A macular hole is a small hole in the macula which is in the centre of your retina.
Macular hole causes problems with your central vision, but does not lead to total loss of sight and is not painful.
Macular hole affects the vision you use when you're looking directly at something, for example when you're reading, looking at photos or watching television. Macular hole may make your central vision distorted or blurry and, over a period of time, it may cause a blank patch in the centre of your vision.
Macular holes usually only affect one eye, though there is up to a 10 per cent (one in ten) chance that it can happen in your other eye in the future. Your specialist is best placed to tell you what your future risk might be.
A macular hole is a very different eye condition from macular degeneration.
A macular hole is not the same as a retinal tear or retinal hole and is treated differently.
The macula is a tiny area of your retina which is very important for seeing detail, colour and things directly in front of you.
When the light enters your eye it is focused onto your retina at the back of your eye. The retina includes a number of layers but the most important for vision is a layer made up of cells called photoreceptors. Photoreceptors are cells which are sensitive to light.
The macula, which is about the size of a pinhead, is a specialised area of the retina that contains a few million specialised photoreceptor cells called cone cells. These cone cells function best in bright light levels and allow you to see fine detail for activities such as reading and writing and to recognise colours.
Away from the central macula is the peripheral retina, composed mostly of the other type of photoreceptor called rod cells. They enable us to see when light is dim and provide peripheral (side) vision outside of the main line of sight. Peripheral vision is the sight you have out of the corner of your eye when looking straight ahead.
What causes a macular hole?
Often there is no known reason why someone develops a macular hole. No one knows exactly why a macular hole is more likely to develop in some people and not in others. Possible causes of macular hole are slight long-sightedness, high degree of short-sightedness and eye trauma.
Another possible cause of macular hole is posterior vitreous detachment (PVD). As you get older the vitreous jelly that takes up the space in your eyeball can change. It becomes less firm and can move away from the back of the eye towards the centre. This kind of vitreous change is called posterior vitreous detachment (PVD) which is very common. Usually the vitreous changing causes no permanent change to sight but it may cause temporary floaters or flashing lights in your vision.
The vitreous jelly in the middle of your eye is attached in different places to the macula and retina at the back of your eye. As the vitreous becomes more watery with age it begins to pull away from the retina and macula. Usually the vitreous comes away from the back of the eye smoothly without causing any problems. For some people part of their vitreous may move away from the retina but not all of it. This may lead to concentrated pulling on parts of the back of the eye where there is remaining traction between the vitreous and the retina.
If traction remains between a part or parts of your retina and vitreous you may be at more risk of developing a retinal tear or detachment. Most people do not develop a retinal tear or detachment and there are very successful treatments if these conditions develop.
If traction remains between the vitreous and your macula then this is called vitreomacular traction. Vitreomacular traction can lead to a macular hole.
How does a macular hole affect vision?
If you develop a macular hole you will probably notice changes in the central part of your vision. These changes can range from straight lines looking wavy in the early stages to a small blank patch in the centre of your vision in the late stages. An early symptom you may first notice is that you have trouble reading small print or that print looks distorted.
There are a number of different stages in macular hole development. These stages are usually classed by the size of the hole and the layers of the eye which are affected. This is important to know because in the early stages it is possible for macular holes to heal themselves. Around 50% of stage 1 holes heal themselves once the vitreous jelly naturally separates from the macular. Around 10% of holes at stage 2 also naturally heal themselves although it can vary how much sight improvement someone will have. This means that sometimes an ophthalmologist (eye specialist) will want to monitor the progression of a macular hole before recommending any treatment.
However in most cases a macular hole will carry on developing and distort vision. In the final stages of a macular hole most central vision will be lost and after a year it can stop you from being able to see the top letter of the eye test chart. Macular hole treatment attempts to stop the macular hole developing to this final stage and to improve vision as much as possible.
What treatment is available for macular hole?
Your ophthalmologist may feel it is best to leave the macular hole for a period of time before checking your eye again to decide if treatment is needed.
If your ophthalmologist feels treatment is needed there are two possible options for macular hole: an injection into the eye which can be used in the early stages of a macular hole developing, and surgery which is used when a macular hole is more developed. Your specialist will advise you on the options and which one would suit you best.
1. Jetrea (ocriplasmin) injection - new treatment for macular hole
Jetrea is a new treatment for vitreomacular traction. Vitreomacular traction can cause distortion and swelling at the back of the eye and lead to a macular hole. Jetrea is an injection into the eye. It loosens or separates vitreomacular traction, that is the traction between the vitreous and macula which pulls the macula out of place. By separating the traction Jetrea allows the macular to lie flat again against the back of the eye. By removing vitreomacular traction the macular hole can close and the surgery mentioned below may not be needed.
Jetrea can be given to patients on the NHS who have a stage 2 full thickness macular hole with a diameter of 400 micrometres or less, and/or which is causing severe symptoms. This means that in general Jetrea would only be of use in the earlier stages of macular hole development. This is because macular holes of stage 3 and above are bigger than 400 micrometres.
