The retina is the light-sensing layer of tissue that lines the back of the eye. A specialized area of the retina, called the macula, is responsible for clear, detailed, central vision. The macula and retina normally lie flat against the back of the eye, like wallpaper lining a wall. A macular hole is an abnormal opening that forms at the center of the macula over a period of several weeks to months. Vision may become blurred and distorted initially. If the hole progresses, a blind spot develops in the central vision, similar to the picture you would get if your camera film had a hole in the center of it. Side vision remains normal, and there is no pain.

Most macular holes occur in the elderly. The vitreous gel within the eye pulls on the thin tissue of the macula until it tears. The torn area gradually enlarges to form a round hole. Less common causes of macular holes include injury and long-term swelling of the macula. No specific medical problems are known to cause macular holes.

A photographic test called fluorescein angiogram may be done in order to determine the extent of the damage to the macula.

A macular hole is a full-thickness retinal, circular defect that occurs in the middle of the macula. A "side view" of a macular hole has a very similar appearance to a volcano. The crater of the volcano represents the actual macular hole, whereas the sides of the volcano represent the retina that is elevated off the back wall of the eye. This retinal elevation is a very small retinal detachment. Although this retinal detachment does not get larger, it does occur in a very critical part of the retina and this results in a significantly more pronounced loss of vision than if the macular hole occurred alone.

MACULAR HOLE SURGERY

It is almost always preferable to perform macular hole surgery together with a cataract surgery if one is present. Unfortunately, not all retinal surgeons perform cataract surgery. If a cataract surgery is performed at the time of macular hole surgery, then the cataract surgery is performed first. Macular hole surgery is then performed by doing a vitrectomy. Once the vitrectomy is completed, the surgeon then focuses his attention upon the macular hole. He may "peel" some tissues in the vicinity of the macular hole to help increase the chances of the hole closing after the surgery. The eye is then usually filled with a gas bubble. All the incisions are then sutured closed and the patient is asked to keep strict face-down positioning for
a specified period of time. It is felt that the gas bubble inside the eye physically forces the retina around the macular hole that is detached to reattach. As this tiny area of retina reattaches, the edges of the macular hole (or crater) will approach each other. This causes the hole to become smaller, and in a minority of cases, to disappear. The vision will also improve from the fact that the tiny retinal detachment is no longer present.

It is critical that patients maintain their face-down positioning at all times as directed by the retinal surgeon. Failure to do so may result in failure of the operation. Sometimes, silicone oil is substituted for the gas bubble if patients are not able to comply with face-down positioning. However, silicone oil use requires another operation to remove in order for vision to improve.

The macular hole usually closes, and the eye slowly regains part of the lost sight over three to four months after surgery. The visual outcome may depend on how long the hole was present before surgery. Vision typically does not return all of the way to normal.