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The Macula, which is a specialized area of the retina, is responsible for clear,
detailed vision. A macular hole is an abnormal opening which, forms in the
center of the macula over weeks to months.
and cross section of a macular hole
The central portion
of the eye is filled with a jelly-like substance known as the vitreous.
With age, the vitreous shrinks and pulls away from the surface of the retina. In most cases, this
pulling away or vitreous separation occurs without any negative effect. In some
individuals, however, there may be an area where the vitreous is firmly attached
to the surface of the retina. As the shrinkage and forward movement of the
vitreous progresses, traction or pulling can be exerted on the retina, and
eventually a small hole may form in the central portion of the retina (the
macula), known as a macular hole.
The fluid which has replaced the vitreous jell in many areas may then seep
through the hole, causing a localized separation of the retina centrally. This
process results in a defect or dark spot in the central vision with distortion
and central vision loss resulting.
Symptoms of a macular hole are common to most conditions
affecting the central part of the retina. They include:
- Blurred central vision.
- Distorted, "wavy" vision.
- Difficulty reading or performing tasks that
require seeing detail.
- Gray area in central vision.
- Central blind spot.
The diagnosis of
a macular hole is made when your eye care provider performs a dilated retinal
examination of the back of the eye. A fluorescein angiogram (injection
of a dye into the vein with photographs taken of the back of the eye) is
sometimes necessary to determine if macular hole is due to
the vitreous traction as described above, and not secondary to other problems.
Until recently, very little could be done to correct the
visual deficit resulting from macular holes. As a result of the introduction of
microsurgical techniques, it is now possible to offer a surgical procedure with
the potential for some visual improvement. This procedure is known as a vitrectomy,
and involves the microscopic removal of the vitreous jell within the center of
the eye. Particular attention is paid to removing any of the vitreous
attachments to the macula, thus releasing the traction or pulling on the
retina which caused the macular hole initially.
In order to completely close the macular hole, however,
additional pressure must be exerted to allow for
complete healing. To assist in this process, a large air bubble is
placed within the eye, which, when it comes into contact with the retina,
presses it against the wall of the eye, sealing the macular hole. This process
acts much like a hand holding wall paper against the wall permitting it to stick
and remain in position as the "wallpaper glue" dries.
In order to have its maximal effect, the air bubble must apply upward pressure
forcing the macula against the retina. Because the macula is located in the back part of the eye, a patientís head
must remain in a "face-down" orientation allowing the air bubble to
exert upward pressure. Patients must maintain
this face-down position for approximately 2-3 weeks after surgery in order to
achieve successful closure of the macular hole and maximize the chances for
vision improvement. This face-down positioning is the single most critical
portion of the procedure for closing macular holes. As a result, emphasis must
be placed on the patientís ability to cooperate with strict face-down
positioning at all times for a period of approximately two to three weeks after surgery.
of air bubble
|Position of bubble
when face down.
to help maintain a face down position, numerous devices have been developed.
These devices can be purchased or rented from a variety of companies such
At the end of the 2-3 week period of strict face-down
positioning, the patient is then permitted to resume a more normal upright
posture. The air bubble itself, however, may take anywhere from 6-8 weeks
following surgery to completely disappear. The air bubble is gradually
by the body, and the vitreous cavity is then fills itself with a liquid that is
naturally produced inside the eye.
The surgical procedure itself is performed typically under
local anesthesia, and sometimes requires an overnight hospital stay. A postoperative examination within 24 hours of
the surgery is required in all cases. Regular follow-up examinations are performed
during the first three weeks of recovery, to monitor for successful closure of
the hole and check for potential complications. Patients typically utilize several eye
drops applied to the operated eye over the course of several weeks following the
Approximately 6-8 weeks after surgery, when the bubble has
completely reabsorbed, the patient is measured for glasses. Full visual recovery
may take as long as three months following the surgical procedure.
Frequently asked questions
Is a macular hole the same as macular
No, macular holes and macular degeneration are two
separate and distinct conditions. As described elsewhere on this website,
macular degeneration is a condition affecting the tissues lying under the
retina, while a macular hole involves damage from within the eye, at the
junction between the vitreous and the retina itself. There is no relationship
between the two diseases.
Is this is an inherited condition?
