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Macular Hole

A Hole in the Macula

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Updated April 28, 2014

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

A macular hole is a hole in the eye's macula. The macula is a highly specialized area of the central retina that gives us the ability to see fine detail. We use our macula and central vision to view detailed objects when reading or driving. Usually occurring in people over the age of 60, macular holes can cause rapid loss of central vision.

Symptoms of Macular Hole

Macular holes usually develop slowly. In the beginning, you might notice missing letters while reading, distorted vision or blurry central vision in one eye. Straight edges may appear bowed or wavy. In advanced cases, you may have a large amount of central vision loss or notice a missing spot in your vision.

Causes of Macular Hole

The back cavity of the eye is filled with a gel-like substance called vitreous. The vitreous is adhered to the the retina in certain spots by tiny fibers. As we age, vitreous begins to liquify and collapse on itself. When this begins to happen, the vitreous may pull away from the retina. Most older adults never notice this process (which is normal) but a few people do experience "floaters" that may come in and out of their vision. Unfortunately, sometimes the gel pulls away from the macula, too, causing a macular hole. In other cases, the tiny fibers that are tied to the retina may pull the macula and cause a macular hole. Fluid may accumulate and cause distorted or blurry vision.

Types of Macular Holes

Macular holes are classified based on size and progression. There are three stages of a macular hole:
  • Stage 1 (macular cyst): A new macular hole sometimes appears as a yellow macular cyst. Up to 50% of macular cysts spontaneously go away and the macula returns to normal.
  • Stage 2 (early macular hole): The cyst begins to take on an oval, crescent or horse-shoe shape. Vision begins to decrease, becoming distorted or blurry. Up to 70% of stage 2 holes progress to stage 3.
  • Stage 3 (full thickness macular hole): A stage 3 hole is defined by its great size. People with stage 3 holes often develop significant vision problems. Stage 3 macular holes are also defined by a rim of elevated tissue.
  • Stage 4: A stage 4 macular hole is similar to a stage 3 but the patient also has a posterior vitreous detachment.

Treatment of Macular Hole

If a macular hole is not caused by trauma or occurring along with other eye disease, the hole can be treated with some reasonable chance of success. Larger and older macular holes have a decreased chance of successful treatment.

Very early macular holes are monitored by an optometrist or an ophthalmologist. Your eye doctor may use an Amsler Grid to check your central vision. Your eye doctor may also dilate your eyes and take digital retinal photographs. A fairly new technology called optical coherence tomography can be used to monitor you closely for possible progression into stage 2 macular hole.

A Stage 2 or greater macular hole is typically treated by surgery performed by a retinal specialist. Most surgery for repair of macular holes centers around removing the vitreous gel and replacing it with a special gas. This gas holds the edges of the macula together to allow healing. (This gas treatment usually requires you to hold your head in a face-down position anywhere from a few hours to 2 weeks depending on the surgeon. Research is currently evaluating how important this step is, as it is very difficult for the patient.)

What You Should Know About Macular Hole

If you develop a macular hole in one eye, you have about a 30% chance of it developing one in the other eye. If you have a macular hole in one eye and the other eye has a posterior vitreous detachment, your chance of developing another macular hole begins to decrease.

If you notice any change in your central vision, see your eye doctor right away. Early detection and treatment of macular is crucial for a positive outcome.

Source:

Sowka, Joseph W, Andrew S Gurwood and Alan G Kabat. The Handbook of Ocular Disease Management, Supplement to Review of Optometry, pp 35-36, 15 APR 2010.

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