Macular Hole

Overview

The most common type of macular hole is the one that results from an aging eye (idiopathic macular hole). As the vitreous (the clear, gel-like substance that fills the interior of the eyeball) condenses and pulls forward with age, the retina (the thin light-sensitive membrane at the back of the eye) is pulled at locations where it makes strong attachments with the vitreous (namely at the area of the macula and optic nerve head). In some situations, this tugging proves to be too great for the retina and a small area of retinal cells at the macula pull free from the back of the eye, producing a macular hole.

The photoreceptors that make up the area of the macula are responsible for central vision. When a macular hole occurs, these photoreceptors are no longer able to send visual signals to the brain and as a result, central vision in the affected eye is significantly reduced and a blind spot results.

Besides idiopathic macular holes, chronic macular edema, solar retinopathy, and blunt ocular trauma can all cause a macular hole as well.

Figure 1: Macular Hole. Courtesy of EyeAtlas.com.

Signs & Symptoms of Macular Hole

Significant reduction in central vision is usually the presenting symptom of people who have a macular hole. Distorted vision may also occur, particularly in cases where a macular hole is imminent but has not occurred yet.

Detection & Diagnosis of Macular Hole

A macular hole is detected when an eyecare professional views the inside of the eye using either a slit lamp or an ophthalmoscope (see Figure). The appearance of the macular hole will vary: there are four different stages of macular hole and each has a characteristic appearance, depending on the degree to which the area around the hole has healed.

Macular Hole Treatment

Depending on the severity of vision loss and the duration since the macular hole first occurred, macular hole treatment varies. The standard treatment for macular holes that are Stage 3 or below and have a duration less than 1 year is a vitrectomy with introduction of a gas bubble to close up the macular hole and restore function to the photoreceptors.

Figure 2: Left: a face-down position allows the gas bubble to press against the macular region of the retina. Right: an upright position has an ineffective gas bubble that presses on the superior retina.

Following surgery, the patient must lie face-down for up to 2 days. This is critical to the success of the procedure as it places the gas bubble directly beside the macular area so that the bubble can press against the retina and allow it to adhere better to the retinal pigment epithelium below (see Figure). Macular hole surgery successfully improves vision in 80% of eyes, but it does have some risks, which are associated with all vitrectomy surgeries: acceleration of cataract formation as well as retinal detachment.

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