Macular Hole

The macula is the very small area in the back of the retina that is responsible for providing sharpness and clarity in our vision.  This detailed vision is necessary for daily tasks such as reading, driving, and watching television.

A jelly-like substance called the vitreous fills the central portion of the eye.  For the majority of our life this substance is fairly solid and homogeneous, similar to Jell-O.  As we age, however, it begins to shrink and condenses toward the front portion of the eye with clear fluid filling the space freed up by the vitreous.  As this occurs, the vitreous gradually separates from the surface of the retina.  For most people, this happens with hardly any side effects other than an occasional floater.  In some patients, the vitreous is firmly attached at the center of the macula, and as it is pulling away, it may initially cause blurriness and distortion.  Later, a central dark spot may appear if the traction from the vitreous creates a full-thickness defect in the macula – the macular hole.  Sometimes, a retinal detachment may occur as a result of that, particularly in patients who are very near-sighted. 

Symptoms

The most common symptoms for a macular hole include:

  • Decreased central vision in both near and far reading activities
  • Distortion in central vision

Diagnostic Testing

An ophthalmologist will perform a dilated retinal examination and examine the back of the eye.  We may also use a fluorescein angiogram to monitor the retinal blood circulation to ensure there are no other conditions present.  Optical coherence tomography (OCT) testing is the most common test performed as it shows whether or not there is a hole in the macula and to which extent the vitreous is deforming the central retina.

Treatment

Minimally invasive, microincisional vitrectomy surgery allows the retinal surgeon to remove the vitreous gel through tiny incisions in the white part of the eye and thus relieve the traction on the retina.  For the macular hole to close, a gas bubble needs to be instilled into the eye at the time of surgery to press the edges of the retinal hole against the eye wall and allow the macula to heal, similar to a cast bracing a bony fracture.  This gas bubble gets replaced with clear fluid by the eye a period of 3-6 weeks.

This same-day surgery is normally performed under local anesthesia with a postoperative exam needed within 24 hours after surgery.  Regular follow up exams will also be necessary for the first three weeks after surgery to monitor the success of treatment.  Eye drops will also be used to help promote successful healing.

In order to achieve optimum results, the patient must remain in a face down position for at least 2 days after surgery.  Depending on various factors, it may sometimes be for a week or longer.  This allows the gas bubble to apply upward pressure against the retinal surface and ensure successful closure of the macular hole.  Remaining face down for the prescribed amount of time is essential for the success of this treatment and to avoid untoward effects, such as cataract formation.  It is important to follow your doctor's instructions concerning limitations of certain activities during this time, such as avoiding high altitudes and flying as long as the gas bubble is in the eye.  This elevated pressure could be very dangerous.

There are several devices available to assist make face down positioning easier.  These devices are designed to allow for patient comfort during sleeping, eating, and reading.  We can arrange for the rental of such equipment, which gets delivered to your home.

Once the bubble is completely reabsorbed into the body, you can be measured for glasses.  Recovery may take up to three months after surgery, and some eyes continue to improve of a period of six months to a year.

As with all surgical procedures, there are certain risks and possible side effects.  These risks include possible retinal tears or detachment during the surgery or in the postoperative period.  These complications, however, are usually repairable.

In addition, patients will likely develop cataracts within six months to two years after surgery, unless they have already undergone cataract surgery.  When this occurs, ambulatory surgery is required to remove the cataracts and the placement of intraocular lenses is necessary.