Overview

A macular hole affects central vision acuity and is a full-thickness lesion of retinal tissue involving the anatomic fovea. The condition typically develops in the centre of the macula, which is in charge of the detailed visual function, as well as most of the colour vision. Hence, even a minor irregularity in this area can have a significant effect on the central vision. Before the early 1990s, there was no established treatment for the macular hole.¹ Nowadays, a macular hole can often be repaired with surgical treatment. Continue reading to find out more about the causes, symptoms, treatment and diagnosis of this serious vision-threatening disease.

Causes of macular hole

Macular holes are believed to result from aberrant adhesion and traction of the jelly, or vitreous humour, which fills the cavity of the eyeball on the surface of the retina. Normally, the jelly covers the whole surface of the eye allowing it to connect with the retina. However, as we age, it weakens, shrinks, and separates from the retina's surface. This process is known as posterior vitreous detachment (PVD), and it is a common age-related ocular condition. It rarely affects those under 40 and typically manifests itself around age 60.²

A macular hole may also be the result of an eye injury or disease, such as:

• High degree of short-sightedness, or myopia
• Inflammation (uveitis) of the eye
• Eye trauma (eye injury or eye surgery)
• Diabetic retinopathy
• Macular pucker - a layer of scar tissue that forms over the macula and has the potential to compress and twist, resulting in retinal wrinkles

Macular hole formation is not believed to be influenced by genetics, environmental factors, or systemic causes.³

Signs and symptoms of macular hole

A macular hole progresses through several stages. The size of the hole and the layers of the eye that are impacted are typically used to categorise these stages. This is crucial to understand because, in the very early stages, a macular hole could repair or disappear on its own without the need for medical intervention.⁴

In the early stages, the symptoms of a macular hole include:

• Blurred vision
• Distorted vision - straight lines might appear bent or wavy
• Trouble reading small print

Late symptoms of this disease are:

• A blind or black area in the middle of the vision
• Loss of the majority of central vision

The location and size of the macular hole, together with its developmental stage, will determine the extent to which vision is lost.³

When the macular hole grows, the patient usually experiences metamorphopsia and decreased visual acuity, which may eventually lead to a central scotoma.⁵

Flashing lights that emerge out of the blue, floaters—specks or flecks that move across your vision or fading sight could be all signs of a retinal detachment. In this case, you should seek medical treatment from a healthcare professional.⁶

Management and treatment for macular hole

The best way to treat a macular hole is through a macular hole surgery known as vitrectomy. During this surgical procedure, the vitreous that is tugging on the macula is removed by a retina specialist. Subsequently, an ocular gas bubble is inserted. The macular hole is held in place and flattened by this bubble as the eye recovers. The gas bubble gradually disappears on its own.⁷ 

This surgery typically results in stable eyesight and reduced vision distortion, even if the hole cannot be completely closed.

In a very small percentage of cases, surgery is not enough to seal the defect, and the central vision may worsen. Nevertheless, hole closure may still be accomplished with a subsequent procedure.⁸

Injecting ocriplasmin into the vitreous is another possible therapy option for certain patients with macular holes. In some macular holes, this medication aids in the relief of vitreous traction.³

In situations when the macular hole is smaller and does not significantly affect vision, the physician could decide not to prescribe any kind of treatment. In this situation, it would be crucial to schedule routine follow-up eye exams as prescribed by the ophthalmologist to identify and address any issues early on.³

Diagnosis

All components of a thorough adult medical eye evaluation are included in the initial assessment of a patient whose symptoms and signs point to a macular hole, with special emphasis paid to those elements that are pertinent to macular holes. The eye examination usually involves a slit lamp exam. The doctor will use eye drops to enlarge your pupils so that the retina may be examined.

