Macular Hole
A macular hole is a small, round opening that develops in the fovea, the very center of the macula, leading to a direct break in the retinal tissue.
5/5
Dr. Bhaskar Gupta
Consultant Ophthalmologist & Vitreo-Retinal Specialist
20+ years experience
Causes
Why it happens ?
- Primary (Idiopathic): The vast majority of macular holes are age-related. As the vitreous gel naturally shrinks and separates from the retina (PVD), it can remain abnormally adherent to the fovea. This persistent pulling or “traction” eventually tears the delicate retinal tissue, creating a full-thickness hole.
- Secondary Causes: Less commonly, macular holes can be caused by:
- High myopia (severe short-sightedness), which can stretch and thin the retina.
- Blunt eye trauma or injury.
- Chronic macular edema (prolonged swelling of the macula).
- Previous retinal detachment or surgery.
Incidence
Macular holes affect approximately 3 in 1,000 people over the age of 55, with a slightly higher incidence observed in women.
Symptoms
Symptoms typically develop gradually over several weeks or months:
Central Blind Spot (Scotoma)
A central "blind spot" (scotoma) or missing patch in the vision : This is the hallmark symptom, making it impossible to see the center of objects, faces, or words. Significant blurring or distortion of central vision.
Blurred or Distorted Central Vision
Central vision may appear unclear or warped, affecting clarity and visual sharpness.
Difficulty with Daily Visual Tasks
Activities such as reading, driving, or recognising faces become challenging due to reduced central vision.
Wavy or Bent Straight Lines
Straight lines may look curved or distorted, especially noticeable on text, door frames, or road markings.
Treatment Options
Treatment for a macular hole depends on its size, duration, and impact on vision.
Small or early holes may be monitored, while most full-thickness macular holes are treated with vitrectomy surgery to close the hole and improve vision over time.
Observation
Very small, partial-thickness macular holes might sometimes resolve spontaneously, but this is rare. Most full-thickness macular holes require surgical intervention to close.
Vitrectomy with Gas Tamponade (Surgical Intervention)
This is the primary and most effective treatment for full-thickness macular holes, with high success rates for hole closure (often over 90%).
- The Procedure: Performed as a microsurgical day-case. A vitrectomy is performed to remove the vitreous gel, eliminating any pulling on the macula. A crucial step often involves peeling a very thin, transparent layer called the Internal Limiting Membrane (ILM) from the macular surface. This reduces residual traction and promotes hole closure. Finally, a special gas bubble is injected into the eye. This gas bubble acts as an internal “bandage” or “splint,” gently pressing the edges of the macular hole together as it heals.
- Combined Surgery: It is almost always combined with Cataract Surgery if a cataract is present or forming. This is critical because the gas bubble injected into the eye will invariably accelerate the formation or progression of a cataract, often to a visually significant degree within months of the macular hole surgery. Performing both procedures at once prevents the need for a second surgery.
- Post-operative Positioning: To ensure the gas bubble correctly presses on the macula, you will be advised on specific “face-down” or side-lying head positioning for a period, typically for a few days to a week. Adherence to this positioning is crucial for successful hole closure.
- Visual Recovery: Vision will be very blurry immediately after surgery due to the gas bubble, which obstructs vision. As the gas bubble slowly reabsorbs (which can take 2-8 weeks depending on the type of gas), vision will gradually return, often from the top of your visual field downwards. Improvement in central vision and reduction of distortion can continue for 3 to 6 months as the macula remodels and heals.