Very myopic - Should macular hole and cataract surgery be done together

[myopic74]

Dear all,

I am in my 40s and highly myopic (+20D both eyes) and recently it was found there is a small full-thickness macular hole in one of my eye.

Had very mild cataracts in both eyes that is not causing any visual disruptions,

Visited two retina surgeons.

A) Surgeon A recommended vitrectomy surgery to close up the hole. I was told success rate is about 80-90% and high chance I will develop cataract in that eye within 3 years. But surgeon A did not suggest doing cataract surgery at teh same time.
B) Surgeon B recommended vitrectomy and cataract surgery together.

Which do you think is more advisable and for high myopes how real/high are the risks of retina detachment (or other complications) resulting from cataract surgery?

Any advice is deeply appreciated!

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

Vitrectomies almost always cause cataracts in those not having and those that do they grow faster.  This is a generalization.  If you have cataract-vitreous surgery at the same time you will immediately have a huge difference in your glasses prescription that you will not be able to wear (aneisometrophia). That is because they won't put in an IOL to make the eye still highly myopic.  Also 2 operations at the same time involve more risk than a single operation at one time. A cataract operation will greatly increase the risk of a retinal detachment where as the vitrectomy will not increase nearly as much. For monst people a single vitrectomy would make more sense and be safer

[myopic74]

Dear Dr Hagan,

Thank you very much for your helpful advice. Really appreciate it and will heed your advice on doing one at a time.

I was also wondering from a medical point of view how complicated is a vitrectomy surgery, especially for high myopes who already have very stretched retina?

How much will the skills and experience of the eye surgeon (the one holding the knife) affect the outcome of the surgery?

I asked that because I have the option to go in as a subsidised patient (ie; cannot choose doctors) or as a private patient (ie; can choose doctors). My consultant is a very experienced eye surgeon but he may not be the one actually doing the surgery unless I specifically requested for him which will then be the private rate (ie; much more expensive).

Many thanks in advance!!

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

Any time you have any surgery the skill and experience is of utmost importance. As a life-long eye surgeon the skills of surgeons varies widely. Think of it like batting averages in baseball. The .336    batter is quite a bit more skilled than the .200 batter even though both are 'major leaguers' So do a good job of vetting the surgeons. Vitreous surgery is very complex, very unique, very much skill dependent, much more so than cataract surgery. As a generalization private practice surgeons are going to be more skillful because patients have choices, they are spending out of the pocket money and poor results get around and you lose clients. The state surgeon has a captive audience, results and reputation not needed to keep volume up. So do you research. In many instances in state run facilities you may not know who your surgeon is until the day before.

[myopic74]

Thank you for your very hrlpful  comments! The surgery went on smoothly two days ago under the very skilful and experienced hands of the eye surgeon. It was over in 15mins and it was like watching a 3D cinematic light display. Now on post-op face down recovery.

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

Best of luck.  Remember the risk of RD or macular hole very high in fellow eye. Have your eyes checked immediately with onset of new floaters, flashes of light, loss of field of vision or sudden change of vision. Avoid trauma, live a healthy lifestyle and avoid contact sports

[myopic74]

There is also macula splitting in the other eye which has not developed into a full macula hole yet.

[MrPresley]

Great news that your retinal surgery was a success. Will you be a patient of this same ophthalmologist for monitoring your eye health going forward? I was fortunate to have been referred to an excellent retinal specialist 8+ years ago when I required a ERM/virectomy procedure for my left eye, and I still see him twice a year for full dilated exams and OCT imaging.

[JohnHaganMD]

I agree in a situation like this for general care a comprehensive ophthalmologist is needed with at least an annual exam by a retinal specialist

[myopic74]

Dear Dr Hagan,

How long does it take for the macula hole to close after the surgery? I still couldn't see significant improvement 4 days after surgery.

Can we move around (ie; walking from one place to another) with the gas bubble inside the eye? Will the shaking of the gas bubble in the eye cause complications like retina tears?

Will it cause much early cataract if the face-down position wasn't maintained consistently due to the exposure of the gas bubble with the eye's natural lens?

Thank you and any advice is much appreciated!!

[MrPresley]

Patience will be key regarding visual improvement. Mine required nine months to reach its final acuity after retinal surgery.

