Macular Hole

What is a macular hole?

A macular hole is a small break in the macula. The macula is located in the center of the retina, an area of light-sensitive cells at the back of the eye. The macula controls central vision, which is the sharp, straight-ahead vision we need for reading, driving, and seeing fine detail.

A macular hole can cause blurred and distorted central vision. Macular holes happen as the result of aging, and people who have them are usually older than age 60.

Is a macular hole the same as age-related macular degeneration?

No. Macular holes and age-related macular degeneration are two separate conditions, but the symptoms can be similar and both conditions are common in people 60 and over. Both conditions are called "macular" because they involve the "macula" area of the retina. Talk to your eye doctor if you think you have one of these conditions.

What causes a macular hole?

Most of the inside of the eye is filled with vitreous, a gel-like substance that helps the eye maintain a round shape. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. Fluids then fill the area where the vitreous has contracted. This process is normal and does not cause symptoms. Some people might have a small increase in floaters, which are little "cobwebs" or specks that seem to float about in your field of vision, but this is usually not harmful.

However, if the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and cause a macular hole. Or, once the vitreous has pulled away from the retina, it can leave behind some fibers that can later contract and cause a macular hole. In either case, the fluid that has filled the space the vitreous used to take up can then seep through the hole onto the macula. This blurs and distorts central vision.

Macular holes can also happen from eye disorders (such as nearsightedness macular pucker, and retinal detachment), diseases (such as diabetic retinopathy and Best's disease), and injury to the eye.

What are the symptoms of a macular hole?

Macular holes often happen slowly. In the early stages, a person with a macular hole might notice a slight distortion or blurriness in his or her straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye might be difficult.

Are there different types of a macular hole?

Yes. Macular holes come in three stages:

  • Stage I: Foveal detachments – Without treatment, about half of Stage I macular holes get worse.
  • Stage II: Partial-thickness holes - Without treatment, about 70 percent of Stage II macular holes get worse.
  • Stage III: Full-thickness holes

The size of the hole and its location on the retina determine how much it will affect a person's vision. A Stage III macular hole can destroy most central and detailed vision. If left untreated, a macular hole can lead to a detached retina. Detached retina is a serious condition that can result in severe vision loss. People with detached retina need immediate medical attention.

How is a macular hole treated?

Although some macular holes heal on their own without treatment, in many cases, surgery is necessary to improve vision. The surgery eye doctors use to treat this condition is called a vitrectomy.

During a vitrectomy, the vitreous gel is removed to prevent it from pulling on the retina. The doctor replaces it with a bubble that contains a mixture of air and gas. The bubble acts as a bandage that holds the edge of the macular hole in place as it heals. This surgery is performed under local anesthesia and the person can usually go home afterwards.

After surgery, you must stay in a face-down position. For some people, this is only needed for three days or fewer, but for others, it can be needed for as long as two to three weeks. This position allows the bubble to press against the macula and be reabsorbed by the eye. This seals the hole. As the bubble is reabsorbed, the vitreous area refills with natural eye fluids.

Keeping a face-down position is important to the success of the surgery. This position can be difficult for many people. Be sure to talk to your doctor about any concerns you might have before surgery.

What are the benefits and risks of surgery?

The most common benefit from surgery for macular hole is that it can improve vision. But vision improvement can be different from person to person. People that have had a macular hole for less than six months have a better chance of getting vision back than those who have had one for longer. Talk to your doctor about your chances of vision recovery before your surgery. Vision recovery can continue for as long as three months after surgery

The most common risk of macular hole surgery is an increase in how quickly cataracts develop. Cataracts can develop more rapidly after surgery, especially surgeries that involve gas bubbles, and often become severe enough to require removal. Other less common complications include infection and retinal detachment. This can happen either during surgery or afterward, and in both cases, can be treated immediately.

For a few months after surgery, you will need to avoid travelling by air. Changes in air pressure can cause the bubble in the eye to expand, which increases pressure inside the eye.

What if I cannot remain in a face-down position after the surgery

If you cannot remain in a face-down position for long enough after surgery, the surgery might not work to restore your vision.

However, there are a number of devices that can make the "face-down" recovery period easier on you. There are also some approaches that can decrease the amount of "face-down" time. Ask your doctor about options that might work for you.

Is my other eye at risk?

If you have a macular hole in one eye, there is a 10 to 15 percent chance that you will get a macular hole in your other eye at some point. Ask your doctor about your risks for a macular hole.