Dr Simon ChenCataract & Retina SurgeonA macular hole is a hole in the centre of the retina that can blur or distort your central vision. A quick, painless OCT scan confirms the diagnosis. Most full-thickness holes need surgery to close, although some very small holes can be monitored.
The retina is the thin, light-sensitive lining at the back of the eye. It sends signals to the brain so you can see. The macula is its central area, responsible for sharp, detailed vision. A macular hole is a gap in this central area; side vision is usually unaffected.
With age, the vitreous — the clear gel filling the eye — shrinks and pulls away from the retina. Sometimes it pulls on the macula enough to create a hole. Scar tissue on the retinal surface can also hold the hole open. Injury and short-sightedness are less common causes.
When the gel stays attached to the macula and pulls without a hole forming, this is called vitreomacular traction (VMT). The traction can settle if the gel releases, or it can progress to a hole. A macular hole is different from macular degeneration. Having a hole in one eye increases the risk of a hole in the other eye.
Further explanation: Why can vision still look distorted after epiretinal membrane or macular hole surgery?.
Further explanation: How does a gas bubble work in macular hole and retinal detachment surgery? How does a gas bubble help the retina heal?.
Central vision may become blurred or distorted: straight lines look bent, letters disappear, or a missing patch appears. This is often more noticeable when you close the other eye. Reading and recognising faces may become difficult.
Because the other eye fills in, a hole is often discovered when one eye is covered, at a routine eye test, or when reading becomes oddly difficult.
An OCT scan (optical coherence tomography) is a quick, painless scan of the retina. It shows the macula in cross-section, measures the hole and helps Dr Chen decide whether monitoring or surgery is appropriate.
After a vision test and dilating drops, the macula is examined and scanned. The scan shows whether the gel is still attached at the centre, whether there is a full-thickness hole or a partial one, and how wide it is. The state of the lens is assessed at the same time, because a cataract is often planned alongside.
Dr Chen explains what the scan shows and whether a period of watching, or surgery, is the sensible next step for that eye.
Most full-thickness macular holes need surgery because central vision may worsen while the hole remains open. Some very small holes close by themselves and can be monitored with repeat OCT scans. Vitreomacular traction can also sometimes settle without surgery. Dr Chen will explain the best option and timing for your eye.
The operation is called a vitrectomy. Through tiny openings in the eye, Dr Chen removes the vitreous gel and peels a thin surface layer around the hole to help it close. A gas bubble is placed inside the eye to support the macula while it heals.
Dr Chen usually performs the operation under local anaesthesia with sedation, so the eye is numb and you feel comfortable and relaxed. It usually takes around 30 minutes, although this can vary. You can generally go home the same day without staying in hospital overnight.
Dr Chen’s usual plan for macular hole surgery is face-down positioning for 5 days: 50 minutes of positioning followed by a 10-minute break each hour, with sleeping on your front. Because gas floats upwards, this brings the bubble against the hole to help it close. Your own written positioning plan takes priority if Dr Chen recommends a different position or duration for your eye.
Face-down positioning can be difficult, so plan support and equipment before surgery. For equipment hire, consider Summit Support at vitrectomy.com.au or 1300 133 116. Check suitability, charges and delivery before surgery.
Dr Chen performs macular hole surgery with the Alcon UNITY Vitreoretinal Cataract System (VCS) through tiny self-sealing openings. A specialised dual dye stains the delicate inner layer of the retina around the hole so that it can be seen and peeled precisely under high magnification.
About the technology in Dr Chen’s practice
Vision will be poor while the gas bubble blocks the view. As it shrinks, you may see a moving horizontal line that gradually moves downwards until the bubble disappears. The gas used for Dr Chen’s usual macular hole operation generally absorbs over about 2 weeks; other gases can last longer. The team will explain the expected duration for your operation.
After the gas disappears, vision may gradually improve. Surgery closes the hole in over 90% of cases, but closing the hole does not guarantee improved vision. The amount of improvement depends on the retinal damage, the size of the hole and how long it has been present. Improvement is less likely if the hole has been present for over a year. Some distortion or a small blind spot can remain. If the hole stays open, a second operation may be considered.
If gas will be used, plan to avoid flying and altitude travel while any gas remains in the eye. Lower air pressure can enlarge the bubble and dangerously raise eye pressure. Discuss mountain travel and your journey home with the team before surgery; do not rely on a particular altitude being safe. Fly only after the gas has completely gone and Dr Chen has cleared you.
If you need another operation, dental treatment or emergency pain relief while gas is present, tell the treating team that you have gas in your eye. Nitrous oxide (laughing gas or gas-and-air pain relief) must not be used while the bubble remains because it can expand the gas dangerously.
A cataract is clouding of the natural lens. Vitrectomy speeds up cataract formation in eyes that still have their natural lens, and cataract surgery will often be needed within a year. Dr Chen can discuss whether cataract surgery should be combined with the vitrectomy or performed later.
Other risks include infection (about 0.1%, or 1 in 1,000), retinal detachment (about 1%, or 1 in 100), bleeding, raised eye pressure, retinal swelling, and a hole that stays open or reopens. These are approximate risks; your individual risk may differ. Most complications can be treated with eye drops or further surgery, but some can cause permanent loss of vision.
Most full-thickness macular holes need surgery because central vision may worsen while the hole remains open. Some very small holes close by themselves and can be monitored with repeat OCT scans. Vitreomacular traction can also sometimes settle without surgery. Dr Chen will explain the best option and timing for your eye.
After the gas disappears, vision may gradually improve. Surgery closes the hole in over 90% of cases, but closing the hole does not guarantee improved vision. The amount of improvement depends on the retinal damage, the size of the hole and how long it has been present. Improvement is less likely if the hole has been present for over a year. Some distortion or a small blind spot can remain. If the hole stays open, a second operation may be considered.
Vitrectomy speeds up cataract formation in eyes that still have their natural lens, and cataract surgery will often be needed within a year. Dr Chen can discuss having both operations together or cataract surgery later, depending on your eye.
Not while any gas remains in the eye. Plan flights and mountain travel before surgery and fly only when the gas has completely gone and Dr Chen has cleared you. Tell any team providing anaesthesia or pain relief that you have gas in your eye: nitrous oxide must not be used while gas remains.
Longer articles by Dr Chen go into these questions in more detail, including what the research shows.
Appointments and enquiries are made through Vision Eye Institute Chatswood.
Level 3, 270 Victoria Avenue, Chatswood NSW 2067Optometrists, GPs and ophthalmologists can refer through Oculo or with the PDF referral form.
Vision Eye Institute confirms your appointment after you submit your request. The request form is not for emergencies. A referral is not strictly essential to request an appointment, but you need a valid one to claim a Medicare rebate for your consultation.