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

myopic74, you are in for the LONG HALL, to know the success of macular hole surgery you are looking at 6-12 months. Vision is usually better but usually not perfect.  For activities you need to ask your surgeon. These cases are all very difficulty and hard to generalize about unlike cataract surgery. The exact cause of the almost always developing cataract is not completely understood. Because cataracts still develop after vitrectomy where no gas put in eye, not likely the most important cause. Remember keeping your other eye healthy is extraordinarily important. Good luck.

[myopic74]

Dear Dr Hagan,

Thank you very much for your insightful advice!

Another question.. Is it also true that most pathological myopia/myopic degeneration patients will eventually progress to myopic CNV at the end-point of the disease, at an older age (for eg; >50 or 60)?

CNV seems to be the most sight threatening and scary part for myopic degeneration patients.

Best regards

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

I don't know if there are any reliable statistics on progression of pathological myopia into myopic CNV. It would vary too much depending on the degree of myopia. But most cases of pathological myopia DO NOT progress to CNV or have RD. It's just that the rates are higher than in normal length eyes. So don't use the word "most' use 'some' and not the majority.

[myopic74]

Dear Dr Hagan,

Thank you very much. It is reassuring to hear that myopic CNV is not that common.

I went back to see my eye surgeon today and it was found there was slightly elevated IOP in the operated eye and he prescribed Simbrinza eyedrops to lower the IOP. Is elevated IOP a common complication after macula hole surgery? Is it temporary? I was told to apply the medication for one month until the next appointment.

I checked with the retina surgeon about maintaining the face-down posture and was told to do it for two weeks (from date of surgery). I asked was it also partly (other than gas bubble float to exert pressure on the macula to close the hole) to reduce exposure of the gas bubble to the lens so as not to accelerate the formation of cataract. The answer was yes. However I was told after two weeks it was not essential to maintain the face-down position. I was abit perplexed as I thought the gas bubble will take about one month to disappear.

So does it mean after two weeks it makes no difference whether or not the gas bubble will be exposed to the lens?

Thank you very much for your numerous kind advice and have a good day ahead!

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

Elevated IOP is common after retina surgery and usally temporary. Also the steroid eye drops can cause 'steroid glaucoma' in a small % of people.   How quickly the gas absorbs is based on how much put in but also wether the gas is air which absorbs very quickly or SF6 when takes many weeks to absorb. I suspect yours was air but ask your surgeon. The tendency is to use as little face down as possible

[myopic74]

Dear Dr Hagan,

Thank you and very grateful for your extremely helpful advice.

I think it could be SF6 because it comes the following warning in my medical bracelet and a note:

“USES OF NITROUS OXIDE (N2O) OR CHANGE IN ATMOSPHERIC PRESSURE WIRH A GAS BUBBLE PRESENT MAY CAUSE AN INCREASE IN PRESSURE IN YOUR EYE, WHICH CAN RESULT IN BLINDNESS”

Just wondering will there be adverse side-effects in applying the Simbrinza eye-drops to relieve the eye pressure?

There are currently already 3 different antibiotic eye drops which I have to apply for one month.

Many thanks & appreciated! ;)

[MrPresley]

In my case I didn’t experience accelerated cataract development from the gas bubble itself, in that it took 18 months for the cataract in my operative eye to progress to the point of requiring treatment. I did not have to maintain face down posture after my retinal surgery.

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

Simbrenza will not have any effect on the gas bubble. The primary risk is in flying where atmospheric pressure can cause the gas to expand.

[myopic74]

Thank you Dr Hagan & Mr Presley!

It has been two weeks post surgery and the bubble has slowly receded and am able to see above the bubble line.

I understand the gas bubble will eventually be absorbed by the body and replaced by body fluid.

However I also realise the vision above the bubble line is cloudy and not clear. Is that normal? Or is it due to the clouding of the lens by the gas? Or is it due to there are still debris and it will take some time for body fluid to clear? Roughly how  long does it take to achieve a clearer vision?

Many thanks and much appreciated.

[MrPresley]

Several months as I recall.

