Macular Hole

What is a macular hole?

A macular hole is a small hole in the middle of the most sensitive part of the retina – known as the macula. The retina is the light sensitive layer lining the back of the eye. The condition usually arises spontaneously but may be associated with trauma in some patients. The current expert opinion as to the cause of macular hole is that there is a shrinkage in the vitreous gel which acts to stretch the retina. The retina may give way at its thinnest point (the fovea – the middle of the macula) and a small hole forms. There will be a tiny pocket of fluid under the edges of the hole which cause distortion of the vision (see Photograph and OCT scan).

Macular holes often arise in patients between 55-75 years of age and will gradually progress to a point where eye sight remains poor.

What are the symptoms?

Initial blurring of vision together with marked distortion of straight lines are the most common symptoms. When the hole is quite large central objects may disappear from the vision and reading is quite badly affected.

Floaters and flashing lights are not common symptoms in macular hole.

In some patients the other eye may be affected – the overall risk of the condition occurring again in the other eye is about 1 in 5 patients over a 5 year period.

What can be done?

You will require a consultation with an eye surgeon who specialises in problems at the back of the eye - a vitreo-retinal surgeon - who is experienced in treating macular holes. It is important not to delay your appointment as it is clear that patients benefit from treatment if they present early to their specialist.

The surgery

Depending on the examination findings your consultant is likely to offer you surgery (Vitrectomy). This involves removal of the vitreous gel at the back of the eye, together with any membranes on the retina. A bubble of special gas (SF6) is placed inside the eye at the end of surgery and you may be asked to lie in a face down position for the first few days after the operation. If you have a cataract your surgeon may remove this at the same time.

What happens after surgery?

You are likely to have poor vision in the eye for up to four weeks after surgery and it can be as long as eight weeks before the gas bubble disappears. During this time you are not likely to feel safe to drive even if your vision is normal in you other eye.

The macular hole usually closes in the first week after the operation and many patients report an improvement in vision after the first 1-2 weeks. The gas bubble makes you extremely short sighted but you might be able to make out a watch face at a distance of 3-4 inches which is an encouraging sign.

Well over 90% of macular holes can be closed by surgery. Occasionally the hole does not close, or in a few cases it can re-open after a few years. Further surgery may be advised for this and there is still a good chance of success.

What will my vision be like?

Patients who have had macular hole surgery are usually very pleased with their eye sight. The major benefit is the improvement in distortion which will allow them to read and drive without the annoyance of poor vision. Many patients will recover eye sight which meets the DVLA standard for driving. On very close analysis most patients will still find a tiny ‘dot’ of missing vision after surgery or a tiny area of distortion and this probably represents the site of healing of the macular hole. This rarely causes significant problems and is often not noticed in daily life.

What are the risks?

There is a small chance that surgery may not close the macular hole. In addition the surgery and the gas bubble make it very likely that a cataract will form after surgery (if not previously removed) within two years of the operation and further treatment may be needed for this.

Occasionally during surgery a retinal tear will form. This is usually treated at the time and there should be no consequences from it. Very rarely this might occur after surgery and there is then a risk of retinal detachment requiring further urgent surgery.

Other risks of Vitrectomy are extremely rare (see Vitrectomy).