TREATMENT OF MACULAR PUCKER

The most common symptoms of macular pucker are distortion and vision loss. In is important to realize that other, more serious and more acute disorders can also cause distortion. If you experience new distortion in your vision, DO NOT ASSUME YOU HAVE A MACULAR PUCKER. You may have something more serious or something that requires urgent attention. You should consult a physician as soon as possible (less than a week) if you have new onset distortion and vision loss in either eye. Sometimes when one eye has a serious vision problem the other eye will take over and you may not notice the problem. Therefore, it is important to check your eyes separately every day to make sure that each eye is seeing well.

The evaluation for a macular pucker typically involves a comprehensive eye examination.

1. Medical History: The eye care professional will ask about your overall health, any medications you are taking, and your family history of eye diseases. They will also inquire about your specific visual symptoms and when you first noticed them and if your symptoms are becoming less or more bothersome.  It is important to differentiate between your vision out of one eye and your vision out of both eyes.  Some patients with vision loss in one eye will see well with both eyes open.  In general, even if a patient sees well with both eyes open, treatment of significant vision loss in one eye is prudent.
2. Visual Acuity Test: This standard eye chart test assesses how well you can see at various distances. It helps determine the clarity of your central vision.  It also helps to determine if there is a problem in one eye or both eyes.  Visual acuity does not always correlate with visual function.  Since visual acuity is assessed in a very high contrast situation, using black letters on a white chart in a dark room, it sometimes over estimates visual function.
3. Dilated Eye Exam: The eye care provider will examine the back of the eye for signs of a macular pucker and assess its severity.
4. Retinal Imaging: Imaging tests such as optical coherence tomography (OCT) are standard of care for assessing macular puckers since they provide detailed cross-sectional images of the retina. OCT is particularly useful in visualizing the retinal thickness and any disruption of the retina anatomy caused by the macular pucker.
5. Fluorescein Angiography: In some cases, a fluorescein angiogram may be performed to evaluate blood flow in the retina. Since macular puckers are common, sometimes patients have two different diseases.  A fluorescein angiogram can be helpful in ruling out a vascular occlusion which may co-exist with a macular pucker and alter the prognosis.

Based on the results of these evaluations, the eye care professional can determine the presence and severity of a macular pucker, as well as the impact on your vision. This information is crucial for deciding on the appropriate course of management, which may include observation, medical treatment, or surgical intervention.

Macular puckers are usually stable. They generally form and affect vision over a time period of about 3 months and then rarely change.

One study followed 84 patients with macular pucker for a year, half with cataract surgery and half without, and there was virtually no change in any of the patients’ macular puckers. Visual acuity and retinal thickness was minimally worse at one year in some patients.(Eye. 23(4):774-9, 2009)

A population-based study of people living in the Blue Mountains west of Sydney, Australia, was performed following all people living in that area for common eye diseases. This study identified, by photography, 2 types of macular pucker – one type that caused retinal folds (premacular fibrosis) and one type that did not cause retinal folds (cellophane maculopathy). At the studies inception, 56 participants (62 eyes) had premacular fibrosis. The lesions progressed in 16.1% of eyes and regressed in 25.8% of eyes. Of the 142 participants (183 eyes) with cellophane maculopathy, the area of involvement decreased in 12.6% of eyes and disappeared in 13% of eyes.(Ophthalmology 2003;110:34–40)

A clinic based study showed that 15% of patients with macular pucker have visual acuity of worse than 20/70. The same study showed no further loss of vision after enrollment in 87% of 47 eyes followed without surgery for 2 to 4 years.(Ann Ophthalmol. 1982;14:876-8)

Several studies have shown that about 25% of people with macular pucker in one eye will develop a macular pucker in the fellow eye.

If you have been diagnosed with a macular pucker you have several options including: no interventions, observation, surgery, or if applicable, treatment of other disease affecting your vision.

No intervention: Macular puckers are not uncommon. If your vision is not affected by the macular pucker, you do not need surgery. Macular puckers rarely progress. If your macular pucker does progress, you can opt to have it operated on when that progression occurs. If your vision is minimally affected by the macular pucker, you have to weight the risks and benefits of surgery. These are discussed further below. Everyone has different visual needs. There are people who cannot work if there vision is minimally compromised and there are people who get along fine with relatively poor vision. You need to decide what is right for you.

