Macular pucker surgery

[thiru666]

I have been diagnosed with Macular pucker in my left eye. I am 61 and also being treated for Glaucoma that is under control. I was told I am a candidate for early cataracts as well. My vison in the left eye has gone fro 20/20 to 20/50 in the last 3 years. I am able to perform my normal duties. The retinal specialist that was refered by my opthalmologist suggests that I undergo vitrectomy. I was explained the risks of this surgery, but the suggestion was to do it sooner than later. I am aware of the documented risks of this surgery. Is there a potential to loose your vision completely as a result of this surgery? Is the risk worth it or should I wait till it gets worse? Would appreciate good advice.  Thanks.

thiru666

[Ray T Oyakawa, MD]

I trained at the institution which promoted macular pucker surgery.  It was developed by Howard Gilbert and popularized by Ron Michels.  I have been doing this surgery since 1981.

1)  Your vision is now 20/50 and you mentioned you have early cataracts.  It is important to determine which component is decreasing your vision.  Puckers which leak on flourescein angiogram or shows edema on OCT tend to progress. These will also have more severe CME after cataract surgery.

2)  Cataract surgery after a pars plana vitrectomy has a higher risk of complications.  Capsular rupture probably being the most common.  This would make a one piece ReStor or Crystalens difficult or impossible to implant.  Cataracts progress after a pars plana vitrectomy in a significant percentage of cases.


3)  I would recommend cataract surgery first.  Pretreat the eye with Xibrom and Pred Forte ( non generic) for a few days before surgery and continue for two months.  

4)  After the cataract surgery edema from puckers can respond to Avastin injections ( I have done this on ReZooms.   I have also successfully used Avastin for CME in diabetics after cataract surgery.  

5)  If after everything the vision is worse than 20/30 or 20/40 from the pucker or it is a significant distortion to you,  I would consider a pars plana vitrectomy for macular pucker.  This surgery is not without risk-the most significant is retinal detachment.  All retinal detachments can not be fixed.  The risk of RD is less than 1%.  However, about 2% to 3% of retinal detachments will not respond to multiple surgical treatments and will lead to blindness.  Also, many retinal detachment will recover partial vision if the macula is detached. (Va less than 20/40).

My two cents!

Dr. O.

[JodieJ]

I had this surgery three years ago, and I believe that you have a lot to gain by it.  I have a few suggestions based on my own experience and research.

1) A macular pucker (AKA epiretinal membrane, epimacular membrane) is a layer of scar tissue on the macula.  In the majority of cases, vision doesn't continue to get worse over time.  However, there is some evidence that visual outcomes are better when surgery is done sooner rather than later.

2) If you do have surgery, choose the very best board-certified retinal surgeon in your area.  You want a doctor who has done a lot of these procedures.  It's probably a good idea to get opinions from more than one surgeon.

3) There is now sutureless vitrectomy equipment which will make your recovery much quicker and more comfortable than the older, 20-gauge equipment requiring sutures.  However, any equipment can produce good results when used by a skilled surgeon.

4) Generally, visual acuity improves by several lines on an eye chart, although some distortion may remain.  According to recent research, including an ILM peeling in the surgery is the best way to reduce distortion post-surgery.

5) Sometimes cataract surgery is done along with the vitrectomy to peel the pucker.  The advantage of this is that you don't need a subsequent procedure to remove the cataract.  Speaking personally, I still would not recommend this.  Cataract surgery today has become refractive surgery, with careful attention to IOL power calculations and choice of lens.  I suspect that the cataract surgery would assume secondary importance if it were done along with the retinal surgery, and the retinal surgeon would probably perform both procedures.  (It might be better to have a cataract surgeon do the cataract surgery.)

6) Any surgery involves risk but the chance of losing your vision is extremely remote.  (I suppose that contact lens wear might also result in a loss of vision.)  There's a lot of information about this surgery available by googling "macular pucker."  I think it's always a good idea to be well-informed before making health care decisions.