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

A bubble will almost always adversely reduce the vision and cause it to be variable.  Independent of the gas bubble macular hole surgery has a LONG healing time and the final result may not be obtained for as long as a year but at 6 months you should have a good idea if the surgery improved things.

[myopic74]

Dear Mr Presley and Dr Hagan,

Thank you very much for your advices!

So you mean is normal for the vision to be cloudy still (not referring to seeing through the gas bubble which is obviously blurry but rather seeing above the gas bubble line as the gas bubble is slowly receding and is now only 2/3 filled)?

Can we wash the operated eyes with normal water now as my 10days’ worth of saline solution (for cleaning the eyes with cotton balls) is used up?

Once again thank you both for your great advice!

Regards,

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

1 Yes that is what I mean  2 That information must come from your surgeon

[myopic74]

Hi all, two months post-vitrectomy surgery the gas bubble has disappeared. However the vision is still not clear although reading small prints is fine at a short distance. May I know generally what causes the blur vision still?

[myopic74]

Hi all, two months post-vitrectomy surgery the gas bubble has disappeared. However the vision is still not clear although reading small prints is fine at a short distance. May I know generally what causes the blur vision still?

[MrPresley]

Give it another six months and revisit the issue. Be aware that cataract development may accelerate simultaneously during your recovery time and impact your vision as well. Your retinal surgeon or optometrist can monitor development of a cataract if so.

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

Likely you have several things going on. If your near vision is good without glasses that means you are myopic and glasses would be necessary to see at distance (more than 20 feet) and intermittent . Your cataracts will grow faster due to the vitrectomy   You had a macular hole, surgery does not restore macular anatomy it mainly is to make the hole not get bigger and deepter. Since the macula is not normal before AND after surgery that can have an effect, blur, distortion, things looking larger or smaller than normal.  

[myopic74]

Thank you all for the very helpful advices!

Went to the hospital yesterday and was told by eye surgeon that macula hole has been closed.

However apparently the “blurness” was due to the fact that refraction has increased quite significantly (by 3D), over the course of the surgery and the last few months when the macula hole elapsed. Because that was the new refraction done at the hospital yesterday. And I look through a pair of ready made spectacle with 3D, the vision was relatively good and clear. Is that (sudden and significant increase of refraction post-vitrectomy surgery) something normal?

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

If you still have your natural lens it is likely that the cataract vitrectomies always cause is developing, this would be especially true of the 3 diptor change is MINUS.  If a buckle is placed for a concurrent retinal detachment that also make the eye more myopic. so likely your cataract is growing. Likely to be a problem in the next 1-2 years.  With that big of a change if you can comfortably wear your glasses that is great, that big of a change often unbalances the glasses and they are not comfortable.

[myopic74]

Dear Dr Hagan,

Thank you for your advice. I don’t understand what you mean. Yes, still has the natural lens. The change in refraction of 3D is MINUS (ie; became even more short-sighted). I am puzzled by what caused the  significant-3D change after the macula hole surgery?

Does anyone who undergone thru vitrectomy also experience similar issues?

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

Yes vitrectomies almost always causes cataracts if none, or if cataracts preexist then grow faster. The exact cause is not known for sure.  The rate that the cataract grows varies from person to person

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

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[MrPresley]

I had minor cataracts in both eyes when I had a vitrectomy performed on my LE in 2015. The cataract in that eye progressed to the point of being problematic 18 months afterward, and had surgery for it in 2017. Still have the natural lens in my RE. I have contacts/glasses for distance correction, with my LE correctable to 20/15 and my RE to 20/25 or 20/30.

[xltjim]

Each of my eyes had victrectomy.   Cataracts were instantaneous in each case.   I had thought my eyes would never recover.     6 months later had cataract surgery.   A year later required yag (both eyes separate timeline).   All good now.   Patience is key here.

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

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[MrPresley]

My non-medical opinion is to not have cataract surgery at the same time as retinal surgery in order for that eye to first reach its final visual acuity. It took nine months for mine to get there, and 18 months before I needed cataract surgery. My retinal surgeon and cataract surgeon were separate specialists  in my case.

[myopic74]

Thank you! I agree with you as well. In fact my first eye consultant did not suggest doing both at the same time. I guess being highly myopic with stretched retina adds another layer of risk for the surgery as well.