Fixing A Macular Hole

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You may have heard of age-related macular degeneration, or AMD, the eye disease that can cause loss of central vision as a result of changes to a small area at the center of the retina called the macula. You may not have heard of a less common eye condition that shares similar symptoms with AMD, called a macular hole. Like AMD, a macular hole also affects the macula and is typically age-related.

At best, a macular hole will heal itself; at worst, it can cause central vision loss. The reality most often lies somewhere in between and depends on the condition’s stage and the size and location of the hole. In most cases, doctors can repair macular holes to varying degrees, but it’s important that they be monitored or treated early before they progress for the best outcomes.

Losing details

The macula’s main role is to process the fine details of objects directly in front of you, such as faces or the text you’re reading right now. Macular holes are small breaks or gaps that arise in the macula and can cause blurry or hazy vision when looking straight ahead. Straight lines may appear wavy, and a dark spot can appear in the middle of your visual field. Although these are the same symptoms that appear with AMD, the two conditions aren’t related, but it’s possible to have both at the same time.

Most macular holes are associated with aging. It’s normal for the vitreous, the gel-like substance that gives the eye its round shape by filling the space behind the lens, to shrink over time. But sometimes the vitreous pulls away from the retina and macula, creating a hole.

Who’s at risk?

Macular holes are most common in people over age 60. Women are more likely than men to have macular holes, according to a study published in the April 2017 issue of JAMA Ophthalmology. Other risk factors include:

  • An eye injury
  • A diabetic eye disease
  • Nearsightedness (myopia)
  • A detached retina
  • Scar tissue on the macula, a condition called macular pucker

According to the American Society of Retina Specialists, the risk of developing a second macular hole in the other eye is about 10 percent.

Diagnosis and treatment

If you have symptoms of a macular hole, your eye doctor will examine the macula in each eye with an imaging test called optical coherence tomography, or OCT, during which your retina is scanned to search for damage to the macula.

Treatment depends on the hole’s size and location. If you’re diagnosed with a tiny hole that doesn’t have a substantial effect on your vision, you may not need immediate treatment. However, you will need regular eye exams to monitor the hole’s progression. In some cases, the hole will close on its own.

Most people need a type of surgery called vitrectomy, which is performed as an outpatient procedure under local anesthetic. During the procedure, the surgeon removes the vitreous to stop it from pulling on the retina. He or she replaces it with a saline (salt) solution and a gas bubble. The saline and bubble are gradually replaced by natural fluids.

When a gas bubble is used, the most challenging aspect of vitrectomy can often be recovery: For proper healing, the patient must constantly maintain a facedown position for at least a day or two and sometimes for as long as two weeks to keep the bubble in place until it is absorbed.

The amount of vision regained varies. More than 90 percent of patients regain some or most of their vision. In remaining cases, macular holes fail to heal or complications such as detached retinas occur. The surgery also increases the risk of a cataract in the affected eye, which can develop rapidly and require surgical removal. A study in Ophthalmic Surgery, Lasers & Imaging Retina in 2018 found that vitrectomy was least likely to succeed if a patient had poor pre-operative vision, experienced complications, or delayed having the surgery.

Some people may be candidates for a drug called ocriplasmin (Jetrea), which is injected in the eye to help seal the hole. However, this alternative to surgery is usually reserved for smaller macular holes and has a lower success rate than vitrectomy.

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