Macular holes

The retina is the seeing part of the eye located on the inner side of your eyeball. Within the retina is a small area called the macula. It is a thinner area highly specialized for very fine vision. It is this area that gives you the ability to read and recognize faces and fine details. Because it is a thinner zone, it is also more fragile. If too much pulling force is exerted on this delicate structure, it can pull up and tear.

A macular hole is the result of sustained traction by the vitreous gel (which occupies the space in front of the retina) on this very thin central area of the retina. Vitreous collapses with age in everyone (see also vitreous floaters), but it is only in a few people that the adherence between the vitreous and the retina is so strong and persistent that it can lead to the appearance of a tear and a hole.

Once the hole is present, the retina surrounding the whole will swell and fill up with water (macular edema). It can also curl outwards making the whole bigger.

What do you see? †What are the symptoms?

A macular hole goes unnoticed for a long time. It is usually detected when the good eye is closed for any reason (you get a speck of dirt in your good eye for example). In the early stages, it usually causes a vague sensation of grayness in the center of vision in the affected eye. All signs can only be experienced when one eye (the good eye) is closed. If the hole gets big enough, the grayness will turn into a dark central spot through which you cannot see. Over several weeks to months, this central dark spot (or scotoma) will enlarge making it difficult in the end to recognize faces or see large letters.

With a macular hole, only the central vision is affected. Your peripheral vision (or navigation vision) remains intact. You do not go blind with macular holes, but your ability to read decreases significantly in the affected eye. If a complete posterior vitreous detachment is not present in the other eye, this eye is also at risk of developing a macular hole.

What are the eye exams that will be done during an office visit?

Your EyeMD (ophthalmologist) will measure your visual acuity and evaluate your macula and retina. We will first start by some simple eye tests to determine your vision, using an Amslerís grid test, an M-chart, and judge your reading speed. We may ask you to tell us if a beam of light projected onto the retina is intact of cut in two (Watske test).

We will dilate your pupil to allow us to examine the retina in detail using a slit lamp (biomicroscope) as well as performing special imaging test using specialized equipment including optical coherence tomography (OCT). Today the OCT is the technique of choice to confirm a diagnosis of a macular hole. High resolution OCTs, using more specialized equipment allow us to judge the quality of the retinal layers and the presence of any epiretinal tissue causing outward traction at the edge of the hole. These details help to decide on the best surgical approach as well as give us an idea of prognosis for you vision.

What can be done?

Once a macular hole is present, spontaneous resolution is rare. If a small hole is present with residual traction from the vitreous, it is possible to inject into the eye ocriplasmin (Jetreaģ). In selected patients, the vitreous traction will disappear and the hole will close. In all other cases, surgery is the better option.

If performed early (in the 6 months following the development of the hole), the prognosis for hole closure and improvement in vision is very good. If the hole is larger or has been present for a long time, the resulting improvement in vision may be more limited, but is still worthwhile.

Your treating EyeMD before the end of the consultation will outline the best treatment options for your particular case.