What is a Macular Hole?
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The macula is the central part of the retina, a thin membrane that lines the back wall of the eye. The macula is responsible for your distance, color, and reading vision. The very central part of the macula is called the fovea, which is the location responsible for detailed vision. This is the region that is affected by macular holes.
The eye is filled with a gel-like substance called vitreous, which helps maintain the shape of the eye. As people age, the vitreous shrinks and pulls away from the retina. This usually causes no problems. Some resilient fibers refuse to let go of the retina in isolated cases (about three per 1,000 people over 60). Essentially, a tug-of-war takes place, with the body of the vitreous shrinking while the “stubborn” fibers hold tight to the retina.
This tug-of-war can cause a hole in the macula. Once a hole is formed, the body’s defenses create scar tissue on the retina. The hole and the scar tissue cause blurriness and visual distortion. A macular hole should not be confused with macular degeneration or a retinal detachment.
A macular hole should also not be confused with a macular pseudohole. A macular pseudohole is not a true hole; rather it is a condition in which scar tissue called epiretinal membrane tugs or pulls on the underlying retina, which can look similar to a macular hole during a clinical eye examination. However, a detailed examination, as well as more advanced imaging, such as optical coherence tomography (OCT), demonstrates that there are, in fact, no holes and no missing retinal layers.
(Joy R. Efron, Ed.D.)
Causes of Macular Holes
Macular holes may be caused by injury or inflammatory swelling of the retina, but they most commonly occur as an age-related event without predisposing conditions.
What are the Symptoms of a Macular Hole?
Macular holes often begin gradually. According to the National Eye Institute, in the early stages of macular hole development, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult.
Treatment of a Macular Hole
Surgery is the treatment of choice for full-thickness (meaning a hole through all layers of the retina) macular holes. The surgery involves the removal of the vitreous gel sac through three microscopic incisions through the sclera. A small scar tissue or membrane layer may also be removed from the retina’s surface. A gas bubble is then placed in the eye.
The surgery takes less than an hour and is minimally uncomfortable. The patient is then asked to maintain a face-down position for three to seven days, depending on the retinal surgeon’s discretion. The gas bubble goes away in two to eight weeks, depending on the type of gas bubble used.
The most common side effect of macular hole surgery is the development of a cataract in patients who have not already undergone cataract surgery. Due to the surgery and gas bubble, there is a high chance of a cataract. Cataract surgery is typically performed after the gas bubble has dissipated to achieve the best possible vision.
What Takes Place During Surgery for a Macular Hole?
Surgery consists of a vitrectomy (removal of the vitreous), peeling of the retinal scar tissue, and inserting a gas bubble in place of the vitreous. Usually, those who have had macular hole surgery need cataract surgery within a year.
What Makes Macular Hole Recovery Challenging?
The pressure of the gas bubble causes the hole to close. Since gas rises and the macula is located at the back of the eye, the patient must be face-down following surgery for the gas bubble to be correctly positioned to exert the necessary pressure on the macula. There is controversy regarding the amount of time needed to lay face-down post-surgery. It is extremely important to follow your doctor’s recommendations for recovery.
What Outcomes Can You Anticipate?
According to the literature, most patients get some visual improvement following surgery, but outcomes vary greatly among patients. It can take a year before maximum visual improvement is achieved.
My Journey and Vision Recovery from Macular Hole Surgery
It has been over fourteen years since my vitrectomy surgery for a full-thickness macular hole in my left eye. It takes more than a year for maximum recovery. I am extremely fortunate.
For many years, my left eye’s visual acuity has been 20/25 without glasses and 20/20 with glasses. I wear my glasses only to drive at night or read small print in dim light. Any horizontal distortion is so minute that it is inconsequential. There is no image size disparity between my two eyes.
Dry Eye and a Macular Pseudohole
I have had dry eyes, a common condition, especially with age, and had to use eye drops for the dryness. However, surgery and the drops used during the recovery period after surgery can reveal other eye problems or worsen existing dry eye syndrome. My doctor also put me on glaucoma eye drops because of a reaction I had to the dry eye drops following my macular hole surgery.
My Journey and Recovery with Macular Hole
I was one of the people who had a problem in the second eye. In 2012, three years after the vitrectomy on my left eye, I had similar surgery on my right eye for a macular pseudo hole. Please monitor your second eye carefully and see your ophthalmologist promptly if you notice any change in your vision.
Joy Efron Ed.D
I inquired about preventive surgery for a pseudohole due to my concern that it might become a macular hole. I was informed that most retinal surgeons are not willing to perform a vitrectomy for a pseudohole when visual acuity is good, and there is minimal visual distortion due to concerns about surgical risks and complications. These risks can include retinal detachment, cataracts, and macular edema (swelling or the accumulation of fluids in the macula). Consequently, my surgery was delayed, and my vision had deteriorated by that time.
I now measure 20/30 in my right eye (without glasses), but this is not a functional vision measurement. There is some central vision blurriness with tiny blind spots in that eye. As a result, my brain has to fill in missing elements from letters or words. Using context clues does not present a problem with familiar material. It is a problem with unfamiliar information, such as a series of random numbers, as in a telephone number.
While the acuity measures well for distance vision in my right eye, it would be difficult to read using that eye alone. It is difficult to determine details with the right (pseudohole) eye. For example, near my home, there is a street called Hillhurst. Looking at the word, “Hillhurst,” you will see six consecutive vertical lines. There is no way I can count those lines with my right (pseudohole) eye. Fortunately, my left eye is dominant, and the brain selects that image.
A vitrectomy frequently results in cataract worsening. During the interval after my surgeries, vision deteriorated in each eye as cataracts progressed. However, my vision recovery following cataract surgery was remarkable.
[Medical editor’s note: Although often referred to as “cataract development,” people with no cataract do not develop one after uncomplicated vitrectomy surgery. However, suppose there is the slightest pre-existing cataract, even one that does not affect vision or was not discussed with the patient as a prior diagnosis. In that case, it will definitely worsen from vitrectomy surgery.]
A Disclaimer
I was an educator of blind and low-vision children for 42 years. Although I have read and researched a great deal and have had extensive discussions with retinal specialists, I am not an ophthalmologist or a medical doctor.
This series of macular hole articles was reviewed by Dr. Antonio Capone 2023.