What is a macular
hole?
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Macular
Hole |
A macular hole is a defect (hole) in the center of the
macula area of your retina. The retina is a clear film
of very delicate tissue that lines the inside of the
back of the eye. The retina is nerve tissue that senses
light that shines into the eye and sends signals through
the optic nerve to the brain, which then processes the
signals resulting in sight. The macula is the center
area of the retina that gives us sharp central vision
and reading vision. The very center portion of the
macula, the fovea, is the thinnest and most delicate
portion of the entire retina. It is in this very thin,
delicate fovea area that a macular hole can develop.
What causes a macular hole?
In most cases a macular hole
develops as a result of anatomical changes that occur
spontaneously in the back of the eye between the clear
vitreous gel that is normally present, and the macula.
These changes are not due to anything the afflicted
individual has done, but are natural changes that become
pathological in a small percentage of people. These
pathological changes result in mechanical stresses in
the macula that may cause a hole to begin to form in
this most delicate area of the retina. This type of
macular hole occurs most commonly in individuals over 50
years of age and is commonly called an idiopathic
macular hole.
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OCT
Normal |
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OCT
Macular Hole |
Occasionally, severe
blunt trauma inflicted directly on the eye can cause a
macular hole to develop. A macular hole can also be seen
in a very small percentage of people with retinal
detachment, or in conditions that cause severe edema
(swelling) of the retina. These other types of macular
holes are very uncommon, occur mostly in people under
age 50, and can be easily distinguished from the much
more common idiopathic type of macular hole.
How does a macular
hole affect vision?
A macular hole affects only the very center portion of
vision. It causes loss of sharp
"straight-ahead" vision and of reading vision
in the affected eye. In the early stages of macular hole
formation, the hole is very small, and the center vision
may be only slightly blurred or distorted. As the hole
enlarges over several weeks to several months the vision
becomes progressively more disturbed. The hole typically
enlarges to a point at which the affected eye can only
see the larger letters of a visual acuity chart.
A macular hole does not
make an eye go completely blind. It affects only the
very center of vision and does not cause a loss of the
peripheral (side) vision.
Is a macular hole the
same as macular degeneration?
No! A macular hole and macular degeneration are
completely different conditions affecting the retina.
For information about macular degeneration please see
that specific section on the VRS website.
Is there treatment for
a macular hole?
Yes. A macular hole can be treated and repaired with
surgery. With current surgical techniques a macular hole
can be repaired with a success rate of greater than 95%.
There is no non-surgical treatment for a macular hole.
What is macular hole
surgery like?
The surgery for a macular hole is called a vitrectomy.
This surgery is usually done as a day (outpatient)
surgery using a local anesthesia. The surgery consists
of making very small incisions on the white part of the
eye (the sclera) 3 mm behind the edge of the cornea.
While looking into the eye through a microscope the
surgeon can use a variety of very specialized
instruments placed through these incisions to work
within the eye. The vitreous gel is first removed and
replaced with a specially designed saline solution. The
surgeon then typically peels a very thin membrane (the
"internal limiting membrane of the retina")
from the surface of the macula surrounding the macular
hole. It is felt that peeling this membrane is important
to cause the macular hole to seal. Finally, a gas bubble
that completely fills the vitreous cavity is used to
replace the saline solution just prior to closing the
surgical incisions with very fine absorbable sutures.
The gas bubble will gradually go away after surgery and
is replaced by fluid that is produced normally inside
the eye.
What is the postoperative care like after
macular hole surgery?
A patch is worn over the eye until
the morning after surgery. Eye drops or ointment that
facilitates healing is then used several times each day
for 2-3 weeks after surgery. The most important part of
macular hole surgery, and the most difficult, is the
requirement for post-operative face-down positioning.
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Gas
Bubble - Face Down |
In order for the macular
hole to seal closed the gas bubble placed in the eye at
the time of surgery must press against the macular hole
after surgery. Since the macular hole is located
directly at the back of the eye, the most effective way
to keep the bubble against the hole is for the patient
to keep their nose pointed directly downward toward the
floor. It requires advanced planning, help from friends
and/or family, and individual will-power to maintain
face-down positioning. A variety of positioning aides,
such as massage chairs and head-rests, are available to
make this requirement more tolerable.
The duration and
intensity of face-down positioning required may vary
depending on the characteristics of the patients'
macular hole, and the experience and judgment of the
surgeon. Some patients may require very little face down
positioning, while others may need to stay face down for
7-10 days after surgery.
How much will my
vision improve after surgery?
The amount of visual improvement will vary depending on
whether the macular hole closes, the age and anatomic
characteristics of the macular hole, and the presence of
any other ocular abnormalities that might limit vision.
It is not unusual to recover vision of 20/20 or 20/25
after successful macular hole surgery. However, some
individuals may have more limited improvement in vision,
and a small percentage of people may not improve very
much at all even with successful surgery. It takes
anywhere from 3 months to 1 year for vision in the
affected eye to reach it's maximal improvement.
What complications may
occur as a result of macular hole surgery?
Any surgical procedure carries a risk of complications
and macular hole surgery is no exception. There are 3
major potential complications of macular hole surgery:
Post-operative infection (endophthalmitis): this is an
infection that develops inside the eye after ocular
surgery. Though most infections can be effectively
treated if identified at an early stage, there is a risk
that an infection can create severe damage that could
lead to blindness in the affected eye. Fortunately,
endophthalmitis is rare, occurring in only 1 of 1000
cases. Retinal detachment: retinal detachment can occur
spontaneously in an eye that has never had surgery of
any type. However, an eye that has undergone surgery is
at greater risk of developing retinal detachment. A
retinal detachment may occur relatively soon after
surgery, but may occasionally develop months or years
later, and can lead to blindness if not repaired.
Fortunately nearly all retinal detachments can be
repaired with additional surgery. The incidence of
retinal detachment after macular hole surgery is between
1 and 2 out of 100 cases. Cataract: Cataracts, or
haziness in the lens of the eye, commonly develop as a
natural consequence of aging of the eye. However, a
cataract will develop or progress to a point of
significant visual blurring sufficient to warrant
cataract surgery in most eyes within 1 year of
vitrectomy surgery. This is not a concern if the patient
has had cataract surgery prior to having a vitrectomy
surgery.
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