Observation: Since macular pucker surgery is successful at improving vision within the first few years of onset of the macular pucker, there is no harm waiting a little while to decide. About 5% of macular puckers improve with time, about 80% stay the same, and about 15% worsen. Usually if they worsen, they do so within the first few months of onset. So waiting a few months is rarely dangerous. Comparing serial optical coherence tomography scans over time can help you gauge if your macular pucker is changing.

Surgery: If you are bothered by your vision loss and want to have surgery for your macular pucker, there is no benefit to waiting. Although it is OK to wait to have surgery, it is not necessary. You are probably a little better off having surgery sooner than later if you are sure that is what you want. The downside to delaying surgery for macular pucker is that the benefit of surgery for macular pucker gradually declines over time.  Eighty percent of people improve with surgery, 15% don’t change and about 5% worsen. If your vision is affected to the point where your eye is not seeing well and your visual function is poor, then surgery is a reasonable option.

Seek treatment of other diseases affecting your vision: Many macular pucker patients have other eye diseases, like cataract, macular edema, and retinal vein occlusion. If you have a concomitant treatable eye disorder, treatment of that disorder might improve your vision enough that your visual function is satisfactory to you and you do not need the macular pucker removed. An added benefit of cataract surgery prior to macular pucker surgery is that it makes the macular pucker surgery technically a little easier and probably safer.

Macular pucker surgery, also known as vitrectomy, is a procedure in which the vitreous gel inside the eye is removed, and the epiretinal membrane causing the pucker is peeled away from the macula. Here are some key points about the surgery:

1. Procedure: During vitrectomy surgery, the surgeon makes small incisions in the eye and uses microsurgical instruments to remove the vitreous gel. The epiretinal membrane is then carefully peeled away from the surface of the macula. The vitreous gel is usually replaced with a saline solution.
2. Effect on Vision: The goal of surgery is to improve or restore vision by eliminating or reducing the distortion and wrinkling caused by the macular pucker. The extent to which vision improves can vary from person to person. On average, about 80 percent of patients have visual improvement and the improvement is usually about half way to normal.  Only about 10 percent of patients regain completely normal vision after macular pucker surgery.  The visual improvement generally occurs mostly over 3 months but then continues to gradually improve for 1-2 years from the date of the surgery.  Some individuals experience significant improvement, while others may have more modest gains.
3. Timing of Surgery: The decision to undergo surgery is often based on the severity of symptoms and the impact on daily life. If the macular pucker is causing significant visual distortion and affecting activities like reading or driving, surgery may be considered. However, if the visual symptoms are mild and not significantly impacting daily activities, the eye care professional may recommend a watch-and-wait approach with regular monitoring.  In general, the sooner the surgery is done, the more likely the vision will improve.  Usually in a macular pucker that is over 3 years old and stable, surgery does not improve the vision much.
4. Risks of Surgery: Like any surgical procedure, vitrectomy for macular pucker carries some risks. Possible complications may include infection, bleeding, increased eye pressure, and retinal detachment. There is also a small (about 1 percent) chance of damaging the macula as the pucker is removed.  When that happens, patients usually see new blind spots in or near their central vision. The overall complication rate is relatively low, and the decision to undergo surgery should be based on a careful assessment of the potential benefits and risks in each individual case.
5. Recovery: Recovery from macular pucker surgery varies, but patients are often advised to avoid strenuous activities for a period after the procedure. Vision may continue to improve over several weeks to months as the eye heals.
6. Postoperative Follow-up: After surgery, regular follow-up appointments with the eye care professional are important to monitor the healing process and assess the outcome of the surgery.

The timing of surgery is a decision made collaboratively between the patient and the eye care professional, taking into consideration the severity of symptoms, the impact on quality of life, and the potential risks and benefits of the procedure. It’s important for individuals diagnosed with a macular pucker to discuss their specific situation with their eye care provider to determine the most appropriate course of action.

65 year old woman with 20/50 vision for about a year. Vision improved to 20/25 1 week after surgery.

57 year-old-female with 20/200 vision for several months. This severe macular pucker was peeled without stain and then the internal limiting membrane was peeled with tissue blue stain. The patient’s visual acuity improved to 20/40 a month or two after surgery. That is better than average. The average patient’s vision returns halfway to normal which for 20/200 would be to 20/100.