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Macular Hole

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What is macular hole?

The macula provides the sharp, central vision we need for reading, driving, and seeing fine detail. A macular hole is a small break in the macula, located in the center of the eye's light-sensitive tissue called the retina.

Who is at Risk?

In 80% of patients, macular holes are associated with the aging process, usually in those over the age of 60. Near-sightedness, trauma, systemic diseases and inflammation are associated with the other 20%. Ten percent of patients will usually go on to develop a macular hole in the other eye. Females tend to be affected more commonly than males and an associations with changing estrogen levels around the time of menopause have been proposed.

Signs and Symptoms

Some of the most common symptoms that patients complain of are distortion of vision, difficulty reading, or a blind spot in the center of vision. If it is the non-dominant eye it may go undetected until it is picked up on a routine eye exam or the good eye is accidentally covered while performing a visual task.

Diagnosis

While direct examination with an ophthalmoscope is often used to detect a macular problem, confirmation that a hole is present may require other tests such as flourescein angiography (FA) and optical coherence tomography (OCT). An FA may be used to identify associated conditions such a diabetic retinopathy or vasculitis. An OCT is used to clearly identify a hole and any associated features such as an epiretinal membrane, vitreous traction or cystoid macular edema.

Separation of the vitreous gel from the retina leads to a tear in the macula and the development of the hole in stages:

1. macular cyst
2. full thickness hole <400 microns in size
3. full thickness hole >400 microns in size
4. full thickness hole of any size associated with complete posterior vitreous detachment (PVD).

Treatment

A vitrectomy is required for Macular hole surgery. This is performed by removing the vitreous gel inside of the eye and replacing it with a gas bubble. The fine internal limiting membrane (ILM) around the edge of the hole is often removed at the same time to increase the success rate of the procedure. This combination of procedures is termed vitrectomy, membrane peeling and fluid-gas exchange. Intraocular laser ("Endolaser") may also be applied if any thin retina, holes or tears are found at the time of surgery.

Patients must remain face down for 5-10 days after surgery to achieve the best possible results. The bubble holds the edges of the hole together while the retina heals. A face down positioning device like a massage table can be ordered to help patients comply with these positioning instructions. The prognosis for visual recovery however also depends on other factors such as the duration of the hole as well as other conditions such as macular degeneration.