Among the pathologies that can affect the macula, the macular hole is an entity quite apart. This type of lesion will develop following traction of the vitreous gel on the center of the fine vision: the macula. This is called vitreomacular traction. The development of a macular hole will therefore first pass through a vitreomacular traction stage (or vitreomacular traction syndrome, lasting more or less long) before leading to a macular hole.
In each case, patients complain of deformed lines (metamorphopsia) and decreased vision, as in any macular pathology.
When we are still in the stage of vitreomacular traction syndrome, surveillance is necessary because this phenomenon can naturally be solved without causing any problem in a significant number of cases. However, if the visual acuity decreased significantly in the context of a wide macular attachment, an intervention may be necessary in order to release this traction and avoid a permanent loss of vision. This decision will be discussed with the surgeon to fully understand the causes, modalities and risks.
A cataract is frequently associated with vitreoretinal conditions such as membranes, exudative macular degenerations, macular holes, diabetic retinopathies or retinal detachments. After vitrectomy, 75% of the eyes develop a significant cataract in the year and 95% within two years, which delays visual recovery. It is a nuclear cataract with index myopia, sometimes posterior capsular, fern leaves by desiccation, related to internal tamponade or contusion of the posterior surface of the lens during vitrectomy. For all these reasons, phakic eyes requiring vitrectomy can benefit from simultaneous ablation of the lens in order to improve the intraoperative visualization of the retina, to avoid the need for a second operation and thus to accelerate the functional rehabilitation of the retinas.
The combined intervention is an already old concept, proposed as early as 1989 in the presence of a cataract in diabetics then in epimacular membranes, in macular hole surgery and in retinal detachments. The development in the 1990s of phacoemulsification associated with micro-incisions and soft implants, as well as the growing role of 23- and 25-gauge transconjunctival vitrectomy, contributed significantly to the development of combined surgery even in the presence of crystal clear.
Everyday experience has shown that many patients undergoing vitrectomy alone consult five to ten years later, without useful vision because of a dense cataract, whose late treatment can become problematic. Indeed, if the phacoemulsification of a lens on a previously vitrectomized eye does not pose a problem in the early years, the intervention can be complicated ten years later, because of the hardness of the nucleus and zonulocapsular fragility.
Some small macular holes may resolve spontaneously and therefore require no surgery. They often go unnoticed by patients, which is why they only have a small proportion of ophthalmic consultations.
However, in the majority of cases, the macular hole is already large and will not disappear spontaneously. Surgery is necessary.
This surgery will consist of a vitrectomy to replace the vitreous gel with a physiological serum adapted to the eye and thus address the internal limiting membrane (or ILM) on the surface of the retina which will be gently removed from the forceps. The detachment of the ILM will stimulate the underlying cells of the retina to organize healing. However, a gas bubble should be injected (except in case of postural concerns), to encourage good healing and good closure of the macular hole.
The indications for combined surgery are largely dependent on the age of the patients, as well as the type of retinal disease. The minimum age to consider a combined procedure on clear lens is around 50years. Indeed, before this age and especially in subjects under 30years, the appearance of cataract is delayed, even after gas tamponade. It will therefore always be possible to achieve secondarily and safely a phacoemulsification. After 50years, the cataract is constant in case of tamponade by gas or silicone especially in myopic patients with axial length greater than 26mm and functional rehabilitation is often not achieved before cataract surgery.
Regardless of age, the only contraindications are high inflammatory risk patients such as diabetics with proliferative or florid retinopathy, evolving uveitis, complicated vitreoretinal proliferative detachments (PVR), in which it is preferable to limit initially, to the surgery of the posterior segment. Currently, we perform a combined intervention in all patients over 60years operated on membrane, in all patients over 50years operated macular hole, as well as in all patients with macular hematoma. Other indications in the presence of diabetic detachment or retinopathy are discussed on a case-by-case basis.
This gas bubble will require to adopt a delicate position, lying on the stomach, for 4 to 7 days, to help the good ocular healing and this bubble will remain on average ten days in the eye before disappearing naturally .
Surgery of vitreo-macular traction syndrome and macular hole