What You Should Know About Macular Holes

What is a macular hole?
A macular hole consists of a small, round defect in the central macula.  The hole is thought to be caused by the vitreous pulling on the central macula, creating a central defect in the retinal tissue. It usually occurs for no obvious reason (idiopathic), although a macular hole can also be caused by trauma or retinal detachment. Macular holes are most common in women in their 60's and are not associated with any systemic medical problems. Approximately 10% of patients with a macular hole in one eye will eventually develop a macular hole in the other eye. 

Normal Macula.		Macular Hole (arrow).

 
What are the symptoms of a macular hole?
The macular hole causes the central vision to be blurred or distorted.  Patients may be completely asymptomatic, especially when the other eye sees normally. Some may experience progressive vision loss, although the vision will stabilize for most patients within 3 to 6 months of the macular hole developing. 

How is a macular hole diagnosed?
You can't diagnose a macular hole by looking in the mirror since your eye will usually look and feel normal. The diagnosis is made with a thorough retinal examination through a dilated pupil. Early stages of macular hole formation are often difficult to diagnose, often requiring additional testing such as optical coherence tomography (OCT) which offers a near microscopic macular image.

OCT scan (top) of normal macula compared to OCT image of an eye with a macular hole(bottom). A piece of macular tissue is suspended above the hole.

What treatments are available for macular holes?

1) Observation. 
Treatment for many patients with a macular hole is often not necessary, since many remain asymptomatic. Surgery should be considered, however, for those people with a relatively new macular hole whose distortion, vision loss, or difficulty with depth perception make their daily activities such as reading and driving difficult. 

2) Vitrectomy surgery. 
Vitrectomy surgery is done at the hospital under local anesthesia. This advanced microsurgical technique allows us to restore vision by peeling and removing the associated macular pucker from the macular surface and filling the eye with a special gas bubble. The gas bubble helps to seal and flatten the hole postoperatively.

Patients go home immediately following surgery. There is usually minimal to no pain, except for minor irritation from sutures which absorb within a week of surgery. Patients need to look down to the floor for 2 weeks, which properly positions the gas bubble against the macular hole. Airplane flying is strictly prohibited while the bubble is present since it can expand in the de-pressurized airplane cabin causing severe pain and possible blindness.  The gas bubble absorbs on its own over several months, at which point it is possible to tell whether or not the hole has flattened. Vitrectomy successfully flattens the macular hole in over 75-90% of cases. With successful surgery visual acuity usually improves by about 50% although it may take several years for maximal vision to return.
 

Preoperative macular hole (arrow) with 20/100 vision.		Normal macular appearance following surgery.  Vision improved to 20/60.

The major side-effect of surgery is a cataract, with many patients requiring cataract surgery within a year or two of vitrectomy. Some patients may also notice side vision loss. There is about a 1 in 20 chance of a recurrent macular hole, along with a very small chance of secondary retinal detachment or infection.