Macular Holes

The macula is the center of the retina. It is responsible for central vision (straight ahead vision), your best vision, and most color vision. The center of the macula is called the fovea.

Q: Description of a macular hole.

A: A macular hole is a defect in the macula.


Q: Symptoms of a macular hole.

A: They are decreased or complete loss of central vision. Other eye problems can cause similar symptoms; the presence of a macular hole can only be determined by a dilated eye exam.


Q: Can macular holes cause total blindness?

A: No, they can only cause loss of central vision.


Q: How common are macular holes?

A: Classic macular holes are a moderately common cause of irreversible central visual loss in people over age fifty. They are three times as common in women as in men, for unknown reasons.


Q: What is the cause of macular holes?

A: Most macular holes are apparently related to posterior vitreous separation. Residual vitreous humor remaining on the retinal surface after this event probably contracts, pulling on the macula and fovea in an outward direction.

Some macular holes are caused by a thin layer of tissue known as an epiretinal membrane. These holes typically have no cuff of fluid around them and are associated with retinal “wrinkles”.


Q: Does hardening of the arteries cause macular holes?

A: No, circulation problems have not been shown to have any relationship to macular holes.


Q: Are eye strain, nutrition, general health, smoking or emotional stress related to macular holes?

A: No, there is no known relationship between macular holes and any of these problems.


Q: If one eye develops a macular hole, will the other eye develop one?

A: Usually not; most patients develop holes in one eye only. The odds are about 6% of developing a hole in the second eye.


Q: What is the treatment for macular holes?

A: Vitreous surgery, placement of a gas bubble inside the eye, forceps/internal limiting membrane peel, and head down positioning for 1-2 weeks after surgery are required to repair macular holes.

Vitreous surgery consists of removing the vitreous to enable injection of a large gas bubble and, in many instances, peeling of tissue from the retinal surface to stimulate hole closure.

The tissue on the retinal surface may be residual vitreous, epiretinal membrane, or ILM. Most, but not all surgeons, peel this tissue away from the retinal surface during vitreous surgery.

Dr. Charles developed forceps membrane peeling techniques in the early 1980s. This technique has been improved by using an inside out, circular motion and special forceps that conform to the retina surface. This method, developed by Dr. Steve Charles, is more precise than the FILMS method.


Q: I’ve heard that ICG dye is sometimes used in this type of surgery. Do you use it?

A: ICG dye is not used by our surgeons  because toxicity of the dye has been reported by others. We do use brilliant blue stain which has been shown to be safe and effective.


Q: Is there a medication for the treatment of macular holes?

A: No: there is no medicine, eye drop, vitamin, herb, or diet that is beneficial to macular hole patients.


Q: Is there a laser treatment for macular holes?

A: No, only surgery can repair a macular hole.


Q: Do holes ever disappear without surgery?

A: Rarely


Q: What is the purpose of the gas bubble?

A: It acts like a bandage to pulling the defect in the retina back together using surface tension.


Q: Why is it necessary to be face down when a gas bubble is in the eye?

A: The bubble floats and is only in contact with the macula when the face is pointed toward the floor. Face down positioning is not needed if prior cataract surgery has been performed, although the patient cannot recline or lie on their back while the bubble is present.


Q: How many hours per day should the patient be face down?

A: Our doctors recommend that strict head down position is kept at all times for 7-10 days after surgery. Patients can sleep and nap face down, read with the book or papers in their lap, watch television by placing a small set on the floor, and walk for exercise while looking down without much difficulty. Some occupations are compatible with this approach while others are not. Driving should limited to emergencies. Limited compliance with head positioning decreases the chance of success of the surgery and increases the chance of cataract formation.


Q: How long does the surgery take?

A: The procedure usually take our doctors less than 30 minutes.


Q: Is the surgery performed on an inpatient or outpatient basis?

A: The surgery is performed on an outpatient basis in all cases unless there is a medical reason to be in the hospital.


Q: Can I fly with a gas bubble in my eye?

A: No. The bubble can expand, causing pressure increase, excruciating pain, and even blindness in the eye. Airplane travel, mountain climbing or travel in or to or through the mountains, scuba diving, and travel to higher elevations by any mode of transportation are to be avoided while the gas bubble is present in the eye. These activities can generally be resumed once the bubble has completely resorbed.


Q: What is the success rate of the vitreous surgery?

A: The rate of closure of the macular hole after successful surgery is about 90%, but the rate of visual improvement varies considerably. Most patients experience some improvement in vision after successful surgery. The final improvement in vision may not be achieved for many months after surgery. All of the factors affecting the degree of improvement are not yet understood, but include:

• the size of the hole.
• the quality of the surgical technique.
• the ability of the patient to remain  in a face down position for 7-10 days.


Q: Are there any complications?

A: Often, there is a significant instance of cataract progression after vitreous surgery. Some doctors believe that patients with an absolutely clear lens develop cataracts as a result of vitreous surgery, but our doctors disagree. The vast majority of patients requiring vitreous surgery for macular hole have nuclear sclerotic cataracts (yellowing of the center of the lens), which can worsen after vitreous surgery. Surgeons differ widely on the percentage of patients that suffer cataract progression due to vitreous surgery. Our doctors believe that the progression rate is almost 100%.

Retinal detachment can occur after vitreous surgery performed for any reason, including macular hole repair. Opinions vary widely on the frequency of retinal detachment after macular hole surgery. Our doctors believe that the incidence is less than 2%.

A small number of patients (about 1%) will experience reopening of the hole after initial success.


Q: If the hole reopens, should surgery be repeated?

A: A second procedure will often close the hole.