Small Hole, Big Problem

Modern surgery repairs tiny defect in center of retina.

Dr. Matthew Cunningham at Florida Retina Institute, with offices in Lady Lake, Mt. Dora and Clermont, treated Laura Wells and Susan Mikels for macular hole using pars plana vitrectomy.

Dr. Matthew Cunningham at Florida Retina Institute, with offices in Lady Lake, Mt. Dora and Clermont, treated Laura Wells and Susan Mikels for macular hole using pars plana vitrectomy.

Laura Wells retired for the first time in 2014. The California native was an administrative assistant for Volkswagen of America based in New Jersey, just across the river from her New York home. 

“It was a receptionist position, but it also involved a lot of facilities management and special projects,” recounts Laura, 62. “I routinely communicated with Germany and with people in other departments within the company.

“Prior to that, I worked as a retail store manager for 10 years. The position at Volkswagen paid a little less but had more benefits. My husband also worked for Volkswagen, so we were able to spend more time together while commuting.”

Once Laura retired, she planned to help care for her aging mother, whose health was beginning to deteriorate. For that to happen, it was necessary for Laura and her husband to relocate. They ended up in the Sunshine State.

“My mother was living in California and didn’t want to move to New York,” Laura relates. “And my husband and I didn’t want to live in California again, so we decided to pick a place we all liked. Florida was it.”

While living in Florida, Laura worked for a while as a cashier at Publix and later as an administrative assistant for the state Department of Corrections. She retired for the second time in April 2020 to spend more time at home with her ailing mother.

As soon as Laura arrived in the Sunshine State, she found local health care providers to manage her various medical needs. In October 2018, Laura noticed a problem with one of her eyes and sought advice from the ophthalmologist she selected.

“There was a blank spot in my right eye,” Laura describes. “It was just a black space in my vision, like there was information missing. It was really strange. I’ve never experienced anything like it before. I thought I just needed a better prescription for my glasses, which I’ve worn since I was 6 years old. But my eye doctor told me I needed to see a specialist. He recommended Dr. Cunningham.” 

Matthew A. Cunningham, MD, is a board-certified, fellowship-trained retina specialist at Florida Retina Institute.

Dr. Cunningham notes that many patients in his clinic present with vague symptoms such as blurred or distorted vision, as did Laura. 

“Ms. Wells came to us with distortion to the central vision of her right eye,” Dr. Cunningham recalls. “She described a missing spot in her central vision. Central visual distortion is a common symptom of many eye disorders, one of which is a macular hole. 

“If we think of the eye as a camera, the retina is the camera’s film located at the back wall of the eyeball. The center of the retina is the macula, which is responsible for our central and color vision. If anything damages the macula, our vision is negatively affected. A macular hole is essentially a small break in the macula.”

The vitreous humor is a gel-like substance that fills the eye and liquefies with age. A macular hole typically forms when the vitreous begins to pull against it’s attachment to the retina. When the vitreous gel peels away from the retina – as it does in 70 percent of people – it can tug too hard and cause a macula hole. 

“Dr. Cunningham explained that there was a hole in my macula, a tear in the tissue in the back of my right eye from the retina being pulled,” Laura confirms. “Because of that, my eye can’t interpret what it sees.”

For years, there was no known treatment for a macular hole. As a result, many people with the condition went blind in the affected eye. A macular hole can now be repaired, however, and in October 2018, Laura was successfully treated in her right eye. 

She wasn’t done suffering from the ailment, though.

“Last August, I was sitting in church, and the pastor’s head began to look a little fuzzy to me,” Laura remembers. “I closed one eye and could see that the distortion was happening in my left eye, and that was a bit frightening. So, I went back to Dr. Cunningham, who told me I had the same condition in my left eye.”

Dr. Cunningham states the chances of someone getting a macular hole in both eyes is about 5 to 15 percent.

“It is not terribly common, but we do see it occasionally in our patient population,” he reports. “Ms. Wells was one of those patients.” 