You cannot have Jetrea if you also have another eye condition called “epiretinal membrane” or “macular pucker”. An epiretinal membrane is when a thin layer of scar tissue forms over the retina at the back of the eye.
How is the Jetrea injection given?
Jetrea is a one off injection given into the vitreous (the jelly-like substance inside your eye). The injection is given through the white of your eye (the sclera). The injection needs to be given in a sterile way and you may have the treatment in an operating theatre, though more commonly it may be given in a room which has been designed for this type of treatment (sometimes called a clean treatment room).
The needle used for the injection is very sharp, small and short and the injection itself only takes a few seconds. As you will have had an anaesthetic drop in your eye the injection feels like a small point of pressure on your eye rather than a scratch. The following are basic steps for giving an injection into the eye; however, your hospital may have their own procedures.
- You will be given eye drops which dilate your pupil. This allows your ophthalmologist to see the back of your eye more easily.
- You will also be given local anaesthetic eye drops or a local anaesthetic injection. These will help to make the injection as pain free as possible.
- The eye and skin around your eye will be cleaned to prevent infection.
- Your face and the area around your eye will be covered by a drape to keep the area sterile.
- A small device called a speculum will be used to keep your eye open and prevent you blinking.
- You may have more anaesthetic drops put into your eye to numb it and prevent you feeling pain.
- Once your eye is numb the injection will be given.
- Following the injection, you will be given antibiotic drops to take afterwards.
After your injection your vision may be blurry for several hours because of the dilating eye drops; this should improve by the next day or the day after. The white of your eye may be red where the injection was given but that should disappear in a few days. You may notice black swirls in your vision for a few weeks which is the drug floating in your vitreous gel. Your eye should feel comfortable by the next day. You may be given some eye drops to take for a few days after the injection to prevent you developing an infection.
The risk of complications from Jetrea is small. Complications are usually due to the having an injection into your eye. The clinical trials showed that the complications from treatment were non-serious, mild in intensity, and resolved. Therefore the complications were not considered to be clinically significant and the risk of Jetrea injection considered to be very low.
These non-serious complications include:
- temporary raised eye pressure: the intravitreal injection increases the amount of fluid in your eye and therefore may increase your eye pressure for a short time after the injection. Usually this increase in eye pressure is temporary and doesn't cause any long term problems
- temporary eye inflammation immediately after the injection
- retinal breaks or tears
- temporary changes in colour vision (called dyscromotopsia) leading to a yellow tinted vision
- vitreous floaters.
In the clinical trials of Jetrea no systemic risks were found, meaning that Jetrea did not cause problems in other parts of the body.
No eye infections were reported during the clinical trials for Jetrea. However, there have been reports of eye infection following Jetrea injection although these cases are rare. Eye infections can normally be treated successfully. Rarely an eye infection does not respond to treatment which can lead to sight loss in that eye.
Although complications are rare it would be very important to seek immediate medical attention following a Jetrea injection if you notice a worsening of your vision or symptoms, or if you notice any new symptoms.
Your specialist will consider both Jetrea and the surgical option when examining your macular hole and discuss with you what treatment would be best in your particular case to give you the best visual outcome.
2. Surgery for macular hole
Your macula needs to lie flat on the back of the eye to receive, through blood vessels, all the nourishment it needs to work properly. The surgery is an attempt to help the macula lie flat on the back of your eye. If this is successful and the macula stays flat on the back of the eye then often sight problems can improve. In the months that follow surgery around 80-90% of people have an improvement in vision. The level of improvement varies from person to person and your ophthalmologist is best placed to let you know what kind of improvement they hope surgery will achieve for you.
If the first surgery is not successful your specialist may need to re-operate to close your macular hole depending on what is happening in your particular case. Most people do not need to have a second surgery as the success rates for the first surgery are very high. There are two main stages to the treatment:
- Surgery to remove the vitreous and insert gas into the eye.
- A recovery period when the gas bubble stops fluid from flowing into the macula hole allowing it to close and heal.
When should I have the surgery?
Once your macular hole has been discovered your ophthalmologist will assess whether you need surgery or whether they want to monitor your macular hole for a period of time. If your ophthalmologist feels surgery is needed they may want to operate within a 6 month period to try and get the best results depending on the stage of your macular hole and how much your vision has been affected. However, someone can still regain useful vision when a macular hole is operated on after 6 months.
Some people experience a small improvement in vision, or at least stop their vision from worsening, if their macular hole is operated within a 12 month period of the hole developing. However, after 12 months there is usually less vision improvement than if the hole had been operated on before.
Will surgery help my vision?
In many cases surgery can stop the visual disturbances getting worse and can help sight to recover to a high standard. How much visual improvement you gain from macular hole surgery can depend on how big the hole is, how old the hole is and how far you could read down the eye test chart before surgery.
