What is a Macular Hole?
The healthy retina is a very thin tissue, which lines the back of the eye. The retina functions like the film in the back of a camera. The central portion of the retina is called the macula. This area provides all of the sharp central vision for activities such as reading and driving. If this area is damaged, the central vision can be severely affected. A macular hole, as the name implies, is a condition that causes a hole to develop in this central area. Macular holes may occur in a number of ways. They may occur after trauma to the eye or from inflammation in the eye. Holes forming from these conditions are more difficult to treat and have a lower chance of visual improvement.

The most common cause of macular hole formation is simple traction, or tugging, of the vitreous gel on the macula. The vitreous is a bag of gel that fills the back of the eye and presses against the retina. With age, the gel can become watery in its center and the skin on the back can tighten and become thicker, pulling on the macula. This can stretch the macula until it breaks at its center. This results in progressive loss of the central but does not usually affect the peripheral vision. The vision usually decreases to the “E” at the top of the eye chart but usually not further.

What Are the Symptoms of Macular Holes?
Patients who develop macular holes initially notice distortion and waviness in the central vision, especially while reading. This may slowly or abruptly worsen. In some cases, the other eye compensates well enough that the patient notices no vision loss until they cover the good eye. The peripheral or side vision remains unchanged.

How are Macular Holes Diagnosed?
Macular holes can be diagnosed with a full eye examination, including drops to dilate the pupil. Optical Coherence Tomography, or OCT, is new type of imaging that can very precisely diagnose macular holes, even in their very early stages. Sometimes it is necessary to look for associated macular swelling with a photographic test called fluorescein angiography. During the test, photographs of the retina are taken and a yellow dye is injected into an arm vein. Photographs of the retina following dye injection may show pooling of dye in the macula in a distinctive pattern, confirming the presence of swelling associated with the hole.

What treatments are available for macular holes?
Macular holes resulting from vitreous traction can be closed with an operation called vitrectomy. In this procedure, the eye is anesthetized and the vitreous gel is then vacuumed out and replaced with fluid. If there is any thickened gel, it is peeled from the macula. The eye is then filled with a gas mixture. The surface of the gas bubble presses against the macula closing the hole. The surgery is usually done as an outpatient and is not painful afterwards. You will use eyedrops for a couple of weeks after the surgery.

In order for surgery to be effective, the bubble must press directly on the macula, which is at the very back of the eye. It is therefore critically important that the patient look straight down continuously for two weeks. This is by far the most important factor for success. Patients may utilize special chairs, beds, and other equipment to make this easier. Your doctor can discuss this further with you.

As an alternative, the eye can be filled with liquid silicone oil. This, like the gas bubble has a 90% success rate, but the silicone must be removed after about 3 months, so this does require an additional procedure.

This surgery, and especially the gas bubble, may result in more rapid cataract formation than normal. This is treatable with routine cataract surgery. In some cases, cataract surgery is combined with vitrectomy surgery for macular holes. Your doctor will more fully discuss these issues with you, and answer any questions you may have.

Surgery succeeds in closing the hole in 80-90% of cases. In 60-70% of cases, this results in vision improvement. If there is too much “wear and tear” from having had the hole, vision may not improve. Complications are very unusual but include bleeding, infection, and retinal detachment. Your doctor will discuss this with you and watch very closely for problems in the postoperative period. If you have any questions, please call us at 419-578-2020 or toll free at 1-888-322-7070