Diseases
Overview
Age-Related Macular Degeneration
Diabetic Retinopathy
Retinal Vein and Artery Occlusions
Flashes of Light and Floaters
Retinal Tears and Retinal Detachments
Macular Pucker (Epiretinal Membrane)
Macular Hole
Vitreomacular Traction
Uveitis (Inflammation in the Eye)

Macular Hole

What is a Macular Hole?
The central area of the retina is the macula, it is responsible for the central vision and is organized in a way that that gives the central vision extra sensitivity. A macular hole is a round defect in the central macula and causes a decrease in the central vision as the retinal photoreceptors are disrupted.  Sometimes the vision is blurred or distorted and other times there can be a visible dark circle in the vision.
 
How does a Macular Hole form?
Inside the main body of the eye is the vitreous gel and it is adherent to the surface of the retina. As a normal process of aging, the vitreous begins to degrade and consolidate causing it to shrink, liquefy, and eventually separate from the retina. During this process, a mechanical pulling force is applied to the retina and in some people, this force can be too strong and a retinal hole can form. The process of developing a macular hole can happen as a natural occurrence due to the way the eye was made or secondary to another process in the eye such as trauma or inflammation.
 
How is a Macular Hole diagnosed?
The key to diagnosis is a detailed examination of the retina through a dilated pupil. The macular hole can be seen in the retina as a circular defect in the retina. To better characterize the hole, a scan of the retina by Optical Coherence Tomography (OCT) is often performed. This allows the visualization of the retina in cross-section and can allow for more accurate staging of the hole as well as detailed measurement of its size.  It is very important that all conditions that can mimic a macular hole and cause macular holes be evaluated for in order that other, potentially more serious, diagnoses are not missed.
 
Are there different types of Macular Holes?
Macular holes can be categorized based on their level of formation and based on their size. 

Stage 1 Macular Hole:
In these holes there is still vitreous traction on the retina but with early disruption of the retina


Stage 2 Macular Hole: 
Hole formation but partially relieved retinal traction


Stage 3 Macular Hole:
Full thickness hole has formed with separation of the vitreous from the macula but a full vitreous detachment has not yet formed


Stage 4 Macular Hole:
Full thickness hole with complete vitreous detachment
Complete exam can determine the difference between Stage 3 and Stage 4 macular holes.
 
 
Macular holes are also categorized based on their size:
  • Small – Less than 250 µm
  • Medium – Between 250 µm  and 400 µm
  • Large – Larger than 400 µm
 
How are Macular Holes treated?
In cases where the macular hole has vitreous traction, ocriplasmin (Jetrea), is available. Ocriplasmin is an active enzyme that is injected into the vitreous and breaks down the vitreous gel causing the traction to release. While closing macular holes is not the primary indication of ocriplasmin, it was successful in about 40% of these select cases.
 
In other patients, the treatment for macular hole is surgery. The procedure, called Pars Plana Vitrectomy (PPV), is performed in the operating room under sterile conditions. Small incisions are made in the eye and, using a microscope for viewing, small instruments are used to remove the vitreous gel that fills the inner eye. If any epiretinal membrane tissue is present it is removed from the surface of the retina and the innermost layer of the retina, the internal limiting membrane, is also removed with the help of a special dye to improve visualization. At the end of the surgery, the fluid is removed from the eye and it is filled with a special gas that occludes the retinal hole and allows it to close. To maximize the success of the surgery and effect of the gas bubble, the eye needs to be positioned looking down to allow the bubble to float up, directly on the macula. Depending on the specific circumstances, the face down position may be required for 3-7 days after surgery. This time is critical for retinal healing and successful surgery. The gas bubble is slowly reabsorbed over several weeks and is replaced with the eye’s natural fluid. During the time the gas is in the eye the vision is very poor as light cannot pass through the bubble well. When the gas resorbs, the vision improves but the overall visual recovery can take several months as the retinal cell’s function improves. Pars plana vitrectomy with intraocular gas has a success rate of over 90% in closing macular holes. It is important to consider that every patient is unique in response to surgery and there are certain macular holes that may not close even with surgery.
Dr Kruti Dajee Dr Jawad Qureshi Dr Johnathan Warminski