A macular hole effects the vision in the center of the retina, known as the macula. The retina is the neurosensory tissue of the eye that transmits the optical images we see into the electrical images our brain understands.
The fovea is the center of the macula and is the most central part of our vision, where the majority of photoreceptor cells are located. The macula is responsible for tasks such as reading, watching TV, and driving. Macular holes are most prevalent in people over the age of 60. Macular holes are a degenerative process and are often spontaneous in nature.
Macular hole symptoms may include blurriness, distortion, or a grey/dark spot in a patient’s central vision, depending on the severity of the macular hole. Straight lines may also appear bent or distorted.
What causes a macular hole?
About 80% of the eye is filled with vitreous humor. The vitreous humor is made up of mostly water, yet it has a firm, jelly-like consistency. The vitreous helps to hold the spherical shape of the eye and keep the retina in place. As we age, the vitreous starts to liquify and partially detach from the retina causing the vitreous to partially or completely detach from the retina. The proteins and collagens in the vitreous also start to thin over time. This is normal and rarely effects vision other than causing small shadows or floaters. This process is most often documented as a partial or complete posterior vitreous detachment.
Sometimes, the vitreous detachment can cause microscopic changes in the integrity of the retina. When the vitreous separates, it may cause wrinkling of the retina known as an epiretinal membrane or macular pucker, or a macular hole. A macular hole rarely leads to a retinal detachment, although it may lead to central vision loss, depending the stage of the macular hole.
Macular Hole (Video)
What are the stages of a macular hole?
1. Stage one macular hole – small foveal detachments with a partial-thickness defect. In stage one, about half of macular holes may progress, without treatment.
2. Stage two macular hole – small full thickness hole/s. In stage two, about 70% of macular holes will progress without treatment.
3. Stage three macular hole – larger full-thickness hole/s without separation from the vitreous, although adhesions or partial attachments to the vitreous are present.
4. Stage four macular hole – larger full-thickness hole/s with separation from the vitreous.
What can I expect during a visit to evaluate a macular hole?
After a comprehensive, dilated eye examination is performed by your ophthalmologist, a series of diagnostic tests may be ordered to better evaluate the health of your retina. The tests include, but are not limited to:
- Fundus Photography
- Optical Coherence Tomography (OCT)
- Optical Coherence Tomography Angiography (OCT-A)
- Intravenous Fluorescein Angiography (IVFA)
Along with a comprehensive eye examination and visual acuity testing, diagnostic imaging directly corelates in the assistance of each patient’s individual plan of care. Utilization of all forms of examination will help your physician to better evaluate your specific retinal needs, in addition to aid in the evaluation of the stage of a macular hole. Your physician may advise to either monitor your eye or suggest surgical intervention in order to best preserve your vision.
What is the treatment for a macular hole?
Some macular holes may seal on their own as the body has the ability to heal itself after the vitreous detaches. In other cases, the macular hole may be in a later stage and surgery may be necessary to restore central vision. Your physician will discuss your needs and may recommend a vitrectomy.
A vitrectomy is a micro-incisional outpatient surgical procedure performed under anesthesia. The surgery involves the removal of the vitreous humor so it no longer pulls on the retina. The removal of the vitreous is necessary to allow the physician to access the retina as well as to halt the vitreous from pulling on the macula, the cause of the macular hole. After the vitreous is removed and the surgery is performed, a mixture of air and gas than replaces the vitreous humor to ensure the macular hole closes and sustains integrity of central vision.
Following a vitrectomy surgery, the patient will temporarily need to maintain a face-down position to secure the gas bubble over their macula to ensure the macula stays in place, much like sealing wallpaper on a wall. Your physician will discuss your personal needs and requirements, and answer any questions. Post- operative devices may be referred to aid in temporary face-down positioning post-surgery. Although these needs are temporary, they are important to increase the chance of a successful surgical outcome, thus restoring vision to its optimum potential. The majority of patients will experience improved central vision following the procedure, although improvement may return gradually.
An Optical Coherence Tomography Scan, or OCT image of a successful retina post-operative repair for a macular hole.