Macular Hole Surgery

WHAT IS A MACULA HOLE
The macula, where holes sometimes develop, is a very small spot in the center of the back of the eye (retina). Light focuses to a sharp point at the macula, which is the only area of the eye that sees crystal clear, color vision (such as for driving or recognizing faces).

When a macular hole develops, most people notice a sudden decrease in vision in one eye. A macular hole can cause blurred and distorted central vision. Macular holes are related to aging and usually occur in people over age 60.

CAUSES
Most of the eye’s interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. The vitreous contains millions of fine fibers that are attached to the surface of the retina. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. Natural fluids fill the area where the vitreous has contracted. This is normal. In most cases, there are no adverse effects. Some patients may experience a small increase in floaters, which are little “cobwebs” or specks that seem to float about in your field of vision.

However, if the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and create a macular hole. Also, once the vitreous has pulled away from the surface of the retina, some of the fibers can remain on the retinal surface and can contract. This increases tension on the retina and can lead to a macular hole. In either case, the fluid that has replaced the shrunken vitreous can then seep through the hole onto the macula, blurring and distorting central vision.

Macular holes can also occur in other eye disorders, such as high myopia (nearsightedness), injury to the eye, retinal detachment, and, rarely, macular pucker.

SYMPTOMS
Macular holes often begin gradually. In the early stage of a macular hole, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult.

DIAGNOSIS
Your ophthalmologist will put drops in your eye to dilate (widen) your pupil. This allows him or her to look through a special lens at the inside of your eye.


Then he or she will take pictures of your eye using optical coherence tomography (OCT). With OCT, a machine scans the back of your eye. This provides very detailed pictures of the retina and macula. Your ophthalmologist studies these pictures to check for problems.

TREATMENT
Although some macular holes can seal themselves and require no treatment, surgery is necessary in many cases to help improve vision. In this surgical procedure–called a vitrectomy–the vitreous gel is removed to prevent it from pulling on the retina and replaced with a bubble containing a mixture of air and gas. The bubble acts as an internal, temporary bandage that holds the edge of the macular hole in place as it heals. Surgery is performed under local anesthesia and often on an out-patient basis.


Following surgery, patients must remain in a face-down position, normally for a day or two but sometimes for as long as two-to-three weeks. This position allows the bubble to press against the macula and be gradually reabsorbed by the eye, sealing the hole. As the bubble is reabsorbed, the vitreous cavity refills with natural eye fluids.


Maintaining a face-down position is crucial to the success of the surgery. Because this position can be difficult for many people, it is important to discuss this with your doctor before surgery.