Macular Holes‍

Macular holes are a common cause of visual loss after 60, more commonly in women. The Macula is located in the central part of the Retina and is responsible for reading, near and central vision.

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The most common symptom of macular hole is a gradual decline in the central vision of the affected eye.

This can occur as:

• Blurring

• Distortion (straight lines appearing wavy) 

• A dark spot in the central vision

Causes and Risk Factors

The majority of cases develop spontaneously without an obvious cause. If a macular hole develops in one eye there is a 5% to 15% risk of one developing in the other eye.

The main cause of Macular hole development is usually vitreous traction: the vitreous is the “gel” that fills up the inside of the eye. With normal aging, the vitreous can shrink and pull away from the retina, sometimes creating a macular hole in the process.

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While Macular Hole formation is usually “Idiopathic” (no known cause), several conditions can increase the risk of macular hole formation, including:

• Injury or trauma: some young people develop macular holes after blunt trauma

• Diabetic eye disease

• High degree of myopia (nearsightedness)

• Macular pucker: formation of a scar tissue layer over the macula that can warp and contract, causing wrinkling of the retina

• Retinal detachment

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Genetics, environmental factors, and systemic causes don’t seem play a role in macular hole formation.

Diagnostic Testing

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Optical coherence tomography (OCT) is the current gold standard in the diagnosis, staging, and management of macular holes. This quick, non-invasive imaging technique allows for evaluation of the macula in high resolution using reflected light, and helps your doctor differentiate a hole from other eye conditions with similar symptoms. No laboratory tests are needed in cases of idiopathic macular holes (those without a known cause).

OCT is also commonly used after surgery to confirm closure of the Macular Hole.

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Treatment and Prognosis

Pars Plana Vitrectomy is the most common treatment for macular holes. This is performed under local anesthesia with sedation and is outpatient. This is a microscopic, minimally-invasive procedure usually performed with a 23 or 25 Gauge Micro-cannula system. In this surgical procedure, the vitreous gel is removed to stop it from pulling on the retina, a small membrane ( the ILM membrane) is peeled to assist in the relaxation of the Macular Hole margins, and a gas bubble is placed in the eye to gently hold the edges of the macular hole closed until it heals.

The patient may be asked to maintain a face-down position for several days, and in some cases up to 2 weeks, depending on the characteristics of the macular hole. This position is of key importance in sealing the Hole.
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Pars Plana Vitrectomy has a success rate of over 90%, with patients regaining some or most of their lost vision. Potential complications of the procedure include cataract formation, retinal detachment, infection, glaucoma, bleeding, and re-opening or persistence of the macular hole (less than 10% of cases). Cataract formation is quite common after surgery and surgery for this is usually required several months later.

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In cases where the macular hole is very small and does not have a large impact on your vision, your doctor may not recommend any treatment at all. He or she may simply observe and track the macular hole’s progression or natural healing. In this case, it would be important to have regular follow-up eye examinations as determined by your eye doctor to catch and treat any problems early.