A macular hole forms when there is traction on the macula from the vitreous that pulls the center of the macula enough to form a hole in the center of the vision.
The retina is the neural tissue in the back of the eye that processes visual information. It works like the film in a camera. The center of the retina is called the macula. This part of the retina is responsible for central vision, which is crucial for activities such as reading, driving, and recognizing faces. A macular hole occurs when there is a small break or opening in the macula.
The development of a macular hole is usually related to aging and changes in the vitreous, the gel-like substance that fills the central part of the eye. As people age, the vitreous can shrink and pull away from the surface of the retina. In some cases, as the vitreous pulls in the center of the macula, it pulls a hole in the macula.
Symptoms of a macular hole may include:
- Blurred or distorted central vision
- Difficulty reading or performing tasks that require detailed vision
- Straight lines appearing wavy or distorted
A macular hole typically progresses through several stages:
- Stage 1: Foveal Detachment (Incipient Hole): The fovea is the center of the macula and that is where macular holes occur. At this early stage of macular hole formation, there is a small partial thickness break or elevation in the center of the macula. Stage I macular holes have about a 50 percent chance of aborting – which means healing on their own without surgery.
- Stage 2: Small Full Thickness Hole: In this stage, the hole progresses, and there is a small break through the full thickness of the macula. Stage 2 macular holes have about a 20 percent chance of healing without surgery. In general, stage 2 macular holes are less than 400 microns in diameter.
- Stage 3: Full Thickness Hole: At this stage, the hole extends through the entire thickness of the macula. Patients may experience a significant decrease in central vision, and the distortion of straight lines becomes more pronounced. These holes are usually over 400 microns in diameter.
- Stage 4: Full Thickness Hole with Posterior Vitreous Detachment: In the final stage, a piece of tissue, called an operculum, may float in the vitreous gel above the macular hole.
The animated image with this text shows a stage 2 macular hole that closed without surgery. Since macular hole surgery is never an emergency, it is sometimes worthwhile waiting a short time (about a month) to see if a small macular hole will close on its own. Usually, over the course of a month, OCT scanning can show if there are changes in the architecture of the macular hole that may favor spontaneous closure.
When macular holes abort, or spontaneously close, the vision often returns all the way to normal over the course of about a year. There is often a small piece of tissue that can sit in front of the fovea, a pre-foveal opercula, that can block the vision. In the accompanying image, the patient took over a year for the pre-foveal opercula to pull free of the macula.
The use of topical anti-inflammatory drops may improve the chance of a small macular hole closing without surgery. Most macular holes have an area of retina swelling at the edge of the macular hole. Anti-inflammatory medication may help reduce that macular edema. Reducing the macular edema can bring the edges of the hole closer together and consequently the macular hole may close.
Since the visual outcomes of macular hole surgery are better the sooner the surgery is done, most surgeons who try medical therapy for macular hole, will give the treatment about 4-6 weeks to show some benefit. If there is no benefit from medical therapy, then prompt surgery is usually best.
Surgical intervention is highly effective in closing macular holes that are fewer than six months old, achieving closure in nearly all cases. Approximately 90% of macular holes successfully close with a single surgery. Following closure, vision improvement is observed in 80% of eyes, with around 50% experiencing substantial visual enhancement to 20/40 or better, and approximately 10% achieving near-normal visual acuity at 20/20.
Even in eyes with initially normal vision, some distortion usually persists for at least a year post-surgery. The primary risks associated with the procedure include retinal detachment (2%-10%), macular damage resulting in visual defects (1%), infection (0.01%), and bleeding (0.1%). Additionally, cataracts may develop in most eyes undergoing vitrectomy, especially in patients over 50.
For individuals with untreated macular holes, central vision loss is common, though peripheral vision remains unaffected. Older patients, particularly those aged 85 and above with a second healthy eye, may opt against surgery for macular holes.
The surgical process involves the removal of all vitreous from the eye, promoting relaxation at the edges of the macular hole. Many surgeons also perform an internal limiting membrane peel to further ease the edges. Following this, the eye is filled with gas, which acts like a drawbridge, pushing the hole closed. Post-surgery, patients are required to look towards the center of the earth to allow the gas to exert pressure on the hole. Various surgeons recommend different postoperative regimens, often involving a few days to a week of 90% face-down positioning. Patients can find support through available rental pillows and massage tables in most cities to aid in this recovery process.
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Most patients with macular hole choose to have 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.
This patient had a two month history of vision loss from a macular hole. The pre-operative OCT scan showed a stage II macular hole with a diameter of about 250 microns. The scan did not show a taught internal limiting membrane. This surgery is done with a short acting sulfur hexafluoride gas and no internal limiting membrane peel. The patient positioned for a week after surgery (Strict for 3 days). The hole closed and the vision has improved to 20/30 at 2 months.
Re-operation for a failed macular hole sugery. In this surgery the internal limiting membrane is peeled using no stain. The high definition video shows the maneuver nicely. This 75 year old female patient recovered vision from 20/200 to 20/30 about 3 monhs after the surgery.
