What is a Macular Hole?
A macular hole is a defect in the center of the macular area of the retina. Additionally, the macula helps give us sharp central and reading vision. The very center portion of the macula, called the fovea, is the thinnest portion of the entire retina. It is in this very delicate foveal area that a macular hole can develop. This is one of the main conditions that we treat at VitreoRetinal Surgery in Minneapolis and Greater Minnesota.
What Are The Causes Of Macular Holes?
In most cases, a macular hole develops as a result of anatomical changes that occur spontaneously and not from anything that the patient has done. This type of macular hole that most commonly occurs in individuals over the age of 50, we refer to as an idiopathic macular hole. Occasionally, severe blunt trauma can cause a macular hole. We also see a macular hole in a very small percentage of people with retinal detachment, or in conditions that cause severe edema (swelling) of the retina.
Symptoms of Macular Holes
A macular hole causes:
- Loss of sharp “straight-ahead” vision
- Loss of reading vision.
In the early stages of macular hole formation, the hole is very small and the central vision may be only slightly blurred or distorted. As the hole enlarges, the vision becomes progressively worse. The hole also typically enlarges to a point at which the affected eye can only see the larger letters of an eye chart. A macular hole does not cause complete blindness and does not affect the peripheral (side) vision.
How is a Macular Hole Diagnosed?
A macular hole is diagnosed by a thorough dilated eye exam. First, the retinal specialist will dilate the pupil and examine the eye with a light. Additional testing, such as optical coherence tomography (OCT), is typically performed. OCT is a special form of imaging that gives a detailed look at the anatomy of the retina.
How Are Macular Holes Treated?
Macular holes are usually repaired with vitrectomy surgery. This procedure is done under light sedation on an outpatient basis and generally takes 30 minutes to an hour to perform. During surgery, the retinal surgeon will place a gas bubble in eye. Patients will typically need to maintain face down positioning after surgery so that the bubble floats up against the back of the eye, where the macular hole is. This helps the macular hole to close.
Macular Hole Surgery
The surgery consists of making very small incisions on the white part of the eye (the sclera). After the vitreous gel is removed, the surgeon peels a very thin membrane called the “internal limiting membrane” from the surface of the retina around the macular hole. A gas bubble is then placed in the vitreous cavity. Newer surgical techniques and instrumentation may allow the surgeon to perform the surgery in some cases through tiny “self-sealing” incisions that do not require sutures. Eye drops or ointment are used for several weeks after surgery to facilitate healing. The gas bubble will gradually go away over several weeks following surgery.
Who is a Candidate For Macular Hole Surgery?
Surgery is recommended for most patients with macular holes. Some patients are not good candidates for surgery due to physical limitations or health concerns. The prognosis for vision after macular hole repair depends a variety of factors, including how large the hole is, how long it has been present, and if there are any other coexisting eye conditions.
Will I Need Anesthesia For Macular Hole Surgery?
At VitreoRetinal Surgery in Minneapolis, our experienced physicians usually perform vitrectomy surgery on an outpatient basis under local anesthesia.
Risks of Macular Hole Surgery
Comparatively, any surgical procedure carries a risk of complications, and macular hole surgery is no exception. Post-operative infection (endophthalmitis) can also be very serious and may lead to blindness in the affected eye. Our team can treat most infections effectively if we identify them at an early stage. Endophthalmitis is rare and occurs in approximately 1 out of 1000 cases. Retinal detachment is another complication that can cause blindness if not treated. Retinal detachments occur in 1 to 2 out of 100 cases following macular hole repair.
The progression of cataract is the third consideration in macular hole surgery. A cataract occurs when the lens in the eye becomes cloudy. This typically occurs with aging but is accelerated by vitrectomy surgery. This is not a concern if the patient has already had cataract surgery prior to vitrectomy surgery.
Other risks of surgery include:
- Loss of vision
- Double vision
- Droopy eyelid
- Anesthetic complications
Your surgeon will review the risks and benefits of surgery with you.
Macular Hole Surgery Post-Operation Requirements
The most important part of macular hole surgery is the requirement for postoperative face-down positioning. In order for the macular hole to close, the gas bubble must press against the macular hole. Since the macular hole is located directly at the back of the eye, the most effective way to keep the bubble against the hole is for the patient to keep their nose pointed directly downward toward the floor. A variety of positioning aids, such as massage chairs and head-rests, are available to make this requirement more tolerable. The duration of face-down positioning may vary but the average time is 4 to 5 days.
Recovery from Macular Hole Surgery
The amount of visual improvement varies depending on whether the macular hole closes, how long the macular hole was present, the anatomic characteristics of the macular hole, and the presence of any other ocular abnormalities that might limit vision. Many patients recover very good vision. However, some individuals may have more limited improvement, and a small percentage of people may not improve very much at all even with successful surgery. It is important to realize that recovery can take anywhere from 3 months to 1 year for vision to reach its maximal improvement.
How Long is The Recovery From Macular Hole Surgery?
The total recovery time is several months. Patients will be asked to maintain face down positioning after surgery, from one to seven days, depending on a variety of patient-specific factors. Patients are on post-operative eye drops for a few weeks. The gas bubble gradually resorbs over two to eight weeks. Patients should not fly in an airplane or scuba diving while the gas bubble is in the eye. During your consultation, your doctor will provide you with details of your procedure, including how long recovery it is estimated to take.
Are There Non-surgical Treatments for Macular Holes?
Although non-surgical treatment options have been studied for the past several years, there is currently insufficient clinical evidence to support their merit in most circumstances. Macular hole surgery is still the gold-standard treatment for repairing macular holes.
What Happens if I Leave a Macular Hole Untreated?
While a minority of macular holes may repair themselves, most require surgical treatment. If a macular hole is not treated, a patient would be left with a permanent defect in their central vision. Peripheral vision would otherwise be left intact. An examination from a board-certified retinal specialist is important in identifying the most appropriate treatment plan with the objective of preserving or restoring eyesight.
Schedule a Consultation
If you are interested in learning more about Macular Holes, please call (800) VRS-2500 to schedule a consultation. We have locations in Minneapolis, St. Paul, Blaine, Edina, Oakdale, Plymouth, St. Cloud and Duluth.