What Is a Macular Hole?

People typically notice that the center of their vision in one eye has become blurry or that there is a small gray or missing patch right where they are trying to look, so faces and words seem to have a hole punched in the middle. Straight lines may also appear bent or pinched toward the center. It is frightening because it strikes central vision directly, and many fear it is permanent or a sign of going blind.

The fovea is the tiny pit at the center of the macula where vision is sharpest, and a macular hole is an actual opening through the retinal tissue at that spot. Because that exact point handles fine detail, a hole there produces a blurred or missing central spot even though the surrounding retina and your peripheral vision remain intact.

A macular hole does not cause total blindness and does not spread to the side vision, but the central defect can make reading, driving, and recognizing faces difficult with the affected eye. The good news is that the retina around the hole is usually healthy, which is why surgery to close the hole can restore much of the lost central vision.

Most macular holes are age-related and stem from the vitreous, the gel filling the eye, which is firmly attached to the macula early in life. As the gel liquefies and separates with age, it can pull on the fovea. That traction, along with changes in the tissue at the center of the macula, can open a hole. Women and people in their sixties and seventies are affected somewhat more often.

Holes can also follow significant blunt eye trauma or occur alongside high nearsightedness, retinal swelling, or an epiretinal membrane that adds tangential pull. Retina specialists describe stages from an early impending hole to a full-thickness hole, and they measure its size, because both stage and size influence the surgical approach and the odds of closure.

Left untreated, a full-thickness macular hole tends to stay or gradually enlarge, and central vision usually does not recover on its own. This is why prompt referral and surgery are generally recommended rather than long observation.

A macular hole is a serious cause of central vision loss, though it is not an immediate blinding emergency in the way an artery blockage is. Central blur, distortion, or a missing central spot that develops over days to a few weeks should be evaluated promptly, because earlier surgery generally yields better outcomes.

Seek more urgent care if vision loss is sudden and severe, if you see a new curtain or shadow spreading in from the side, or if a shower of new floaters and flashing lights appears, since those can signal a retinal detachment, a different and time-critical problem.

A dilated retinal exam lets the doctor see the round defect at the center of the macula, but the essential test is optical coherence tomography, or OCT. This painless cross-sectional scan confirms that the hole is full-thickness, measures its size, and distinguishes it from look-alikes such as a pseudohole caused by an epiretinal membrane or a lamellar (partial-thickness) hole. OCT of both the affected and fellow eye also guides the treatment plan and helps predict how well surgery is likely to work.

The standard treatment for a full-thickness macular hole is surgery: a vitrectomy performed by a retina surgeon. The gel is removed from the eye, a very thin surface layer of the retina (the internal limiting membrane) is often peeled to release traction, and a gas bubble is placed inside the eye. The bubble presses gently on the macula and holds the edges of the hole together while it heals, and it slowly absorbs on its own over several weeks — up to about two months for longer-acting gases.

After surgery, patients are usually asked to keep a face-down or head-positioning routine for a period of time to keep the bubble against the macula, which improves closure rates. Because the eye contains a gas bubble, air travel and trips to high altitude must be avoided until it dissolves. Most holes close and central vision improves, with better results for smaller holes treated sooner. Cataract commonly develops afterward in eyes that still have their natural lens. Very small or early holes are sometimes observed briefly, since a few can close without surgery.

• Do not wait months hoping central blur will clear on its own; a full-thickness macular hole rarely closes without treatment and does better with earlier surgery.
• Do not fly in an airplane or travel to high altitude while a gas bubble is in your eye, because the bubble can expand dangerously and raise eye pressure.
• Do not skip the head-positioning instructions after surgery if your surgeon prescribes them, as positioning helps the hole close.
• Do not ignore new flashes, a burst of floaters, or a shadow moving in from the side, which can indicate a retinal detachment.
• Do not assume new glasses will fix the central spot, since the problem is a physical gap in the retina.

Call for a prompt exam if the center of your vision in one eye becomes blurry or distorted or develops a small missing spot, so the macula can be imaged with OCT and referred quickly if a hole is found. Patients in the Hanover area are evaluated at May Eye Care Center and connected with retina specialists when surgery is needed. Seek emergency care instead for sudden severe vision loss or a curtain, shadow, or shower of floaters, which may mean a detachment.

A macular hole is a gap in the center of the macula that blurs and distorts central vision; it usually needs vitrectomy surgery with a gas bubble, and results are best when the hole is treated sooner rather than later.