The macula is a small area found in the centre of your retina (the light-sensitive layer at the back of the eye). It’s responsible for the detailed, central vision we need for things like reading or driving. A macular hole happens when a gap forms in the central retina.
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Macular hole symptoms
People with a macular hole will notice a difference in their central vision. It usually happens in one eye, and your side (peripheral) vision won’t be affected.
Common symptoms can include things like:
- Blurriness or distortion
- Straight lines looking kinked, or bent
- Difficulty reading, watching TV or with close-up work
- A dark or blank spot in your central vision
These symptoms will vary depending on the size and depth of your macular hole. You won’t experience any pain and you won’t lose your vision totally, but it’s important to see your optometrist when you notice these symptoms as treatment is often very successful.
Causes of a macular hole
It’s not always clear what causes a macular hole, although it can be linked with other conditions like:
- Long lasting swelling of the macula (known as cystoid macular oedema)
- An eye injury
- Retinal detachment
- Having long sight (hyperopia)
- Having severe short sight (myopia)
Another cause is linked to changes to the gel-like fluid that fills the eye, called the vitreous, that is attached to the retina by lots of tiny fibres. As we get older, the vitreous begins to shrink and starts to pull away from the retina – this is completely normal and usually doesn’t cause any problems.
In most cases, the cause of the macular hole is unknown, but it is thought that as the vitreous jelly comes away from the back of the eye (a process known as posterior vitreous detachment), areas more firmly attached to the retina may tug the macula enough to form a small hole.
Diagnosing a macular hole
If you have any of the symptoms mentioned above, it’s important that you go and see your optician as soon as possible. If they suspect that you have a macular hole, they’ll refer you to a specialist (ophthalmologist) for further tests.
Your ophthalmologist will use dilating eye drops in order to get a clear view of the back of your eye and use an OCT scan which shows the thickness and structures of the retina in great detail. This will help them to identify a macular hole or rule out any other possible conditions.
If they find that you have a macular hole, they will be able to determine the kind of treatment you’d need, if any, or if they’d like to monitor your eye for a few months.
Surgery for macular hole
If the macular hole is in the early stages, ophthalmologists will often choose to monitor you for any changes over time.
If treatment is needed, it will usually involve surgery which aims to repair the hole and improve your vision. However, in the vast majority of cases, your vision will not get back to normal.
This is the main part of the surgery to repair a macular hole.
The operation involves removing the vitreous gel inside the eye and replacing it with a gas bubble in order to help the macula to heal. Taking the vitreous out stops it from pulling on the retina anymore, and the bubble lightly presses on the hole to encourage it to heal – a bit like a bandage.
The gas bubble will make your vision quite blurry, but over a few weeks the bubble will get smaller and eventually go away altogether. During this time, the eye will naturally produce some more fluid to replace it.
Recovering after macular hole surgery
You’ll be given some eye drops to use for a few weeks, and it’s best to avoid rubbing your eye, wearing eye make-up, going swimming or doing strenuous exercise while you’re recovering.
While the gas bubble is in your eye, your vision will be quite poor – so you won’t be able to drive for a few weeks and you’ll need to be careful with your day-to-day activities.
It’s very important that you don’t fly or go to high altitudes until the bubble has disappeared, as the pressure causes the bubble to expand, which can permanently affect your vision. If you have any other kind of procedure while you have the gas bubble, let your doctor know, as the gas can react with other substances.
Your ophthalmologist may also want you to position yourself in a particular way throughout the day in order to allow the bubble to stay in contact with the back of the eye as much as possible. This is called ‘posturing’ and involves either lying on your front or sitting at an angle. It can be quite bothersome, but your specialist will give you some advice on how best to do this.
As with any kind of surgery, there are risks of complications, and your specialist will go through all of this with you. One of the most common complications after macular hole surgery is the development of cataracts (a cloudiness in the eye’s natural lens). This usually happens the year after your macular hole surgery and can be treated with another operation.
Finally, if at any time after the operation you’re worried about additional symptoms, or if the eye becomes painful, get in touch with your ophthalmologist or go to your nearest eye casualty department.
With treatment, 90% of macular hole cases can be successfully repaired by surgery within 6 months. Treatment aims to close the hole which will help with distortion and may get some clarity back, but it is unlikely to restore vision fully.
It typically takes between six to eight weeks to fully recover from macular hole surgery.
A macular hole can only affect the very central part of your vision (this affects the detail of things you’re looking at) rather than your peripheral vision, which will remain unchanged. How much detail is lost will depend on the stage and size of the hole.