Macular Hole

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Macular Hole

A macular hole is a general term for a break or defect in the macula, which is the part of the central retina responsible for our most detailed vision. There are different types of macular holes including partial thickness and full thickness macular holes as well as lamellar holes and pseudoholes.

Risk Factors, Causes & Symptoms

Causes

The vitreous is the gel that fills the back portion of the eye. At a young age that gel is attached to the macula. With aging, the gel eventually undergoes a process when it separates from the macula without disruption to the architecture of the retina. In some patients the gel is particularly sticky and as the gel separates, it pulls on the macula to a degree that creates a hole in the center of the retina. This is the most common cause of partial thickness and full thickness macular holes.

A less common cause of macular holes is trauma. Some patients can develop macular holes associated with retinal detachments as well. Lamellar macular holes and pseudoholes occur due to pulling/tension from epiretinal membranes (see Epiretinal Membrane).

Symptoms

The symptoms of a macular hole include central visual blurring or distortion. If a patient with a macular hole looks at a straight line, they may notice the line is distorted or that part of the line is missing. Some patients with partial thickness and full thickness macular holes will also describe similar symptoms of central blurring in their vision.

Risk Factors

Macular holes typically form after age 60 and are more commonly found in men compared to women. Other risk factors for macular hole development includes a history of retinal tears and/or detachments, macular pucker, diabetic eye disease (diabetic retinopathy), eye trauma, or inflammation.

Treatment

Macular hole repair is one of the most predictably successful surgical procedures for our retina surgeons, with a single operation success rate in excess of 90%. Surgical treatment with pars plana vitrectomy, internal limiting membrane (ILM) peeling, and gas injection is the “gold standard” for macular hole treatment. Historically, patients needed to assume a “face-down” position after surgery for many days but those requirements have been reduced or eliminated with modern techniques used by the retina surgeons at Colorado Retina.

In cases where the macular hole is very small and does not have a large impact on your vision, your Colorado Retina physician may not recommend any treatment at all. In some cases, small holes will self-resolve without surgical intervention and eyes with other macular diseases may not experience any additional impact on their function from a macular hole. Regardless of the size of a macular hole, it is important to undergo regular follow-up eye examinations to determine the best treatment plan moving forward.

Diagnostic Testing

Optical coherence tomography (OCT) is the current gold standard in the diagnosis and staging of macular holes. This quick, non-invasive imaging technique allows for evaluation of the macula in high resolution using reflected light, and helps your doctor differentiate a hole from other eye conditions with similar symptoms.

Treatment

Macular hole repair is one of the most predictably successful surgical procedures for our retina surgeons, with a single operation success rate in excess of 90%. Surgical treatment with pars plana vitrectomy, internal limiting membrane (ILM) peeling, and gas injection is the “gold standard” for macular hole treatment. Historically, patients needed to assume a “face-down” position after surgery for many days but those requirements have been reduced or eliminated with modern techniques used by the retina surgeons at Colorado Retina.

Pars plana vitrectomy is the most common treatment for macular holes. In this surgical procedure, the vitreous gel is removed to stop it from pulling on the retina, and most commonly a gas bubble is placed in the eye to gently hold the edges of the macular hole closed until it heals. The patient may be asked to maintain a face-down position for several days depending on the characteristics of the macular hole. This will allow the bubble to gradually dissolve and be replaced by natural eye fluids. Vitrectomy has a success rate of over 90%, with patients regaining some or most of their lost vision.

If you have a larger and chronic macular hole, highly myopic eyes with posterior pole staphyloma or a traumatic macular hole, your surgeon may recommend internal limiting membrane (ILM) peeling to increase the chance of success to regain vision. ILM peeling may reduce the duration of face-down positioning required for macular hole closure. With ILM peeling, five or fewer days of face-down positioning may be adequate to effect hole closure. Peeling the ILM eliminates all tangential traction around the edges of the hole, the process believed to contribute to macular hole formation. It also ensures removal of any hyaloid remnants or epiretinal membranes that could otherwise be missed.

Pneumatic vitreolysis is when a gas bubble is injected into the eye in clinic then when the patient bends forward over and over the bubble rolls across the back of the eye attempting to break the connection between the gel and the retina, sometimes allowing the hole to close once that connection is broken. Pars plana vitrectomy is the most successful way of closing the hole but requires going to the operating room for surgery. Surgically the gel is removed from the eye, a layer called the internal limiting membrane of the retina is removed, and then the eye is filled with a gas bubble. That gas bubble helps push the hole closed. Gas bubbles dissolve away on their own over a period of 3 to 8 weeks. Sometimes your surgeon will ask you to maintain a face-down position to maximize the changes of surgical success.

In cases where the macular hole is very small and does not have a large impact on your vision, your Colorado Retina physician may not recommend any treatment at all. We may simply observe and track the macular hole’s progression or natural healing. In this case, it would be important to have regular follow-up eye examinations as determined by the doctor to catch and treat any problems early.

Diagnostic Testing

According to the American Society of Retina Specialists (reference) Optical coherence tomography (OCT) is the current gold standard in the diagnosis and staging of macular holes. This quick, non-invasive imaging technique allows for evaluation of the macula in high resolution using reflected light, and helps your doctor differentiate a hole from other eye conditions with similar symptoms. No laboratory tests are needed in cases of idiopathic macular holes (those without a known cause).