The Entire Equation

To diagnose a macular hole, retina specialists begin with a dilated fundus exam. With the eyes dilated, the physician can directly view the retina and macula and visualize any defects.

“We also use a technology called optical coherence tomography, or OCT,” Dr. Cunningham details. “OCT produces high-resolution cross-sectional images that reveal what is occurring in the back of the eye on a microscopic level. It aids in confirming the diagnosis and determining the diameter of the hole.”

The treatment for macular holes is a surgery called pars plana vitrectomy. This procedure has been in use since the 1970s, and the technology has improved dramatically over the decades.

“During modern vitrectomy, we first remove the vitreous gel from the patient’s eye,” Dr. Cunningham describes. “We then use microforceps to peel the inner layer of tissue surrounding the macular hole to release the tangential traction. After that, we fill the space with a gas bubble to help push the edges of the hole inward to assist with closure.

“We’re able to close the macular hole and improve vision in more than 80 percent of patients, but the degree of vision improvement varies. In many cases, the improvement occurs over a six-month period, so it isn’t a quick fix. It takes time to see the maximum healing.”

The gas bubble remains intact in the eye from three to eight weeks depending on the type of gas. As the bubble dissipates, vision steadily improves. To help hold the bubble in place, patients must remain face down for three to five days immediately following surgery. 

“I always stress to patients that surgery is only half of the equation,” Dr. Cunningham asserts. “The other half is compliance with positioning because that’s almost as important as the surgery. Patients who are extremely compliant with positioning experience the best outcomes.”

Like any surgery, there are risks associated with vitrectomy, but the incidence of complications is low. Dr. Cunningham reports that there’s a 1 to 3 percent chance of adverse events, which may include a retinal tear or detachment, infection or bleeding. 

“Vitrectomy does speed up the development of cataracts,” he adds. “In many cases, people don’t require cataract surgery until they are older, but once we perform vitrectomy, patients typically need cataract surgery within a year of the procedure. 

“We aren’t sure exactly why this occurs; the reason is likely multifactorial. Some surgeons think it’s related to the oxygen exchange that occurs during vitrectomy, and others believe it has something to do with the gas bubble that we place into the eye.” 

Laura confirms Dr. Cunningham warned her that the surgery could advance cataracts.

“I underwent cataract surgery on both eyes between the two macular hole procedures,” she recollects. “They did both eyes to make the vision in my eyes comparable. After my cataract surgery, Dr. Cunningham performed my second macular hole procedure.”

Untimely Transition

Susan Mikels lived most of her life in the quaint borough of Strasburg in Pennsylvania’s Lancaster County. She later resided in Nashville, Tennessee, for a couple of years before retiring and moving to The Villages® in December 2019.

“Before retiring, I was a commercial Realtor for 33 years,” shares Susan, 65. “I started out in commercial lending for a local bank and then transitioned into the sales end of the business at a brokerage. 

“One reason I made the transition was because the income potential was a lot higher on the sales end than on the lending end. I also knew a lot of people in the community, and I felt that I could reach out to those people as sales clients.”

Susan favored commercial over residential real estate partially because of her background. She was already familiar with commercial lending, and she liked dealing with clients who were business-oriented.

“I enjoyed the challenge of evaluating properties and marketing them to the appropriate clients,” Susan elaborates. “With residential real estate, you’re selling houses to individuals and families. With commercial, you’re selling businesses and commercial and investment properties to business people. I prefer that to showing homes.”

Like Laura, Susan developed a problem with her right eye. Unlike Laura, Susan didn’t experience any obvious symptoms of distress, just slight blurry vision in the damaged eye.

“Last October, I went to my regular eye doctor for my annual checkup, and he said, I see a little something with your macula. It’s probably nothing,” Susan remembers. “He probably didn’t want to scare me, but he referred me to Florida Retina Institute. I got in to see Dr. Cunningham right away.”

