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. As it ages, it breaks up. This may result in symptoms of floaters. As the vitreous gel separates from the retinal surface, an abnormal adherence in the macular region may result in traction or pulling resulting in a hole in the central retina. There are 4 stages of a macular hole, all of which can result in some degree of symptoms. The most common symptom includes distortion as well as reduced vision for both near and distance. A macular hole is diagnosed by the ophthalmologist after dilated retinal examination.

Only within the past 10 - 12 years has surgery been considered as an option for patients who have macular holes. Prior to this, holes were not treated. The visual loss associated with a macular hole may vary from minimal to significant.

The surgical procedure for the repair of a macular hole includes that of a vitrectomy. Surgery is typically performed in an ambulatory setting under local anesthesia, although general anesthesia can be utilized. A light source is placed in the eye to visualize ocular structures, and an instrument is used to remove the vitreous. The residual membrane or vitreous on the retinal surface is identified and removed, reducing any traction on the macular hole. All patients do receive an air bubble to help put pressure on the hole. This helps facilitate closure of the hole which may take a few weeks after surgery. For the air bubble to take effect, it is necessary for the patient to remain in a prone (facedown) position anywhere from 1-3 weeks. It may take up to 8 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. Again, one must wait for the air to resolve and for patient to be given glasses. If a cataract is present pre-operatively, often we recommend concurrent cataract removal to eliminate the need for an additional surgery.

What are complications associated with macular hole surgery?

Retinal tear and detachment may occur in up to 5% of cases. This is usually treated in the operating room at the time of surgery. Also failure of the hole to close occurs about 10% of the time.

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 for up to 1-3 weeks as much as possible. 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 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.