Macular Hole Symptoms and Treatment

Macular hole symptoms include blurry or distorted vision over time. This condition consists of a small hole in the center of the retina. Learn more about what it is and how it's treated in this article.

Written and verified by the biologist Samuel Antonio Sánchez Amador.

Last update: 27 May, 2022

A macular hole is an eye condition that, as the name suggests, affects the macula. That’s the central and most important part of the retina because it allows you to read, drive, and see the world around you in detail. Therefore, an injury to this part of the eye causes a decrease in visual acuity.
The School of Sciences at Alicante (Spain) states that a macular hole is much more common in patients over 60 years of age. In addition, they affect 3 out of every 1000 people. Also, there’s a clear gender bias since it affects more women than men, at a ratio of 3 to 1.

Keep reading to learn more about macular hole symptoms and treatment.

What is a macular hole?

According to the University of Navarra Clinic, a macular hole is a small circular opening in the macula of the eye. The macula is the central area of the retina and is a light-sensitive tissue that captures light stimuli. Then, it perceives the images that will be sent to the brain.

While a macular hole is a normal injury, patients may also just be experiencing the natural macula degeneration that comes with age. Both conditions have very similar symptoms, which we’ll discuss later in the article.

Here are the stages of macular holes:

• First degree: The fovea is the depression in the center of the macula. At this stage, the foveal area of the retina will detach, but it won’t form a complete retinal foramen. If you don’t treat this, half of these conditions with progress.
• Second degree: A small, complete retina hole will show up in the fovea area. Without treatment, approximately 70% of these problems will worsen.
• Third degree: There’s an increase in the hole’s size, to about 400 or more microns.
• Fourth degree: Vitreous humor is the gelatin that’s inside our eyes. In this phase, the macular hole will cause a posterior vitreous detachment.

As you can see, macular hole symptoms will vary depending on the severity of the condition. The size of the hole, as well as where it is on the retina, will determine how much the patients’ sight will be impaired. 

What causes them?

According to the previously mentioned studies, there are two types of macular holes based on the cause of the hole. They are:

1. Idiopathic macular hole

This is also called senile, because it affects patients between 50 and 70 years of age, with normal refractive errors (or without them) and without associated systemic conditions. The vitreous humor becomes disorganized and starts to contract with age. As a result, this change causes traction on the macula that results in a hole.

The National Eye Institute states that up to 15% of patients who develop an idiopathic macular hole are at risk of developing one in the other eye over time. 

2. Secondary macular hole

Macular holes can also appear as a secondary consequence of a previous condition. For example, in patients who have had severe myopia or who have suffered an ocular injury. In addition, those with a retinal detachment or who have developed cystic macular edema are at greater risk of developing this type of injury.

However, only 1% to 9% of blunt eye injuries end up causing a traumatic macular hole. Also, in young people, they can close up on their own. 

Macular hole symptoms

The American Society of Retina Specialists (ASRS) shows us some of the most common macular hole symptoms. In most cases (unless they’re caused by a direct blow), they’ll appear gradually. As a result, the patient will notice that their vision gradually gets blurry. 

In addition to reducing your eyesight, people with macular holes may notice that straight lines start to bend. The types of distorted vision are called metamorphopsies. In addition, you may notice dark areas appear in your field of vision (scotomas).

Macular hole diagnosis

The first step in detecting a macular hole is to see an ophthalmologist as soon as possible. They will give you special drops in the affected eye that will dilate the pupil. Then, they’ll be able to inspect your eye. After that, they’ll use optical coherence tomography (OCT) methods.

OCT is based on optical coherence interferometry and is used to get tomographic images of the patient’s ocular fundus tissue. It’s very similar to an ultrasound. The difference is that in this case, they use light instead of sound waves to map the internal parts of the eye.

Macular hole treatment

The American Academy of Opthalmology (AAO) shows us the general treatment for a macular hole. However, each patient’s individual treatment will depend a lot on the progression of the injury and its location in the eye. 
In stages 2 to 4, treatment requires surgery. The doctor will do a vitrectomy which is a surgery that is done to remove the vitreous humor that’s causing the ocular macula to protrude. The surgery requires local outpatient anesthesia and the following instruments:

• A fiber-optic light to illuminate the retina
• An irrigation cannula to maintain intraocular pressure.
• An instrument that cuts and removes excess vitreous gel.

This procedure is very minimally invasive, since it’s done using a series of very small, strategic incisions. After removing the excess vitreous humor, the surgeon will place a kind of gas bubble in the eyes that will keep the macula in place and stabilize it until the eye heals.

Risks and postoperative

According to the Institute of Ocular Microsurgery (IMO), there’s a 15% chance that the macular hole will reopen over time. In addition to that, patients should keep the following points in mind if they’re going to undergo surgery:

• Your eye may hurt after the operation. You may need to take some short-term medications.
• You need to keep your face in the same position for up to a week or more to keep the gas bubble in place. Therefore, you cannot go about your normal routine.
• You cannot take airplanes or climb mountains until the gas bubble has dissolved. Any activity that changes the intraocular pressure can put the operation’s results at risk.

In addition to all those considerations, you have to keep in mind that healing is gradual and that the macular hole won’t close suddenly. 

Also, the percentage of vision that the patient will get back depends on the size of the hole and how long it was there. The operation doesn’t have to fix your vision 100%. 

It’s not serious, but recovery is slow

As you can see, macular holes aren’t a serious clinical condition. However, the recovery process after surgery is quite slow and cumbersome. The simple fact that the patient has to keep their head in the same position for more than 7 days is remarkable in itself.

Therefore, before undergoing surgery for a macular hole, you should plan your activities well and let those around you know. However, the most important thing is that you don’t let any more time pass than is necessary before getting it checked out.