Macular hole
What a macular hole is, whether surgery is needed, and what to expect.
What is a macular hole?
The macula is the centre of the retina — the part responsible for sharp central vision, reading, and seeing in colour. A macular hole is a small, circular gap at the centre of the retina. It causes blurred and often distorted vision, where straight lines look wavy or bowed, and there may be a patch of missing vision at the centre.
A macular hole is not the same as age-related macular degeneration, although the two conditions can sometimes be present in the same eye.
Why do macular holes happen?
We do not know why most macular holes develop. They occur most often in people aged 60–80 and are twice as common in women as men. Other causes include severe eye trauma, high myopia, retinal detachment, or longstanding swelling of the central retina.
Do I have to have surgery?
If untreated, there is a small chance some very small holes can close spontaneously. In the majority, central vision will gradually worsen, though peripheral vision is not affected — you will not go completely blind from this condition. Macular holes have a lower chance of closure after surgery if they have been present for over one to two years, so Rahila generally recommends earlier surgery.
If the hole has been present for less than a year, surgery is successful in closing it in about 90% of cases. Of these, more than 70% will see two or three lines more on a standard vision chart. Even if this improvement does not occur, vision is at least stabilised and many patients notice less distortion.
For large macular holes, or holes that have not closed after a first operation, Rahila offers additional surgical techniques including the use of amniotic membrane, which can improve the chance of closure in these more challenging cases.
Risk to the other eye
Careful examination can assess the risk of developing a macular hole in the other eye, ranging from very unlikely to approximately a 1 in 10 chance. It is important to monitor for any changes in vision in the fellow eye and report these promptly.
What does surgery involve?
Macular hole surgery requires a vitrectomy — keyhole surgery through three small incisions in the white of the eye. The vitreous jelly is removed, a delicate membrane (the inner limiting membrane) is peeled from the retinal surface around the hole, and the eye is filled with a gas bubble to press against the hole while it seals. The bubble slowly disappears over about 8 weeks.
Surgery usually takes 45–90 minutes and can be done under local or general anaesthetic, often as a day case.
Posturing after surgery
The aim of posturing is to keep the gas bubble in contact with the hole. Rahila generally asks patients to maintain an “eyes down” position, similar to reading a book in your lap, for 45 minutes in each hour for 3–5 days after surgery. Posturing aids such as horseshoe-shaped pillows are available.
Travel restrictions
You must not fly or travel to high altitude while the gas bubble is in the eye (4–8 weeks). The bubble would expand at altitude, causing severe pain and permanent vision loss.
Risks of macular hole surgery
Failure to close
Occurs in 1–2 out of 10 patients. Repeat surgery is usually possible.
Cataract
Almost certain within a year if you haven’t already had cataract surgery. As cataract is inevitable, combined cataract extraction can sometimes be offered at the same time as macular hole repair.
Retinal detachment
Occurs in 1–2% of patients. Usually repairable but requires further surgery.
Raised eye pressure
Common in the days after surgery due to the expanding gas bubble. Usually short-lived and controlled with drops or tablets. If high pressure is extreme or prolonged it may affect the optic nerve, though this is uncommon.
Bleeding
Very rare, but severe bleeding can result in blindness.
Infection
Very rare (about 1 in 1,000) but if it occurs needs urgent treatment.
Most people will need 10–14 days off work, depending on the type of work and speed of recovery.
Most people will need to change their glasses prescription after surgery — usually at around 3 months once the gas bubble has gone. Please check with Rahila before visiting your optician.
Post-operative review is usually the day after surgery or within a few days, then 7–14 days later, and again at about 1–3 months.
For further information: RNIB helpline 0303 123 9999 · Macular Society helpline 0300 3030 111.