Coming into Hospital

What to expect on admission to hospital
What happens during surgery?

 

What to expect on admission to hospital

You will be welcomed at the hospital and shown to the ward where you will be settled in. A nurse will carry out routine investigations including checking your pulse and blood pressure. The nurse will also record details of any medications you are taking and ask questions about your general health. Once this has all been completed the nurse will instil the drops which dilate your pupil in readiness for the operation.

The Ophthalmic Nurse will come to see you to explain what will happen during and after the operation, and to answer any further questions you may have.

You will be asked to sign a consent form to state that you have been provided with, and understand all the information given relating to the operation (including the risks and benefits of surgery) and that you agree to the proposed treatment.

You will be taken to the operating theatre in your own clothes, so it is important to wear something comfortable.

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What happens during surgery?

The surgical procedure to correct a macular hole begins with a vitrectomy.

Vitrectomy means removal of the vitreous, the jelly-like substance that fills the eye behind the lens; this is a necessary part of the treatment for a number of conditions affecting either the retina of the eye or the vitreous itself. In your case, vitrectomy allows access to the macula for the peeling of any scar tissue (which frequently forms around a macular hole) and creates space for a gas bubble to be injected.

After the operation, the gas bubble re-absorbs and the vitreous cavity fills with natural aqueous fluid that is produced by your eye.

Surgery is usually carried out under local anaesthesia, which involves gently injecting anaesthetic around the eye. The anaesthesia will numb the eye and allow it to remain still during the procedure. You may be offered sedation if you are particularly anxious, which will help you relax whilst the procedure is carried out. You will be awake during the operation and will be aware of some movement and touch, but the procedure will be painless.

You will be made comfortable on the operating couch, following which the skin around your eye will be thoroughly cleansed and a sterile cover (“drape”) will be placed over your eye and face. The cover will be lifted off your mouth so you can talk and breathe easily. Your eyelids will be gently held open, although your eye will feel closed.

You will see little of what is happening during surgery but we will explain what we are doing as the operation goes along. The theatre staff will make sure you are comfortable and help you relax. Someone will be there to hold your hand if you wish. The operation usually takes about forty-five minutes, but in some cases may take longer.

 

Surgery is performed with the aid of an operating microscope and special lenses which give the surgeon a clear image of the vitreous and retina. Three tiny incisions are made in the sclera (the white of the eye) to enable instruments to be passed into the vitreous.

 

The first of these is a saline infusion (a “drip”) to replace fluid in the eye, maintaining the pressure and therefore the shape of the eye during surgery; the second is a fibre-optic light to illuminate inside the eye; and the third is for the operating instrument, starting with a vitrectomy cutter which enables safe removal of the vitreous gel from inside the eye.

Following removal of the gel we use extremely fine forceps to peel away any membrane from around the macular hole. A dye is used to stain this membrane to enable better visualisation of areas to be peeled.

The primary aim of vitrectomy surgery for macular hole is to fill the vitreous cavity of the eye with an inert gas. The water which has filled the eye during the removal of the vitreous jelly is first replaced with air.

Although this can occasionally be sufficient to repair the macular hole, air only lasts a few days within the eye and in most cases the final event of the surgical procedure is to replace the air with an inert gas. This gives a longer lasting fill (taking up to eight weeks to disappear completely from the eye) and improving the chance of macular hole repair by successfully re-attaching the small cuff of detached retina around the central tiny hole. It is re-attachment of this macular tissue which constitutes “closure” of the macular hole.

Traditionally the three scleral incisions are sutured at completion of the operation but, with the finer instruments now available, most patients will benefit from a “sutureless” technique and self-sealing incision sites.

For those having combined cataract and vitrectomy surgery

For those patients who have not yet had implant lens surgery, a combined cataract extraction and vitrectomy operation is performed. Your lens is removed by the process of “phaco-emulsification”.

A very small incision is made in the peripheral cornea (the clear part at the front of the eye covering the iris and pupil) through which a tiny probe is inserted. The incision is self-sealing and does not require sutures.

The natural lens of the eye is contained within a “capsular bag”. The aim of surgery is to remove the lens contents whilst leaving the capsular bag intact, apart from a circular hole on the front surface through which we work. An ultrasonic probe breaks up and then vacuums away the cataract material, leaving a cavity into which the new implant lens is inserted.

The rolled-up implant lens slips into the eye through the tiny corneal incision and once situated within the capsular bag, unrolls and is adjusted into position. You will not be able to feel this new implant lens.

An easy way to visualise this process is to think of the cataract as a smartie, the chocolate being removed to leave an empty case in which the new implant lens will sit.

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