to score 20/60, sometimes but rarely, a little better because I had learned how to negotiate the crease during the vision tests. I was not really looking through the middle but working around it.

Around the time of the detachment in the left eye, there were some small tears in the right retina. Those were repaired by laser surgery, and I never had a detachment. My vision has remained stable for seventeen years following these procedures.

I have quickly over the last several months developed a macular hole in my left eye, the one compromised by the earlier retinal detachment surgery. It is a fourth stage hole--which means, I think, that it is as big as it is going to get. Oddly, at least for now, the central blind spot is not all that bad compared to the crease that I had and when I look now through just the left eye, the rest of the image is not squashed. Most of the vision in that eye, right now, with the hole is more normal, although I did terribly on my eye test because I was using the same techniques in taking it that I had used to negotiate the crease. I am quickly learning how to negotiate the hole. My retinologist did not want to hear much about my subjective experience.

He is trying to convince me that a vitrectomy is what I should do? I am trying to figure out why. If this is as bad as the macular hole gets, I can live with the vision; and I find the downside risk of complications such as another detachment (frightens me to death because I think the additional scar tissue would blind the left eye if a detachment occurred--I just read someone's report about just that kind of development); almost certain later cataract surgery, possible bleeding in the eye from the surgery (another factor that would make it impossible to see), an infection, and increased risk for glaucoma (because of increased eye pressure) to be absolutely terrifying. I am already at risk for glaucoma because of the shape of the cup near the optical nerve, although I do not have it. My eyes are quite near-sighted. the left one is two whole points plus worse than the right one.

I am not diabetic; I have maternal grandmother who was diabetic. I suspect that the genes responsible for diabetes in her are expressing themselves in me in connection with eyesight. There is a connection. My retinal surgeon, a very competent man, assures me over all of my doubts that I would be making a mistake if I did not let him try to close my fourth stage macular hole. He says, and I believe him, that he has closed other fourth stage macular holes. I have asked whether any have reopened. He says not since they started using something the name of which I do not remember in surgeries.

I greatly fear that not leaving that macular hole alone and allowing him to do the surgery will only spawn the need for numerous additional operations on my left eye that will eventually simply ruin the eye.

What I know now is that I can still see with this fourth stage macular hole. My retinal surgeon tells me that I could develop)  epitheal pigmentosis (I hope that I have the term right) if I leave the macular hole alone. In other words there would be a slow deterioration in the vision in that eye over time, so that I would not in the end (perhaps twenty years from now) have much sight at all in it. He admits that a fourth stage macular hole generally stabilizes and that it is also possible that I could retain the vision I now have for the next twenty years too.

My inclination is to leave this alone, if it is not going to get any worse. He makes that arguments about the right eye. What If a trauma occurs to my right eye? Well, I could get hit by a car tomorrow, it is true. Life is full of what ifs; and I know that 1 in 10 people who get macular holes in one eye get them in the other. Generally speaking, though, getting a macular hole in two eyes is rare; and I am pretty sure that the one in the left eye is the long-term residual of the long time swelling of the left macula as a residual of the earlier surgery in which this same retinal surgeon saved my sight seventeen years ago. Since the left eye is the most near-sighted one, I would expect it to have been the most likely locus for a macular hole if I were going to develop one, anyway. I could be one of the ten percent. It is probably more likely than I will be part of the ninety percent (you have to say your prayers and hope you know).

I don't know what to do. All I know is that I can see now and live with this present vision. I would be going into an operation with all of my vision in the left eye except what I am experiencing as a small central blind spot; and the retinologist cannot be concrete about whether my vision will even improve. He acknowledges that It could remain the same. He cannot guarantee that it would not get worse; and it is possible that I could lose my sight. Yet he recommends that I do the surgery. I can't see any good reason to take the risk for the possible benefit. I don't know what to do. I am deeply conflicted and need to make a responsible judgment call. Should I do this? I just don't have a good feeling about it.

[Luvtoski]

Until someone of "expertise" responds, I just wanted you to know that I feel your pain and understand your dilemma. I had ERM/Vitrectomy 1 year ago and cataract surgery 4 months ago in the Vitrectomy eye.  I have a remaining central "blank spot" like you and my macula/retina remains swollen--probably permanently .  (around 400 on the OCT chart)

Anyways, sometimes it is better to "leave well enough alone"...but I encourage you to do exactly what you are doing by researching as much as you can until you feel like whatever decision you make is the "right one".  I never make a decision on one specialists' opinion alone as I went to 4 Retina specialists before ERM (scar tissue) surgery and all 4 had different opinions and techniques for surgery.

Good luck, and keep us posted.  

[puppy900]

Thank-you for your reply. I hope that someone with some knowledge will reply. I am making the calls for second opinions. The experiences of others are important and relevant, although each body is different. It is a judgment call and my judgment is not settled. If I have the surgery, I want to be as sure as the surgeons that it is the best thing to do. The dilemma for me is going into an operation with sight, not knowing what the odds are of totally losing the left eye because of an operation intended to be a cure. ????????

Puppy900

[John C Hagan III, MD, FACS, FAAO]

Ultimaely you alone make the decision. There are many informative discussions on these eye forums which you can access using the search and archives.

JCH MD

[puppy900]

That is, of course, true--but reliable and accurate criteria for a judgment are indsipensable.

Puppy900

[John C Hagan III, MD, FACS, FAAO]

By reviewing the posts especially those of Jody J who had macular pucker surgery you will have the benefit of scores of people that chose to have the surgery as well as others that opted not to have the surgery.

JC MD

[puppy900]

Thank-you for your second reply. It is not straightforward how to get to the Jody J posts from here; but I did plug a google search that pulled her up. There does not seem to be anything precisely on point except for the suggestion to get a second opinion. I am in the process of doing that; but it would still be good to get some input here. If you have any particular suggestions about the kinds of eyes that are good and bad risks for vitrectomy surgery, I would be most grateful.