Macular hole
A macular hole is a tear or gap in the macula at the centre of the retina. A macular hole causes blurred or distorted vision because the macula is responsible for our central vision, which we rely on to see fine details and for driving and reading.
Macular hole is most common among people between the ages of 60 and 80 and occurs more often in women than men. It typically causes blurred or distorted vision, making straight lines appear wavy and leading to difficulties with fine vision use, such as when reading.
Macular hole is not the same as age-related macular degeneration. Both conditions are more common in people over 60 years old, affect the macula, and cause similar symptoms.
It's important to see an optician if you experience changes in your vision. They'll be able to tell the difference between these and other eye conditions.
Macular hole stages and types
Macular hole typically follows three stages:
- Foveal cyst (Stage 1) – untreated, about half of cases get worse.
- Small full-thickness macular hole (Stage 2) – untreated, about 90% of cases worsen.
- Large full-thickness macular hole (Stage 3 and 4) – most cases at this stage will get worse if untreated.
A macular hole will rarely get better without treatment. But usually, untreated macular holes worsen, and treatment is recommended. Treatment within six months typically has a better success rate (Source: NHS).
Macular hole symptoms
The first symptom of a macular hole is usually a change in vision. You might notice your vision becomes more blurred or distorted, and you have trouble seeing fine details when reading or watching TV. You might also notice that straight lines start to look wavy or bumpy.
As macular hole progresses, it can create a missing patch or black spot in your central vision. However, because the macula is responsible for central vision, a macular hole doesn't affect your peripheral vision (also known as side vision), and the condition isn't painful.
If a full-thickness (stage 2) macular hole develops, you can lose most of your central vision so it's important to see an optician if you notice any of these symptoms.
Macular hole diagnosis
If your optician suspects you have a macular hole, they'll refer you to see an ophthalmologist (eye specialist) who will do more detailed tests to examine your eye.
You'll be given eye drops to dilate your pupils, so the ophthalmologist can look closely at the back of your eye. They'll probably use optical coherence tomography (OCT), a machine that produces highly detailed images of the retina and macula.
They should be able to assess the stage of the macular hole and recommend a treatment plan.
Eye tests and macular holes
Although you can't prevent a macular hole from occurring, regular eye tests can help detect it in good time. The NHS recommends having an eye test every two years to help identify a range of eye conditions, some of which develop without obvious symptoms at first.
Macular hole treatment
In some cases, a macular hole may close by itself without needing treatment. Therefore, in the early stages, your ophthalmologist may monitor your condition for a while before recommending treatment. Normally, however, you will need surgery called vitrectomy.
Surgery for macular hole
Most people with a macular hole will have an operation known as a vitrectomy. This keyhole surgery uses tiny instruments to remove the vitreous jelly inside the eye. Then a thin layer of material is peeled away from the surface of the retina to relieve the pressure keeping the macular hole open.
The vitreous jelly is then replaced with a gas bubble which presses the hole to the back of the eye, helping it seal. This gas bubble will affect your vision but is gradually replaced by the return of natural fluid in the eye over six to eight weeks.
Vitrectomy surgery is done under a local or general anaesthetic, so you don't feel any pain during the operation.
You may be offered an alternative treatment to vitrectomy surgery if your macular hole has developed due to vitreomacular traction and if the macular hole is still at an early stage. An ocriplasmin injection can encourage the gel in the eye to come away from the macula, letting the gap close.
Macular hole causes and your vision
In most cases, the cause of a macular hole isn't known. Some risk factors may increase the chance of developing the condition, for example, macular hole can be associated with a condition called vitreomacular traction. This happens when the gel-like liquid (vitreous jelly) filling the eye, which helps maintain its shape, starts to shrink. This is a normal part of ageing, but as the vitreous gel moves away from the retina at the back of the eye, this can create a macular hole if it causes a tear.
Other examples include:
- Retinal detachment - when the retina detaches from the back of the eye
- Eye injury
- Severe short-sightedness (myopia)
- Slight long-sightedness (hyperopia)
- Cystoid macular oedema - long-lasting swelling of the central retina
- Rarely, macular pucker can cause a macular hole
When to get medical advice
If you notice any changes to your eyesight, visit your optician. They can check for a range of eye conditions and refer you to a specialist if necessary. Don't put it off, because for many conditions, including macular hole, an early diagnosis gives treatment a better chance of success.
Living with a macular hole
Being diagnosed with a condition that affects your sight can be an upsetting time, and you might worry about how you'll cope with lasting changes to your vision. However, there's support available to help you adjust to any changes, and you may be reassured by hearing from others who've been there before you.
Frequently asked questions
Medically reviewed by: The Royal College of Ophthalmologists on 18/10/2022
Edited by: Nick Astbury FRCS FRCOphth FRCP
Clinical Associate Professor
LSHTM
The Royal College of Ophthalmologists champions excellence in the practice of ophthalmology and is the only professional membership body for medically qualified ophthalmologists. The RCOphth is unable to offer direct advice to patients. If you’re concerned about the health of your eyes, you should seek medical advice from your GP, optometrist or ophthalmologist.