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The vitreous is a jelly-like substance that fills the middle of the eye. Over the course of our life, it changes and becomes more liquefied. This change causes the vitreous to separate from the retina at the back of the eye. Separation of the vitreous from the retina normally occurs in people between 55 and 75, but can happen at any time. It is a normal phenomenon that occurs in all eyes, although it appears faster in people who are near-sighted and have had prior inflammation, trauma or surgery.
The vitreous separates in several steps; initially the core of the gel becomes more liquefied. Most people will notice some translucent floaters during this phase. The next step of separation occurs over the macula, but this is often asymptomatic. In some patients, the vitreous pulls on the macula during the separation and produces symptoms that include blurred vision and distortion.
The final stage takes place when the gel separates from the front part of the retina. During this phase, patients may notice an increase in floaters and flashing lights in the peripheral vision. In some cases, the vitreous pulls on the front part of the retina, causing tearing or detaching of the retina.
Once the gel has separated, patients may experience residual floaters in their vision. These are often more noticeable under high contrast conditions, such as looking at a white wall. Some patients have disabling floaters that impair their vision.
The macula is the part of the retina in the back of the eye responsible for our central, fine vision. It is what allows us to see and decipher words on the page of a book or to make out the details on something smaller or a longer distance away.
In the early stage of vitreous separation, the gel can pull on the central macula. This initially produces swelling that makes the vision blurry and may be associated with distortion. This is called vitreomacular traction (VMT ).
If there is progressive traction, a gap in the tissue develops, resulting in a macular hole. The vision gets blurrier and the distortion worsens.
In some cases, the vitreous separates from the macula but leaves a residual sheet of gel that contracts and wrinkles the macula, producing swelling. This may also cause visual blurring and distortion, and is referred to as an epiretinal membrane, or macular pucker. Macular puckers may also occur in association with other conditions, including trauma, inflammation, retinal vascular disorders, retinal tears and detachments, or prior eye surgery.
In the acute phase of separation, patients may notice more float ers in their vision, and can experience flashing lights. When these symptoms first appear, the retina should be examined to make sure there are not acute problems, including retinal tears or detachments.
Most people continue to see some floaters in their vision. In some cases, these can cause problems and interfere with vision. In more serious circumstances, vitrectomy surgery can be considered to remove the floaters.
Many people with macular pucker or macular hole do not experience symptoms. Among those who do, here are the most common:
Both macular puckers and holes can be diagnosed by your eye care professional while he or she is performing a dilated retinal exam, in conjunction with conducting such tests as optical coherence tomography (OCT ) or fluorescein angiography (FA ).
The vitreous gel can be safely removed during an outpatient surgical procedure called a vitrectomy. Vitrectomy is performed to remove significant vitreous floaters and symptomatic vision loss associated with macular puckers and macular holes. Removal and separation of the vitreous is necessary to relieve traction on the macula, close macular holes and remove epiretinal membranes.
During vitrectomy surgery, the vitreous is removed via three microscopic openings in the sclera (the white part of the eye). The surgeon may use certain medications or dyes to help visualize the vitreous and epiretinal membrane. Membranes are peeled from the macular surface with microscopic instruments. At the end of the procedure, the surgeon may leave the eye filled with saline―or a gas bubble (a mixture of air and gas that applies pressure to the edges of the macular hole)―in order to facilitate the healing process.
If a gas bubble is used, your doctor is likely to ask you to lie still with your head positioned for at least several days to ensure that the bubble stays in the correct position in the eye. Flying or traveling to high altitudes is contraindicated while the gas bubble is present, since it can expand in the event of pressure changes and cause serious damage. The gas bubble will dissipate within a month or two.
In patients with macular puckers and macular holes, the retina relaxes after surgery. The vision improves over the course of several months. A vitrectomy carries with it certain risks, although the likelihood is small. Those include:
Please discuss the risks and beneﬁts thoroughly with your doctor before the surgery.
Some forms of vitreomacular traction and small macular holes can be treated with in-oﬃce procedures. These include an intraocular injection of a FDA approved drug called ocriplasmin (Jetrea®) or an intraocular injection of gas. Not all patients are candidates for these procedures.