Introduction

People with myopia (short-sightedness) are more likely to develop a macular hole. A macular hole is caused by the pulling forces from jelly-like (aqueous humour) substances in the eye, tissue on the surface of the macula, and progressive thinning of the back of the eyeball.¹

High myopia can lead to various macular problems, like macular retinoschisis, shallow retinal detachment, lamellar macular holes, and full-thickness holes.²

A macular hole is commonly seen in myopic people with an axial length greater than 26.5 mm and a refractive error greater than -6.00 dioptres. Studies have found that myopic macular holes are greater in Asians compared to Caucasians and those of black ethnicity, likely due to the higher prevalence of myopia in the Asian population.¹ 

Did you know that having high myopia can increase the risk of developing macular holes? Continue reading to learn more about this vision-threatening condition.

What is a Macular Hole?

A macular hole is a rare eye condition that leads to the loss of central vision, characterised by a central macular defect that extends through all the layers of the retina.¹ As the macular hole develops, an individual may experience a blurred, wavy, or distorted central vision, which can lead to loss of central vision but does not affect peripheral vision.³

What is High Myopia? 

Myopia, also called (short-sightedness), is a condition where closer objects appear clear but distant objects are blurred.⁴ High myopia is likely to occur when a patient has greater than -6.00 dioptric power and an elongated axial length that is greater than 26.5 mm.⁵

Complications associated with high myopia

Conditions associated with high myopia, include:

• Macular retinoschisis 
• Retinal detachment from peripheral retinal tears
• Lamellar macular holes full-thickness
• Macular holes with or without retinal detachment⁶

Connection between macular hole and high myopia

People with high myopia have an increased risk of developing macular holes, due to their elongated axial length (having longer eyes). This is due to increased stretching of their retinas, so they become more susceptible to retinal tears. In severe cases, this can lead to retinal detachment and macular holes. 

Additionally, those with myopic eyes often have a shrunken vitreous. This can further contribute to the development of macular holes, as a degenerate vitreous has a higher chance of separating from the retina and causing a hole in the macula.⁵ 

Signs and symptoms

If you have macular holes associated with high myopia, you might notice specific signs and symptoms that indicate this condition. These include:

• Blurred or distorted vision 
• Central vision loss 
• Difficulty reading or recognising faces 
• Metamorphopsia (straight lines appearing wavy) 
• Scotoma (dark or blank spot in the centre of vision) 
• Rapid decline in visual acuity 
• Increase in floaters or flashes of light 
• Changes in colour perception
• Difficulties in distinguishing between similar shades or colours
• Eye fatigue and strain

These symptoms can vary from person to person, and they might get worse over time. If you're experiencing any of these symptoms, it's important to get checked by an eye doctor as early as possible so that they can take the right steps to help you keep your vision.^7,8

Risk factors

The main risk factors for developing myopia and subsequent macular holes are:

• Older age
• Elongated axial length (over 26.5 MM)
• Refractive error greater than -6.00 diopter

Other risk factors 

Ethnicity 

Some studies have reported that Asians have a higher risk of developing myopic macular holes compared to those of Caucasians or Black ethnicity. This is because myopic refractive errors are more common in the Asian population.¹

Statistical data and studies linking high myopia with macular holes

Studies have found that individuals with high myopia are more likely to have certain types of eye conditions which also include macular holes compared to those with low myopia. About 8.4% of individuals with high myopia have macular holes.¹

A recent study has found that about 6.26% of individuals with high myopia developed macular holes. Which leads to the loss of central vision. Interestingly, this study also disclosed that some of these individuals didn't notice any vision problems and their vision was good. However, some of these individuals reported a reduction in vision later. This study shows how important it is for individuals with high myopia to get regular eye examinations and treatments.⁹

Diagnosis

When it comes to finding macular holes in individuals with high myopia, eye care professionals typically use combinations of examinations. It's crucial to do this for individuals who are highly myopic because they are more likely to get macular holes and other retinal pathologies. 

Common diagnostic procedures 

Visual acuity testing

This test checks whether you can see the letters on the chart. It also assesses how well you can see. It can show if you have any vision problems. That might be caused because of the macular hole.

Ophthalmoscopy

This test helps the eye care professional to see the macula at the back of your eye and detect any problems Including macular holes.