Macular holes are diagnosed using several types of tests:

• Pupil dilation - opening up the pupil for a better view of the retina 
• Optical coherence tomography (OCT) - measures the thickness and looks for swelling in the patient’s retina by scanning it with a laser
• Fluorescence angiography - this technique allows the healthcare professional to search for macular holes by injecting dye and then obtaining pictures

Risk factors

You might have a larger chance of getting a macular hole in your second eye if you already have it in one eye. Any changes in the vision in your "at risk" eye should be reported to an optometrist, who will examine you and possibly recommend that you see an ophthalmologist.⁶

Other risks of developing a macular hole include:

• Ageing (macular holes appear to be more common in those 60 years of age and older)
• History of a retinal tear or retinal detachment
• Diabetes, mainly if it is not under control or if you have diabetic eye disease
• Prior ocular surgeries or inflammation of the eyes
• A high degree of short-sightedness

Complications

If left untreated, a macular hole can result in these complications:

• Loss of vision, particularly the central vision
• Retinal detachment
• Enlargement of the macular hole

Vitrectomy is associated with certain complications such as:⁹

• Cataract
• Glaucoma
• Retinal tears
• Retinal detachment
• Visual field loss
• Endophthalmitis
• Gas-related complications

The following are ocriplasmin-related reported side effects:¹⁰

• Retinal tears
• Floaters (typically brought on by the posterior vitreous detachment progressing)
• Dyschromatopsia, blue-yellow vision, or dark vision 
• Photopsias 
• Abnormalities in the visual field 
• Modifications in electroretinography 
• Weakening of zonular fibres and potential lens subluxation

FAQs

How can I prevent macular hole?

A macular hole cannot be prevented in any way. Most cases occur on their own, with no apparent reason for their development.³ As a result, there is currently no effective strategy to inhibit their creationand growth. Nonetheless, the best method to make sure that any eye problems are found early is to have an eye test at least every two years.

How common is a macular hole ?

Macular holes are considered to be relatively rare. According to the American Academy of Ophthalmology (AAO) Retina/Vitreous Panel, Preferred Practice Pattern Guidelines 7.8 out of 100,000 people in the general population get a macular hole. People between the ages of 65 and 74 account for more than 50% of cases; and 72% of those who have macular holes are female

What can I expect if I have a macular hole?

If you have a macular hole at first you can notice that everything appears distorted or hazy when you look straight ahead. Straight lines or objects, such as window frames, may appear wavy, twisted, or as though they are missing a section in the middle. It could be more difficult to perform routine tasks such as writing, driving, and reading. Over time your central vision may become blurry or develop a blind spot. You may be missing words or letters when reading.¹¹

Over 90% of vitrectomy operations are successful. Your prognosis, or expected outcome is better if you receive appropriate therapy sooner or if the macular hole is smaller.¹²

When should I see a doctor?

Consult a medical professional right away if the macular hole is growing larger, worsening, or seriously impairing your eyesight.

If you experience sudden flashing lights, fading vision, or floaters—specks or flecks that move across your vision it may be a sign of retinal detachment. In this situation, you should seek urgent medical attention.⁶

Summary

A macular hole is a tiny opening that appears in the macula which affects  the central vision. The main cause of macular hole is the age-related constriction of the jelly located in the middle of the eye. The hole progresses through several stages which are classed by the size of the hole and the layers of the eye that are impacted. Depending on the stage, the symptoms will vary. In the early stages of macular hole growth, the symptoms can be as subtle as straight lines appearing wavy, and in the later stages, the changes caused by macular holes result in a small blank area in the centre of the vision. Surgery is required for most macular holes. With surgery, the hole is closed in an attempt to stabilise and improve the patient’s vision. Early detection of macular holes is crucial as the longer it is neglected, the less likely it is that treatment will be successful. An eye examination is the most effective means of making the diagnosis. If treatment is not received, the condition may lead to certain complications. The best approach to ensure that the eyes are healthy and that no new conditions are emerging in the eyes is to have an examination done as recommended by the optometrist, preferably every one to two years.