Macular Pucker

Macular pucker is a condition where a fine layer of scar tissue forms on the retinal surface causing wrinkles that can distort and blur vision. This scar tissue can also be called an “Epiretinal Membrane”.

The formation of a fine layer of scar tissue is very common in eyes of people over the age of 70 because it is usually triggered by collapse of the vitreous gel within the eye as a normal aging process. In the vast majority of people, the mild surface wrinkling does not cause any significant visual disturbance.

What are the symptoms?

The most common symptoms from macular pucker are blurring of vision, distortion causing lines to appear bent and occasionally “image rivalry” which occurs because the two eyes see different images and this confuses the brain – it is unclear if there are two separate but similar objects.

Who needs treatment?

Macular pucker is only treated if there are troubling symptoms – not just because it has occurred.

What is the cure?

Treatment is by an operation called a vitrectomy and membrane peeling. This removes the surface scar tissue and allows the retina to return to a near normal location.

The surgical procedure is called a vitrectomy and was pioneered by Prof. Robert Machemer in the 1970’s. A/Prof Heriot was trained by Prof Machemer himself at Duke University Eye Centre.

The Surgery

The surgery is performed in the operating theatre, usually as a day case so you will go home once stable after surgery.

You will have to fast for around 6 hours prior to the anaesthetic and procedure.

You will have to attend at least one hour prior to the planned commencement time.

Prior to the procedure, the anaesthetist will discuss any potentially significant health issues with you and then give some short-term sedation by vein so that the eye can be made pain-free by local anaesthetic injections without any distress. General anaesthetic is very rarely necessary because the eye will be pain free and some ongoing tranquillisers ensure a stress-free procedure.

A Vitrectomy is performed after the eye is pain free. The eye is washed with antiseptic and a small “speculum” is inserted between the eyelids to keep them open. An operating microscope is placed over the eye to visualise the internal contents. An “infusion line” with synthetic eye fluid is inserted to prevent the eye from collapsing. Very fine needle-like instruments are inserted into the eye cavity for the procedure. The surgeon holds an illuminating light source in one hand and alternates between the “vitrector” to remove some of the abnormal vitreous and micro-forceps to peel the scar tissue off the retinal surface. A special tissue stain is used to highlight the abnormal scar tissue from the normal retinal tissue. Peeling the scar tissue is a similar process (but at the microsurgical level) to slowly peeling sticky tape off a picture.

It is occasionally necessary to reinforce any weak areas in the retina by laser therapy and/or a gas bubble.
After the surgery, patients are taken to the recovery area where drinks (tea or coffee etc) and sandwiches are provided to “break the fast”.

A/Prof Heriot will review you the day following surgery and during the weeks following.

What are the risks?

Firstly, it is important to note that the scar tissue process is not just a retinal surface change but that there are also reactive changes within the retina itself. As such the vision does not always return to complete normality. There can be some residual distortion and some blurring despite an ideal removal of the scar tissue from the retinal surface.

The most common problem following vitrectomy and membrane peeling for macular pucker is the formation of a cataract. If a cataract is already present it may be removed during the surgery as well as a ‘’combined procedure”. The indications vs contraindications for combined surgery will be discussed with you in detail prior to booking the surgery.

Other uncommon risk factors include intraocular infection, retinal tears, retinal detachments, haemorrhage or inflammation or damage form the bright light used to see inside the eye during the surgery.

After the surgery

  • The eye will be bloodshot and may feel a bit scratchy as if there was something in it.
  • Usually only Panadol is needed for a day or two to relieve any discomfort.
  • You will have eye drops to use for a few weeks following surgery. Generally, there is an antibiotic and an anti-inflammatory drop to be used 4 times a day. You will be advised of exact details following surgery.
  • Vision improves over a number of weeks following the surgery and then at a slower rate for up to 18 months after the scar tissue is removed.