What is a macular hole?
A macular hole is an opening or defect at the fovea, the very centre of the macula. The fovea provides our sharpest central vision and allows us to read, recognise faces and see fine detail.
The term can describe different types of defect:
- A full-thickness macular hole extends through the full thickness of the retinal tissue at the fovea.
- A lamellar macular hole is a partial-thickness defect in which some retinal tissue remains intact.
- An early or impending macular hole occurs when traction is affecting the fovea but a complete full-thickness opening has not yet formed.
- A traumatic macular hole may develop following an injury to the eye.
- A myopic macular hole can occur in highly short-sighted eyes, where stretching and thinning of the retina may make the condition more complex.
When a macular hole develops, central vision can become blurred, distorted or interrupted by a dark or missing patch. Objects may also appear smaller or less distinct when viewed with the affected eye.
The visual effect depends on the type, size and depth of the defect. Full-thickness holes are more likely to cause a noticeable central gap in vision, while lamellar holes may produce milder blurring or distortion.
A macular hole usually affects one eye. However, careful assessment of both eyes is important because the other eye may show vitreous changes or traction that require monitoring.
At The Retina Clinic London, macular holes are assessed using high-resolution retinal imaging, particularly optical coherence tomography, known as OCT. OCT provides detailed cross-sectional images of the fovea and allows the consultant to assess the type, size, stage and characteristics of the hole.
What symptoms can a macular hole cause?
Symptoms may include:
- Blurred central vision
- Distorted vision
- Straight lines appearing bent or wavy
- Difficulty reading
- A dark, blurred or missing spot in the centre of vision
- Objects appearing smaller or less distinct
- Reduced detail when looking directly at an object
- Difficulty recognising faces
The severity of symptoms depends on the type, size and duration of the macular hole.
A small, early or lamellar hole may cause relatively mild distortion. A larger full-thickness hole can create a more noticeable missing area at the centre of vision and significantly affect reading, facial recognition and other detailed tasks.
These changes can also occur with other macular conditions, so specialist retinal assessment is needed to establish the cause.
Why do macular holes develop?
Most macular holes develop because of traction, or pulling, at the surface of the retina.
As the vitreous gel inside the eye changes naturally with age, it usually separates from the retina. If it remains attached to the fovea and pulls on its centre, an early defect or full-thickness macular hole can form.
Other causes and associations may include:
- Eye injury or trauma
- High short-sightedness
- Previous retinal detachment
- Previous retinal surgery
- An epiretinal membrane
- Other conditions affecting the macula
How are macular holes diagnosed?
The key diagnostic test is OCT imaging.
OCT provides a highly detailed cross-sectional scan of the fovea and macula. It shows:
- Whether the defect is full-thickness or partial-thickness
- The size and shape of the hole
- Whether vitreous traction is still present
- Whether an epiretinal membrane or another retinal change is contributing
- The condition of the retinal tissue surrounding the hole
At The Retina Clinic London, assessment may also include:
- Visual acuity testing to measure the effect on central vision
- A detailed dilated retinal examination
- Ultra-widefield retinal imaging to assess the wider retina
- Additional retinal imaging where appropriate
Together, these investigations allow the consultant to classify the hole accurately, assess both eyes and determine whether monitoring or surgery is the most appropriate approach.
Does every macular hole need surgery?
Not every macular hole requires immediate surgery.
An early or impending hole may occasionally resolve if the vitreous releases naturally. Some lamellar holes remain stable and can be monitored when symptoms are mild and the retinal structure is not deteriorating.
Full-thickness macular holes are more commonly treated with vitrectomy surgery, particularly when they are affecting vision or are unlikely to close without an operation.
The decision is based on:
- The type of macular hole
- Its size and stage
- How long it has been present
- The effect on vision
- The OCT appearance
- The condition of the surrounding retinal tissue
- The health of the other eye
The consultant will explain clearly whether observation or surgery is the most appropriate approach.
How is a macular hole treated?
Vitrectomy is the established surgical treatment for most symptomatic full-thickness macular holes.
During the procedure, the surgeon removes the vitreous gel from inside the eye and releases any traction affecting the fovea.
A very fine layer called the internal limiting membrane, or ILM, may then be carefully peeled from the retinal surface. The ILM is the retina’s delicate innermost layer. Peeling it helps release residual traction and supports closure of the hole.
For larger, longstanding, highly myopic or otherwise complex macular holes, the surgeon may use an advanced technique such as an inverted ILM flap. This uses a carefully positioned part of the membrane to provide additional support for tissue repair and hole closure.
If an epiretinal membrane is also present, this may be peeled during the same procedure.
A gas bubble is commonly placed inside the eye at the end of surgery. The bubble rests against the fovea and supports the hole while the retinal tissue heals.
Lamellar macular holes require individual assessment because their structure, visual effects and treatment needs differ from those of full-thickness holes.
The exact surgical plan is tailored to the type, size, duration and characteristics of the macular hole.
What can surgery achieve?
The principal aim of surgery is to close the macular hole and improve or stabilise central vision.
Visual recovery is usually gradual and may continue over several weeks or months. The degree of improvement depends on factors including:
- The type and size of the hole
- How long it has been present
- The condition of the retinal tissue
- Vision before surgery
- Whether the hole closes successfully
Although surgery can provide meaningful improvement, vision may not return completely to how it was before the hole developed.
What is recovery like?
Recovery varies according to the surgical technique and the type of gas bubble used.
Vision will be blurred while the gas bubble remains inside the eye. As the bubble becomes smaller, patients may notice a moving line across their vision before it disappears completely.
Patients may be asked to maintain a particular head position, sometimes including face-down positioning, for a period after surgery. The consultant will provide clear, personalised instructions based on the hole and the surgical approach.
While a gas bubble is present:
- Air travel is not permitted
- High-altitude travel must be avoided
- Patients must tell any doctor or anaesthetist that there is a gas bubble in the eye
- Nitrous oxide anaesthetic gas must not be used
Eye drops are prescribed following surgery. Regular follow-up appointments include OCT imaging to confirm whether the hole has closed and to monitor retinal healing.
Our approach
The Retina Clinic London combines advanced retinal imaging with specialist vitreoretinal surgical expertise.
Macular hole surgery is performed by experienced vitreoretinal surgeons in our dedicated onsite operating theatre using advanced operating microscopes and microsurgical systems.
Our surgeons tailor the operation to the individual macular hole and can use specialised techniques, including the inverted ILM flap, for larger or more complex cases where appropriate.
Patients receive a clear explanation of:
- The type and characteristics of their macular hole
- Whether monitoring or surgery is recommended
- The proposed surgical technique
- The role of a gas bubble
- Any positioning requirements
- Expected recovery and realistic visual outcomes
Close postoperative follow-up, including high-resolution OCT imaging, allows healing and hole closure to be monitored carefully.
The next step
If you have blurred or distorted central vision, a missing patch in your central vision or have been told that you may have a macular hole, a specialist retinal consultation can provide clarity and guide the appropriate next step.
To book your consultation, please call us on +44 (0)20 4548 5310 or visit https://www.theretinacliniclondon.com/book-a-consultation/
We’ll be glad to guide you through the next steps.