Macular Hole

A macular hole is a defect in the centre of the macular area of the retina. It is caused by the vitreous gel stretching the retina and the hole forms in the centre ( the macula).
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 occurs most commonly in individuals over 50 years of age and is called an idiopathic macular hole. Occasionally, severe blunt trauma can cause a macular hole and a macular hole can also be seen in a very small percentage of people with retinal detachment. A macular hole causes reduced vision and distortion of the central vision particularly when reading. 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 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 vision.

Management

A macular hole can be treated with vitrectomy surgery. With current surgical techniques, most macular holes can be repaired with a success rate of about 94%. 

The surgery consists of making three tiny incisions in the white part of the eye (the sclera). After the vitreous gel is removed, I then peel a very thin membrane called the “internal limiting membrane” from the surface of the retina around the macular hole which helps it to close. A gas bubble is then placed in the vitreous cavity. The gas bubble will gradually go away over several weeks following surgery.
Recently an alternative treatment has become available to treat certain types of macular hole. This is called Ocriplasmin (Jetrea) and is given by an injection into the eye. As with all treatments, there are risks and benefits and I will discuss all treatment options with you in clinic.

Results

The most important part of macular hole surgery is the requirement for post-operative face-down positioning. The rationale being that the bubble floats up to support the retina. I usually ask patients to posture face down during the day for five days after the operation (at night sleep on either side). Some surgeons do not use posturing at all but I believe that posturing improves the success rate of my surgery. I audit my results regularly and these show a success rate of 94% in closing the hole and improving vision.
Any surgical procedure carries a risk of complications and epiretinal membrane surgery is no exception. Post-operative infection (endophthalmitis) can be very serious and may lead to blindness in the affected eye. Most infections can be effectively treated if identified at an early stage. Endophthalmitis is rare and occurs in approximately 1 out of 2000 cases. Retinal detachment is another complication that can cause blindness if not treated. Retinal detachments occur in 1 out of 100 cases following macular hole surgery. The progression of cataract is a third consideration. A cataract occurs when the lens in the eye becomes cloudy and typically occurs with aging but is accelerated by vitrectomy surgery. If there is any degree of cataract before the vitrectomy, I tend to combine the vitrectomy procedure with cataract surgery to avoid a second procedure and speed visual rehabilitation.

For more information see: www.beavrs.org