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What is a Macular Hole?

 

To understand what a macular hole is, you must understand the function of the eye.  The human eye functions like a camera.  Like a camera, it has a lens at the front of the eye, and film at the back of the eye.  The film of the eye is called the retina.  The retina is a thin layer of tissue that lines the inner back surface of the eye.  It takes the picture of what we see and transmits it to the brain by the optic nerve.  The central portion of the retina, the macula, is responsible for central vision.  The macula is a very small area, the size of the head of a pin.  Only the macula is capable of the detailed vision necessary for many daily tasks such as reading, watching television, or driving.  A macular hole is a small hole in the center of the retina called the macula. 

 

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In order to maintain its round structure, the center of the eye is filled with a jelly-like substance known as the vitreous.  At birth, the vitreous has a fairly solid structure.  As a person ages, the vitreous gel becomes more liquid and shrinks toward the front part of the eye.  As the vitreous shrinks, it pulls away from the surface of the retina.  This vitreous separation usually occurs without any negative effect.   In some individuals, however, the vitreous may be more firmly attached to the surface of the retina around the macula.  In these individuals, as the vitreous separates it pulls a small hole in the macula.  This results in a defect or dark spot in the central vision with distortion and central vision loss.

               

What are the symptoms of a Macular Hole?

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Symptoms of a macular hole include decreased central vision for both distance and reading activities, distortion in central vision, a missing spot in the central vision where letters may disappear when reading. The diagnosis of a macular hole is made when an ophthalmologist performs a dilated retinal examination and examines the back of the eye.  A scan of the macula called an OCT is the best test to confirm and evaluate a macular hole.

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What is the treatment of a Macular Hole?

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Once a macular hole has fully formed, it is very unlikely to get better without treatment. There is generally no medical treatment for macular holes.  Full-thickness macular holes are treated by surgery.  This procedure is known as a vitrectomy and involves the microscopic surgical removal of the vitreous gel from the eye. Particular attention is paid to removing any of the vitreous attachments from the macula, thus releasing the traction or pulling on the retina which caused the macular hole initially. This allows the retina to settle against the wall of the eye.

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In order to completely close the macular hole, pressure must be exerted directly on the macula.  To assist in this process, a large gas bubble is placed within the eye, in the vitreous cavity.  The bubble presses against the retina, causing it to flatten, sealing the macular hole. In order to have its maximal effect, the gas bubble must apply continuous upward pressure against the macula.  Because the macula is located in the back part of the eye, a patient’s head must remain in a “facedown” position to allow the air bubble to rise toward the back of the eye and exert this pressure.  Patients must maintain this facedown position 20 hours per day for 5 days after surgery in order to achieve successful closure of the macular hole and maximize the chances for vision improvement. 

 

It is very important that the patient is able to cooperate with facedown positioning as much as possible for a period of 5 days after surgery in order to achieve a successful outcome.

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With successful closure of the macular hole, vision should improve.  It will not return fully to normal.  The amount of improvement in vision depends on the size of the hole, the duration the hole was present, and the underlying health of the retina. 

In order to increase the patient’s ability to comply with these instructions, numerous devices have been developed that assist the patient in maintaining this facedown position throughout the day and at night as well. Some patients buy or borrow a massage table which also works well. 

 

At the end of the period of facedown positioning, the patient is then permitted to resume a normal upright posture. The gas bubble itself, however, may take anywhere from 2-4 weeks following surgery to completely disappear.  While the gas bubble is in the eye, the vision is very poor.  In fact, the vision is worse than it was prior to surgery.  The gas bubble is gradually resorbed by the body and replaced by fluid from the body.  It does not need to be removed with further surgery.  While the bubble is in your eye, you cannot travel by airplane and you must stay at or near sea level. This is because at high altitudes the gas can expand and cause the eye pressure to go up to dangerous levels.

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The surgical procedure itself is performed typically under local anesthesia in the operating room at the Pasqua hospital.  It is a day surgery procedure, which means the patients go home that same day.  You will be at the hospital for approximately 3 to 5 hours on the day of your surgery.  The surgical procedure takes 45 to 60 minutes to complete.  You will have a post-operative assessment anywhere from 1 to 4 days after your surgery.  If everything is healing as expected, you will be re-examined 4-6 weeks after surgery to monitor for successful closure of the hole.  You will be given a prescription for an antibiotic eyedrop to be used for one week and an asteroid and anti-inflammatory eye drop, both to be used for approximately two months after surgery.  In about 30% of patients, the pressure increases in the eye after surgery.  If this happens, you will be started on an extra eye drop to lower your pressure for a few weeks and you may have a few extra post-op appointments to monitor the pressure. 

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Full visual recovery may not occur until three to six months after the procedure.  Some patients continue to notice a very small gradual improvement in vision for up to 2 years after the procedure.  Please ask Dr. Varma when you are ready to see an optometrist to update your glasses after surgery.

In patients who have not already undergone cataract surgery, the development of a cataract occurs in almost all individuals within six months to two years after vitrectomy surgery. Surgical removal of the cataract and placement of an intraocular lens is then required.

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Vitrectomy surgery is successful in closing 95 to 98% of macular holes.  A second surgery may be offered for the holes that do not close, depending on the health of the eye.  As with all surgical procedures, there are potential complications or side–effects associated with the repair of the macula hole. These occur in a small percentage of individuals and include retinal tears or detachments during the surgical procedure itself, or in the immediate postoperative period.  Other complications include a bleed in the eye (vitreous hemorrhage), high pressure in the eye (glaucoma), infection (endophthalmitis) loss of vision, and very rarely, loss of the eye.  These problems are usually repairable but may result in permanent damage to vision that cannot be corrected even with glasses or further surgery.

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