Macular holes

What is a macular hole?

A macular hole is a small gap that opens in the macula, the part at the very centre of your retina responsible for sharp, detailed vision such as reading and recognising faces. It causes blurred or distorted central vision, but it will not make you completely blind, since your side vision stays normal.

Symptoms of a macular hole

Macular holes often start gradually, and how much you notice depends on the size of the hole. You might have:

• blurred or hazy vision in the centre of your sight
• distorted vision, where straight lines or letters look wavy or bent
• difficulty reading small print, or finding that letters seem to be missing
• a dark, black or ‘missing’ patch in the centre of your vision as the hole gets bigger.

A macular hole usually only affects one eye. Even so, because your brain combines the images from both eyes, people often notice that the good eye's vision is thrown off by the affected one, and some find it easier to cover or close the affected eye until it's treated.

Causes and risk factors

Doctors don't know exactly why macular holes develop, but most are linked to the natural ageing process. The vitreous, a jelly-like substance that fills your eye, gradually shrinks and pulls away from the retina as you get older. Sometimes it stays stuck to the macula as it pulls, and this traction can tear a hole.

Macular holes are most common in people aged 60 to 80, and are more common in women than men. You might also be more likely to develop one if you are long-sighted or very short-sighted, or if you have had eye inflammation, a retinal detachment, an eye injury, previous eye surgery, or persistent swelling of the central retina.

Types of macular holes

There are two main types. A primary macular hole develops on its own, with no other underlying cause. A secondary macular hole develops because of another eye condition or an injury, such as trauma to the eye or long-term swelling of the retina.

Your ophthalmologist may also describe the hole using a staging system, from an early, smaller hole through to a larger, more established one. This helps guide whether watching and waiting or surgery is the right approach, and how good the outlook is likely to be.

How is a macular hole diagnosed?

Your ophthalmologist will use eye drops to widen (dilate) your pupils, then examine the back of your eye. The main test used to confirm a macular hole is called optical coherence tomography (OCT), a scan that produces a detailed cross-sectional picture of your retina and can tell a macular hole apart from other conditions that look similar.

You might also have a fluorescein angiography or fundus photography, which use dye and photographs to look more closely at your retina. Your doctor might also shine a thin beam of light into your eye and ask you to describe what you see, which helps confirm whether the hole goes all the way through the retina.

How is a macular hole treated?

Non-surgical options

If your macular hole is small and your symptoms are mild, your ophthalmologist may suggest watching and waiting rather than treating it straight away, since some early-stage holes close by themselves without any treatment.

Eye drops, glasses and laser treatment cannot close a macular hole. In some cases, a very small hole may be treated with an injection of medicine into the eye instead of surgery, though this option isn't suitable for everyone and works less reliably than surgery.

Surgical treatment

The main treatment is an operation called a vitrectomy, a form of keyhole surgery performed under a microscope:

1. Your surgeon makes three tiny incisions in the white of your eye.
2. They’ll remove the vitreous jelly, and carefully peel away a delicate layer around the hole to release the traction holding it open.
3. Your eye is then filled with a temporary gas bubble, which presses gently on the hole to help it seal as it heals.

The operation usually takes 45 to 90 minutes and is most often done under local anaesthetic, so you're awake but won't feel pain, sometimes alongside a sedative to help you relax. Some people have a general anaesthetic instead, and the procedure is often done as a day case.

Surgery closes the hole in around 90% of cases when it's caught within a year of symptoms starting, and more than 70% of these people go on to read two or three lines further down an eye chart than before.

Even when the hole does not fully close, your vision usually at least stabilises and often becomes less distorted. If the first operation is not successful, a second attempt can still work.

Recovery from surgery

Afterwards, you may need to keep your head in a face-down position for part of each day, so the gas bubble stays in contact with the hole while it heals – this is usually recommended for 2 to 5 days for larger holes, though it may not be needed for smaller ones. If face-down posturing is not advised for you, you will likely just be asked to avoid lying on your back for about two weeks instead.

While the gas bubble is present, your vision in that eye will be poor, a bit like being underwater, and this can affect your balance and judgement of distances.

You won’t be able to fly or travel to high altitude until the bubble has gone, as the change in pressure can cause severe pain and permanent vision loss. It should be safe to do these things from around 6 to 12 weeks afterwards, but check with your surgeon for a more accurate estimate for you.

Most people also need about two weeks off work, though this depends on the type of work you do.

You'll usually be prescribed eye drops, including an antibiotic and a steroid, which are gradually reduced over the following weeks. You'll typically be seen again the day after surgery, again after about 2 weeks, and once more around 3 months later, by which point your glasses prescription may also need updating.

As with any operation, there are risks to be aware of. You'll almost certainly develop a cataract within about a year if you haven't already had one removed, and this is sometimes treated at the same time as your macular hole. Less common risks include the hole failing to close, the retina detaching, bleeding inside the eye, infection, or a rise in eye pressure. Your surgeon can talk you through how likely each of these is in your case.

When should I see a doctor?

See an optician or GP as soon as possible if you notice blurred or distorted vision, or a dark spot in the centre of your sight. You'll usually be referred to an ophthalmologist, and starting treatment within a few months of your symptoms beginning tends to give the best chance of improving your vision.

It's also worth having regular eye check-ups even if you feel fine, since a macular hole is easier to treat successfully when it's caught early and still small. If you've already been treated for a macular hole, watch for any new changes in your other eye and report them urgently, as this can occasionally also develop a hole.

After surgery, contact your eye team immediately, or go to your nearest eye casualty department, if you have severe pain, your vision becomes worse than it was the day after your operation, or you notice a shadow across your vision.