Sometimes a small hole develops in the center of the retina, particularly in the fovea (see Anatomy section), that can cause a profound loss of vision and is called a macular hole. For many years this was thought to be an untreatable condition; however, in 1983 one of our partners, Dr. Willis, began suggesting that doing surgery on macular holes might, in fact, improve vision. In 1990 the first paper and a following clinical trial showed the benefit of surgery in this disease.
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Macular Hole A large macular hole forms in the center of the fovea and decreases the patient's vision to 20/200. The patient sees a blind spot in the central field or narrowing of lines in the center of vision. |
The symptoms of a macular hole may be sudden or may be slow in onset. Many patients will notice a sudden dark spot in the center part of their vision, with loss of the ability to read centrally. They may notice just a blurring of vision as the macular hole is forming, while some patients only note a distortion. Eye specialists do a test called the Watzke sign, in which they place a thin line of light over the macular hole with a slit lamp and ask if the patient can actually see the entire line of light. This helps to determine if a hole is actually present in the retina in questionable cases. A fluorescein angiogram and OCT will show the extent of the macular hole.
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OCT of Macular Hole A large macular hole forms in the center of the fovea and decreases the patient's vision to 20/200. The patient sees a blind spot in the central field or narrowing of lines in the center of vision. |
The treatment of a macular hole is simple. There are only two options; either observation or surgery. The surgical treatment of a macular hole includes a vitrectomy and membrane peeling to peel away a thin membrane that is around the majority of these holes. The surgery involves removing the vitreous jelly (see Vitrectomy section) using various instruments to free the macular hole and allow it to settle. A few years ago several substances were investigated to determine if adding specific growth factors would aid in closing the macular hole, but these were found to be unneeded. The hard part of macular hole repair for the patient is the postoperative period. In the majority of cases, a gas bubble is placed in the eye and the patient asked to remain in a face down position for approximately one to two weeks following surgery. The gas bubble, therefore, is positioned on the hole, keeping the hole closed and allowing your body to heal the area of the hole (put the bubble on the trouble). An alternative to gas bubble injection is a silicone oil injection, in which the eye is filled with liquid silicone oil. This bubble does not require that the patient stay face down, but a second operation is necessary several months following the initial operation to remove the silicone oil.
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Post op Macular Hole The macular hole shown above is closed six weeks following surgery and the patient ultimately has marked vision improvement. Note that the central hole show above is gone. |
Recently, Indocyanine Green dye (ICG) has been used intraoperatively to stain the internal limiting membrane of the retina to allow for better removal of the membrane and presumably better vision. Several papers now suggest that ICG might be damaging to the RPE (see Anatomy section) and we use an alternate technique of intraocular Kenalog (one drop) to help with the membrane/ILM removal.
The complications of macular hole surgery are those of any vitrectomy surgery, and can include bleeding, infection, and retinal detachment, as well as increased pressure formation and the macular hole itself may reopen. All of these complications are very uncommon, and are only a low percentage of possibility.
The chance of developing a macular hole in the second eye after having a hole in the first eye is approximately 10%. This certainly needs to be taken into consideration when one is considering macular hole surgery. The chance of visual improvement after macular hole surgery is improving with time, and is 90+% for closure of the hole itself and approximately 60-70% or greater for significantly improving vision.
In the two decades macular holes have gone from being irreparable to a fairly high success rate of improving significant vision in patients
Disclaimer Stuff: The opinions expressed in this website are those of RVT. Diagnosis and therapy should be based on a thorough examination by and recommendations of a qualified eye provider.