Macular Hole

A macular hole describes a central defect in the retina. The macula is the central region of the retina, and is responsible for critical vision including reading, driving, and watching television. A hole develops as the vitreous gel ages. This gel which fills the eye has the consistency of jello. The vitreous gel goes through changes with age which frequently results in floaters. Abnormal adherence of the vitreous to the macular region may result in traction or pulling resulting in a macular hole. There are 4 stages of a macular hole, all of which can result in some degree of symptoms. The most common symptom includes distortion and reduced vision for both near and distance. A macular hole is diagnosed by the ophthalmologist after dilated retinal examination. Optical Coherence Tomography (OCT) helps evaluate macular holes.

Refinements in the surgical treatment of macular hole has steadily improved outcome.  The procedure involves the removal of the vitreous gel (vitrectomy), placement of a temporary gas bubble in the eye and often removal of a membrane surrounding the hole. Surgery is typically performed in an ambulatory setting under local anesthesia, although general anesthesia can be utilized. The gas bubble is put in the eye so the hole can close under “dry” environment, the fluid in the eye can keep the hole open.  In order to keep fluid away from the hole while it closes it is necessary for the patient to remain in a prone (facedown) position anywhere from several days to 2 weeks. It may take up to 6 weeks for the air bubble to completely resolve from the eye.

Questions on Macular Holes:

What is the visual prognosis of macular holes with and without surgery?

Patients with macular holes as mentioned may have varying degrees of visual loss. It is possible that the condition if not operated on may still remain stable with no further loss in vision. However, there also may be deterioration over time. This is impossible to predict. Visual results after surgery depend on a number of factors including the presence of a cataract, the longevity of the hole, and any other associated macular conditions such as macular degeneration. Typically, it has been shown that if a hole is present for less than 6 months, at least a 3 line improvement in vision will occur with hole closure. It can take anywhere from 2 to 3 months to regain vision after surgery. The vision is often diminished from cataract progression, maximal vision improvement may require cataract surgery. Approximately 5-10% of macular holes are not closed successfully with surgery, sometimes repeat surgery may lead to closure.

What are complications associated with macular hole surgery?

Cataract progression in patients without previous cataract surgery is very common following macular hole surgery. Other complications include the development of a retinal tear and detachment which is diagnosed in the operating room and treated accordingly.  With any surgery there are risks and side effects that should be discussed prior to planning the procedure.

What are the physical restrictions relating to the presence of an air bubble utilized during macular hole surgery?

To insure surgical success, one must remain face down as much and for as long as your retinal surgeon recommends. One is allowed to assume normal position for transient periods of time to facilitate functions of daily living. Most important, the patient is unable to fly when air bubble is in the eye. It is also important to mention to the other doctors that if additional surgery is needed for any other reason, then nitrous oxide should not be utilized during any anesthesia.

Are there associated conditions with a macular hole?

This condition, which can affect one or two eyes, is not directly associated with other ocular or systemic conditions. Macular degeneration, which is a separate, distinct entity, can occur in patients with macular holes. That condition will limit the visual gain even after successful macular hole closure. A macular hole is not a condition associated with any hereditary patterns. It is also felt not to be related to nutrition or sun exposure.

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