Macular Pucker

Diagram of the human eye
Diagram of the human eye | Source

Glaucoma. Macular Degeneration. Cataracts. Diabetic Retinopathy. These are the more well known eye problems or diseases that we have to watch out for to protect our eyesight, but there is another age related disease that can creep up on you without you initially even noticing. It is an eye disease, that from my experience, is not well known. It is called Macular Pucker. Not too long ago I was diagnosed with this eye disease. It took me quite a while to figure out that I had it. This is my story.

It is Incredible What the Brain Can Do

Early signs of macular pucker and probably even macular degeneration can go undetected because the human brain has the incredible ability to filter and correct the vision that comes from our eyes. This is especially true when the disease occurs in only one eye. In my case, I am right eye dominant and the condition affected my left eye, so I was completely unaware that I had any problem. The bad side of the brain's ability is that it can mask serious eye problems until they become worse to the point that the brain can not compensate anymore.

The standard Amsler Grid created by Marc Amsler and used since 1945.
The standard Amsler Grid created by Marc Amsler and used since 1945. | Source

The Amsler Grid

The Amsler Grid or eye chart is a grid of horizontal and vertical lines that is used to diagnose vision problems and is particularly known for detecting macular degeneration. I have a relative who has macular degeneration in one eye so she has an Amsler Grid magnet on her refrigerator. One day, I was curious so I looked at the grid, one eye at a time, and I was shocked when I found out that the lines were wavy when looking at the grid with my left eye.

The first thing that I thought of was, now I had macular degeneration. I have to admit that I was scared. I had none of the risk factors that can cause or accelerate the disease but that didn't calm my fears. Obviously I made an appointment with an ophthalmologist but finding out what I had wasn't going to be so easy.

What a person may see if they have macular pucker.  A person with macular degeneration may see the same thing since both diseases affect the macula but they are not the same disease.  For my condition, the lines are wavy but not this dramatic.
What a person may see if they have macular pucker. A person with macular degeneration may see the same thing since both diseases affect the macula but they are not the same disease. For my condition, the lines are wavy but not this dramatic. | Source

The Diagnosis

The ophthalmologist who examined me could not find anything wrong with my left eye. He told me not to worry about it but if I was still concerned he recommended that I go see a retinal specialist and have pictures taken. Since he couldn't find anything I decided to do nothing more. I was content that everything was okay.

However, three months later, I started to think otherwise. I noticed when I was tired and I was reading, the lines of text would become wavy. I constantly found myself looking at straight lines, such as the edge of the television screen, the bathroom tiles, the point where the wall meets the ceiling. It is interesting how we as humans favor geometry with straight edges and lines while nature itself abhors such things. Apparently now that I knew I had this problem my mind could not filter it out anymore.

The big concern that I had was the fear of having the same condition occur in my right eye, but as the three months passed I actually noticed no change, which was good. I still, however, became obsessed with what was causing this, so I decided to do my own research which took a few days before I finally hit on something on a forum. Some one wrote about surgery that they had to remove scar tissue on their retina. They had a condition called Epiretinal Membrane, another name for macular pucker.

The more I looked into this condition, the more I came to realize this is what I had. The scar tissue is nearly transparent but it does have a cellophane type appearance so it can block some light. I became aware, soon after I noticed the problem, that my l left eye is slightly less sensitive to light. Everything appears slightly darker.

I know that it is not a good thing to diagnose your own symptoms but one thing I learned about macular pucker is, that in its mild form, it can easily be missed by an ophthalmologist. Once I realized this, I decided to go to a retinal specialist.

Without telling him what I thought I had, sure enough, the specialist confirmed that I did indeed have the condition. The examination was thorough. It involved the following steps:


  1. My eyes were dilated and then I was given a glaucoma test. I was then sent back to the waiting room.

  2. When I was called back in, the doctor had me sit in a chair where he had me lean back in a near lying position. He then examined my eyes having me look up, look down, and look from side to side. An assistant was in the room typing in the results as the doctor called out what he saw. Sure enough, when he examined my left eye he called out epiretinal membrane. Once he was finished, I was instructed to go to a different waiting room where I was to wait for pictures to be taken.

  3. The photo process involved two steps. The first involved simply taking pictures while the second step involved injecting a dye and then taking a second set of pictures. This second set called Fluorescein Angiography looks for any circulation problems or bleeding behind the retina. Once the photos were taken I was again instructed to go back to the waiting room.

  4. Finally, the doctor called me into another room where two large monitors showed images of both eyes. He explained to me what macular pucker was. He then showed me the scar tissue on the left retina. It was somewhat faint but still easy to see. It looked like a spider web or a paint ball splat.


The first set of pictures and the first examination is used as a baseline to monitor any change over time. There are potentially other serious conditions that can pop up with macular pucker so it is good to understand what is actually going on.

A diagram of what the scar tissue looks like on the retina.  Also known as the epiretinal membrane.
A diagram of what the scar tissue looks like on the retina. Also known as the epiretinal membrane. | Source

What Is Macular Pucker?