There is no known inheritance pattern for macular
holes, and there is no evidence that macular holes are carried from one
generation to another.
If I have a macular hole in one eye, does
it happen in the other?
Depending upon the degree of attachment or traction
between the vitreous and the retina, there may be risk of developing a macular
hole in the other eye. Your eye
care provider can determine the
status of the vitreous jell and its degree of traction on the retinal surface in
the uninvolved eye. In
those cases where the vitreous has already become separated from the retinal
surface, there is very little chance of developing a macular hole in the other
eye. On the other
hand, when the vitreous remains adherent and pulling on the macular region in
both eyes, then there may be a greater risk of developing a hole in the
Is there anything that caused the macular
hole, or is there anything that can be done to prevent a macular hole from
developing in the other eye?
In very rare instances, trauma or other conditions
lead to the development of a macular hole. In the vast majority of cases,
however, macular holes develop spontaneously. As a result, there is no known way
to prevent their development through any nutritional or chemical means, nor is
there any way to know who is at risk for developing a hole prior to its
appearance in one or both eyes.
Does it matter how long I have had the
macular hole if I am interested in having surgery done?
There is evidence in the scientific literature that
macular holes present for less than six months have a better chance of repair
and visual recovery than those present for more than six months. Studies have
shown, however, that some vision improvement can take place in patients with
more long-standing macular holes, but rapid evaluation and treatment is
preferable in patients with this condition. If a macular hole exists in one eye,
it is therefore very important to monitor for any vision changes in the second
eye, and report these vision changes to your eye
care provider immediately.
If I have surgery, what type of vision
improvement can be expected?
Typically, for macular holes less than six months in
duration, a vision improvement of approximately three lines on the eye chart (or
50% improvement) can be achieved. Obviously, this is an "average"
visual improvement. Vision recovery varies on a patient-by-patient basis, and
each patient must be evaluated on an individual basis and discuss with their eye
care provider the expectations for visual recovery. Some patients achieve only a
small amount of vision recovery, while others achieve a more significant
How important is it really to maintain the
Face-down positioning is crucial to the success of the
operation. If a patient is not able to maintain face-down positioning, it is
unlikely that the operation will succeed. Therefore, before macular hole surgery
is considered, a patient should experiment at home with maintaining a face-down
position for a period of time to ensure that they are able to comply with the
restricted activities necessary in the postoperative period. Some patients,
because of medical conditions or physical limitations, may be unable to comply
with the positioning and would not likely be good candidates for this procedure.
When will I get my vision back?
During the postoperative period, the air bubble in the
eye will be pressing on the macula to ensure closure of the hole. While the air
bubble is present in the eye, the eye is unable to focus light properly, and
therefore vision is significantly disrupted. Often patients are only able to see
shapes, shadows or hand movements in front of their eyes while the bubble is
large. As the bubble begins to shrink, usually between the third and fourth
week, vision begins to return. Final vision recovery is often not achieved for
6-12 weeks following the operation after the bubble completely resolves, the
macular hole heals, and a final prescription for glasses is given. For those
patients who have not had cataract surgery, the vision may begin to exhibit
gradual deterioration approximately 6-12 months after the operation as a
cataract develops. Once cataract surgery is performed, vision would then
typically return to its maximal level.
Am I able
to travel after macular hole surgery?
Patients are not permitted to fly when there is
a large air bubble present inside the eye. When a person travels by air, there
are changes in air pressure which can result in expansion of the air bubble and
increased eye pressure. In order to prevent this complication, patients are
restricted from any type of air travel until the bubble is nearly gone, or small
enough that the patientís eye care provider considers it safe to fly.
Are there any special chemicals used to
close the macular hole?
When surgery is performed to close a macular hole, no
laser treatment is applied to the hole itself, as laser can be damaging to the
delicate central tissue of the macula. In order to avoid this damage, the air
bubble alone is used to help provide the seal between the retina and the wall of
the eye. Experiments have been performed in recent years in an attempt to
determine if chemicals applied to the surface of the macular hole at the time of
surgery will increase the success rate for the operation. Studies have not yet
conclusively demonstrated that application of any chemicals are necessary to
have a successful result from the surgical procedure.
Please note that much of the above content was
provided compliments of: Vitreous-Retina-Macular
Consultants New York
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