Macular Hole

  • Overview
  • Stages
  • Treatment

The macula is the center of your retina.  It is responsible for your straight ahead vision.  While reading the print on this page, you are using your macula.  The cornea and lens in the front of your eye focus the image of these words onto your macula.  The macula converts the light from the image on this page into a neurological signal that is processed by your brain. 

Since the very center of the macular is the thinnest part of the retina, it is also relatively weak. Some patients have an abnormally tight attachment between the vitreous gel that fills the eye and the center of the macula.  When the vitreous gel contracts with aging, or after an injury, these people can develop a macular hole.

Macular holes are staged from 0 to 4.  A stage 0 macular hole is not visible.  It only shows up as a vitreous attachment at the center of the macula with optical coherence tomography scanning.  Most eyes with stage 0 macular holes never develop a symptomatic macular hole.  A stage 1 macular hole is not a full thickness macular hole.  It forms when the center of the macula is tented upward from traction but a hole has not formed.  Less than half of eyes with stage 1 macular holes develop a full thickness macular hole.  Most of these eyes heal on there own.  Stage 2 macular holes are small full thickness macular holes.  Five percent of these holes will heal on there own.   Most do not.  Stage 3 macular holes are larger macular holes where the vitreous is still attached to the hole.  Stage 4 macular holes are larger macular holes where the vitreous is not attached to the hole.

Surgery is successful in closing macular holes that are less than 6 months old nearly 100 percent of the time.  Once a macular hole is closed, the vision improves some in 80 percent of eyes, a lot in 50% of eyes (to 20/40 or better), and to nearly normal in 10% of eyes (20/20).  Even eyes with normal vision usually have some distortion in the vision for at least a year from the surgery.  The risk of surgery is mostly that of retinal detachment (2%-10%), infection (0.01%) and bleeding (0.1%).  Cataracts from in most eyes undergoing vitrectomy for any reason in patients over 50.  (Video Macular Hole Surgery)

 

Interesting, 90% of macular holes are in woman.  We don't know why that is true.

Without surgery macular hole patients usually only lose the very center of their vision.  The side vision stays good.  Many older patients (85 and up) with a second good eye may decide not to have surgery for macular hole.

 

To repair a macular hole, the surgeon first removes all the vitreous from inside the eye.  This relaxes the edges of the macular hole.  Many surgeons also do an internal limiting membrane peel further relaxing the edge of the hole.  Then the patients eye is filled with gas.  The gas pushes the hole closed like a draw bridge.  In order for the gas to push on the hole, the patient must look toward the center of the earth after the surgery.  Many different surgeons recommend different regimens.  Most require at least one week of 90% face down positioning.  There are pillows and message tables available in most cities for rent if patients want the extra help.

 

Most patients with macular hole opt for surgery. Macular holes over 6 months old can be closed, but the visual acuity results are not as good as they are for fresh holes. Even old holes, five to 10 years old, can be closed with surgery.  In these situations there is about a 50% chance of improving vision.