The center of the eye is filled with a gel like substance called the Vitreous Humor. As a person ages the vitreous shrinks. In some cases when the vitreous pulls away from the retina it can harm it. The scar tissue forms as an immune response to protect the retina. However, the scar tissue can tighten and buckle the retina causing images to be distorted.

The Macula is the part of the retina responsible for the ability to see fine detail. It is only about 1.5 mm in diameter. Hence, the name macula pucker comes from the affect the scar tissue has on the macula. Along with wavy lines, my central vision in the left eye is also affected. Luckily, it is only minor. I can still see a good amount of detail. The symptoms with this condition can vary from simple wavy lines to partial or total loss of central vision which will manifest as a grey area or a blind spot.

Generally, the condition will not change but there can be complications. The doctor told me the warning signs, and if any of them would occur, I was supposed to see him immediately.

What a person would see with severe macular pucker.  Since the condition affects the macula, the symptoms are nearly similar to macula degeneration.
What a person would see with severe macular pucker. Since the condition affects the macula, the symptoms are nearly similar to macula degeneration. | Source

Complications

It is rare but the following complications can take place with macular pucker:

  • Macular Edema

Cause: Since the scar tissue can pucker or raise the macula, fluid can collect under the macula causing it to swell

Symptoms: Distortion or loss of central vision

  • Macular Hole

Cause: If the vitreous is firmly attached to the retina when it pulls away, it can tear a hole in the macula, where fluid can then enter

Symptoms: Similar to macular edema, distortion or loss of central vision

  • Retinal Detachment

Cause: A retinal tear, such as a macula hole, can progress when the fluid that builds up causes the retina to detach

Symptoms: Increased number of floaters, flashes of light outside the center of vision, and/or loss of vision outside the center of vision

  • Blood Vessel Tear

Cause: When the vitreous pulls away it could possibly tear a blood vessel in the retina

Symptoms: Increased number of floaters

Again, I want to emphasize that these complications are very rare with macular pucker.

Treatment

Generally, nothing is done with macular pucker since most cases are mild. You can adjust to the condition. I can say this from experience because I didn't even know that I had macular pucker. I don't even know when it actually occurred. My biggest problem is that now that I know I have it, I see slight waves in some things, especially text, like what I am writing now. Once I became aware, it became more difficult to filter it out. When I don't think about it, I generally don't see it. When I do think about it, I definitely do see it.

From what I understand, some cases can be alleviated by corrective glasses. However, if vision becomes extremely distorted, surgery may have to be performed. Since the vitreous is mostly water, it is replaced with a saline solution. The scar tissue is also removed. On average, about half of lost vision will return, but surgery should be avoided because of potential complications such as infection and retinal detachment.

For people over 60 years old macular pucker is usually permanent. For people younger, there is the possibility that the scar tissue will separate from the retina allowing vision to return to normal.

This brings me to the final question, why does this happen?

Why Does Macular Pucker Happen

This condition is simply a result of aging. There is nothing that can be done to prevent it, such as diet or drugs. As mentioned earlier, when the vitreous shrinks as we age, in most cases, there is no damage to the retina. More than 75 percent of adults over 65 years of age will have this condition. The number that will actually develop macular pucker, I don't know. The vitreous shrinking for people in their late 40s and early 50s is more rare. This is the age group that I am in. So I am going to go out on a limb on this one. It is mere speculation but I think the 10 cycles of chemotherapy that I had over the course of 14 years for two bouts of cancer had an effect.

I don't think everyone knows the full long term effects of chemotherapy. For myself, I noticed a sudden increase in dry skin on my face after I was declared in remission about three years ago. I also had pain in both of my knees, something that I never had before. A lot of times, I had a hard time walking. Considering that caffeine can dehydrate you, I stopped my intake and soon all of the symptoms went away, especially the pain in my knees. Over many years, I never had any problems with caffeine until after my last chemotherapy treatment.

Another effect of chemotherapy is tissue hardening. This is why cancer patients have to go through cardiovascular screening before being put on chemotherapy. The reason is that some chemo drugs can damage your heart by this tissue hardening. The effect is permanent. There is a lifetime limit for some chemo drugs. After my treatment I became extremely farsighted. Now, I am also becoming more nearsighted. Once, when I was at the oncologist for a six month checkup, I asked some of the other patients about their eyesight and they said that they were having the same problems that I was having concerning seeing both near and far. If the tissue that makes up the lens of the eye hardens then, it will make it more difficult for a person to see both near and far.

The questions I have concerns all of what I just mentioned. Did the chemo harden the lenses of my eyes? Is the extreme dry skin that I had also a form of skin hardening? Can the vitreous also be affected by chemo in the same manner? I don't know with certainty but I have the feeling that “yes” chemotherapy did have an affect. I would entertain any other answers.

Well, regardless of what causes some eye problems it is always prudent to have yearly checkups. For macular pucker you don't even really need an amsler grid to check for it. Something like a simple spreadsheet program that always displays a grid on a computer monitor will suffice.

Were you aware of the eye condition macular pucker before reading this hub?

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If you have macular pucker, what was your age group when you were diagnosed?

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