Dr. Cunningham examined Susan’s right eye and noted that there was a tear in the macula. He told Susan the tear could possibly heal on its own, so she was advised to give the defect time to heal and have it reevaluated in a few months.

“But when I went for my follow-up appointment in the beginning of March, the tear had turned into a hole, and Dr. Cunningham said I needed surgery,” Susan recounts.

It was her first time undergoing surgery, so she was nervous.

“On the day of surgery, the anesthesiologist put me into a deep sleep to numb my eye.
Then he brought me out of that and I was conscious for the procedure,” she recalls. “I could see the operating room and hear
Dr. Cunningham’s voice, but I couldn’t see anything that was going on with my eye.

“During the surgery, Dr. Cunningham cut into the back of my eye and placed a gas bubble to assist with closure of the hole. After surgery, I had to keep my head down, looking at the floor, for five days. That was the hardest part of the whole experience.” 

“Back to Normal”

To help make the recovery process more comfortable, Susan rented a special chair from a medical supply company. The chair supported her upper body and neck as she sat face down during the critical five days after surgery.

“It’s almost like a massage chair, but it’s specifically made for this purpose,” Susan describes. “It took all the strain off my neck when I put my face down. I placed a mirror below my face, and the TV reflected onto it so I could watch TV. 

“After the five days, I still had to take it easy because Dr. Cunningham didn’t want me bending at the waist. While the gas bubble was there, my vision was blurry. But as the bubble got smaller, I could see more and more. I could see around the bubble very clearly.”

“Now, my vision is very good, back to normal. I was just at Florida Retina Institute for a follow-up appointment, and they took pictures of my macula. It looks perfect. The surgery was a huge success.

“Dr. Cunningham was great through the whole thing. He has a nice personality, which I appreciate. I also appreciate how he explained everything and kept things upbeat. It wasn’t all doom and gloom. He made me feel like I wasn’t the only one in the world that this has happened to.”

Fears Relieved

Laura also complied fully with positioning.

“The instructions are quite involved,” she contends. “I had to remain face down for six days. That meant very minimal face-up time – only to put drops in my eyes and go to the restroom. I learned to sleep on my stomach instead of my side to stay face down. If I didn’t, my eyes might not heal properly. I did whatever I needed to do.”

Laura’s efforts paid off. She achieved an excellent outcome from her vitrectomy procedures. According to Dr. Cunningham, Laura’s vision today is close to 20/25.

“I’m extremely happy,” Laura raves. “I have no problems focusing my eyes or reading things close-up. My vision is as good or better than it was before surgery.” 

When Laura first noticed the black spot hovering in the vision of her right eye, she became concerned. She was worried about more than the potential condition and fearful of her doctor’s examination because she hates having her eyes touched. But any anxieties were relieved by Dr. Cunningham.

“Dr. Cunningham’s bedside manner is amazing,” Laura relates. “He has a positive outlook and such confidence that I wasn’t afraid. And while I don’t like anyone to touch my eyes or do any type of procedure on them, he put me totally at ease.

“Having gone through the first surgery with Dr. Cunningham, I understood just how skilled he is, so I was extremely relaxed and not nervous at all about the second surgery. I knew I didn’t have to be concerned about that procedure. 

“With the macular hole, I could have lost my vision entirely, but Dr. Cunningham took the problem very seriously. My vision was very important to him.” 

© FHCN article by Patti DiPanfilo. Photos by Jordan Pysz. mkb
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    • Florida Retina Institute

      Founded by James A. Staman, MD in 1979, Florida Retina Institute has 19 locations throughout Central Florida, North Florida, and Southeast Georgia. They have proudly delivered Excellence in Vitreo-Retinal Diseases and Surgery for 40 years. T... Read More

    • Matthew A. Cunningham, MD

      Matthew A. Cunningham, MD, is board certified by the American Board of Ophthalmology. He earned a bachelor of science degree from the University of Florida in Gainesville and a Doctor of Medicine degree cum laude with honors in research from t... Read More