Imaging techniques

Optical coherence tomography (OCT)

OCT gives detailed pictures of the macula. It is an Imaging test that can be used in finding and measuring macular holes.¹⁰

Fluorescent angiography

Fluorescent angiography is a technique used to examine the anatomical structure of your eye which involves the examination of the size, location, and severity of a macular hole and the detection of other eye problems. In this technique, the eye care professional injects a specific dye in your arm which runs through your blood vessels and finally makes its way to your eye. The dye highlights blood vessels in the retina (back of your eyes).

Fundus autofluorescence (FAF)

FAF is another technique to examine the retinal structures (back of your eye). This gives more details about the pigmented layer of the retina around the macular hole, which helps eye care professionals diagnose and understand the effects of the macular hole on the nearby retinal tissues.¹¹

Treatment and management

Non-surgical treatments

Observation and monitoring

Some experts recommend that if you have macular hole due to high myopia, you should be observed for at least 6 months. This is due to the probability that the macular hole may recover on its own without any surgery. While this approach requires close monitoring it may be suitable for cases where surgical intervention may not be immediately necessary.¹²

Vitreous cavity injections

Vitreous cavity injection is also called pharmacological vitreolysis. In this process, ocriplasmin is used to treat certain retinal diseases such as macular holes. This treatment separates the jelly-like structure (aqueous humour) from the back of the eye (retina) and helps in the healing of the macular hole.¹³

Surgical treatments

Vitrectomy

If the individual has a macular hole associated with high myopia different surgical techniques can be used to treat this condition. They are:¹ 

• Inverted internal limiting membrane (ILM) insertion
• Vitrectomy with ILM repositioning
• Vitrectomy with modified temporal inverted limiting membrane flap
• Large semicircular inverted internal limiting membrane flap
• Autologous transplantation of internal limiting membrane for refractory macular holes
• Vitrectomy combined with ILM peeling
• Microincision vitrectomy surgery (MIVS)

Postoperative care and visual rehabilitation

Regular check-ups

After the surgery, it is important to have regular follow-up visits with your eye care professional to check how your eyes are healing. This can help your eye care professional to monitor your vision and how your eyes are healing.

Visual function assessment

During your visit to the eye care professional, the doctor will measure your vision using a special chart. This helps your doctor keep track of the changes in your vision over time.

Anatomical assessment

Your doctor will also use a special dye and camera to take pictures of the inside of your eyes at certain times after the surgery. This helps them to track the healing of your eyes and the closing of the macular hole.

Safety Evaluation

The eye care professional needs to make sure you're not having any bad reactions or complications from the treatment. They will ask you certain questions and do regular examinations to check for any issues.

Surgical Procedure

The eye care professional will also explain the surgery and what they did to help fix the macular hole. This helps you understand what to expect as you recover and how to take care of yourself.¹⁴

Prognosis and Long-Term Management

After surgery for macular holes associated with high myopia, patients have promising results in closing up their macular holes and experiencing better vision. Research indicates that all eyes with high myopia had successful healing of macular holes after surgery. Patients also have significant visual improvement, with a positive impact on visual acuity. 

The outcomes for macular hole repair in highly myopic eyes were similar to those in low myopic and emmetropic eyes. Although some individuals had minor changes in the back of the eye, it didn't affect their recovery. Regular eye check-ups and detailed exams are important for the best results after surgery.^1,2

Strategies for managing high myopia to prevent macular holes

To prevent macular holes in people with high myopia, it's important to:

• Get regular eye check-ups to monitor any changes, such as refractive error progression, axial length changes, and the development of any associated macular abnormalities to facilitate timely intervention
• Control and manage vision changes with corrective lenses, orthokeratology, pharmaceutical interventions, or other treatments to reduce the risk of developing macular holes
• Use methods to control myopia, like special contact lenses or eye drops, to slow down vision changes and prevent macular holes
• Learn about the risks and make lifestyle changes, like taking breaks from close-up work, to reduce strain on the eyes.
• If macular holes develop, timely surgery can help prevent further vision loss⁵

Summary

Individuals with high myopia are at a greater risk of developing macular holes, which can lead to central vision loss. Symptoms may involve unclear vision, trouble with reading, and distorted sight. Routine eye examinations are crucial for early detection and management of this condition. Timely intervention, whether through observation, non-surgical treatments, or surgical procedures, can significantly improve outcomes and help preserve vision.