Macular hole surgery can often improve vision by up to two lines on the eye test chart and sometimes more. This means that after the surgery and recovery you should be able to read more letters on the eye test chart than you could before your macular hole surgery. Even if your surgery does not enable you to see more on the eye test chart, it usually improves distortion and stabilizes vision. Surgery does not normally fully correct vision to what it was before the macular hole started. Your ophthalmologist would be able to discuss with you how they hope you will benefit from surgery depending on the health of your eye and stage of your macular hole.
It can take up to six months after surgery for the eye to fully recover and for someone to know ultimately how much vision they have re-gained. Most of the eye's and vision recovery takes place over the first 2-3 months after surgery.
What is involved in the surgery?
The operation can be performed under general or more commonly local anaesthetic.
Using delicate instruments the surgeon removes some of the vitreous jelly from your eye. The surgeon takes particular care peeling the vitreous away from the macular area of your retina. This stops the vitreous from pulling on your macular and allows your macula to lie flat against the back of your eye again. Removing the vitreous leaves a space inside the eye into which a gas is inserted.
The gas is inserted to help the macular hole heal. This gas is lighter than air so it floats upwards. The gas bubble sits on the macula and stops fluid from flowing into the macula hole allowing it to close. It also helps to protect against the risk of further damage or retinal detachment.
To make sure that the gas is sitting on the correct part of your retina and helping the hole to close, it might be necessary for you to have your head positioned face downwards. The correct posture is important because it makes sure that the gas is blocking the hole properly which allows it to heal. This part of the process is often called “posturing”.
Not all patients have to posture after surgery. If a patient needs to then they would normally posture for 3 days, and occasionally up to a week. Your ophthalmologist can discuss with you what they feel is needed in your case. They would also take into account what they feel you can manage. For example, some people with arthritis or back problems may not be able to posture for so long.
Flexibility around posturing timeframes is due to research which suggests that, depending on the size of the macular hole, the surgical procedure used and the amount of gas used, the macula can heal just as well without posturing. The amount of gas used can vary and your ophthalmologist will assess how much you need.
The research found that there was no extra benefit in posturing after surgery for people with idiopathic (meaning no known cause) macular hole of less than 400 microns in diameter. However, two out of three clinical trials suggested a benefit in posturing if a macular hole is more than 400 microns in diameter.
Your ophthalmologist will assess what is happening in your case and decide on the best course of action to give you the best chance of a good outcome.
During the two to three months that follow your surgery the gas bubble inside your eye slowly gets smaller so that eventually it dissolves completely and is no longer in the eye. As this happens the space that was taken up by the gas is filled with aqueous fluid ̶ the natural fluid made by the eye. You will not be left with an empty space in the middle of your eye.
Gas inside your eye usually causes distortion and blurred vision, but when this gas has been absorbed and the aqueous fluid has taken its place, your sight should improve.
Possible complications after macular hole surgery
Macular hole surgery has a high success rate. All surgery carries the possibility of complications or risk, although the risk rate is low and if a complication develops there are treatments available. For this reason it is rare for someone to lose vision from a complication following macular hole surgery. Your ophthalmologist is best placed to advise you on what the complications are and the chances of them happening. Complications from macula hole surgery include:
Almost everyone that has this operation will develop a cataract. A cataract is a clouding of the lens of the eye. A cataract caused by macular hole surgery can normally be removed the same way as other types of cataracts and it may not develop or need to be removed until months or years after your macular hole surgery.
Sometimes an ophthalmologist will choose to perform both your macular hole surgery and a cataract surgery at the same time. Often this depends on whether you have the signs of a cataract already. If you do have signs of a cataract then it would be more likely for the macular hole and cataract surgery to happen at the same time. Please see our information on cataracts for more details.
Following all types of eye surgery there is a risk of raised eye pressure, which is different from your blood pressure. Eye pressure will usually go up in the short-term following surgery and you will be given drops to help reduce eye inflammation and lower eye pressure whilst you recover. Eye pressure comes down to normal for most people during their recovery, but for some patients eye pressure may go very high or stay elevated in the long-term, which can damage the optic nerve at the back of the eye and affect vision. There are medications and treatments to help manage eye pressure and protect vision if needed.
Following all types of eye surgery the eye may develop an infection. You will be given antibiotic drugs after surgery to safeguard as much as possible against an infection and if someone develops an infection it can usually be treated. In rare cases, around 1 in 1000 patients, vision may be lost by a serious eye infection.
When the ophthalmologist peels the jelly from your retina there is a small chance that the retina may detach away from the back of your eye. If this happens then steps will be taken to reattach the retina as soon as possible, sometimes during the macular hole surgery. There are treatments to reattach the retina so it is rare for this complication to lead to blindness in that eye. Please see our information on retinal detachment for more details.
Surgery can cause the very rare complication of bleeding within the eye which can cause blindness.
Posturing after surgery
The head down posturing following your operation can be an important part of recovery from macular hole surgery for some people. Managing it well may help the results of the operation on vision.
Staying face down for a long time can be difficult. It may be made more difficult if you have other problems such as arthritis. It is important to discuss any other medical problems that may affect your ability to posture with your ophthalmologist. If your ophthalmologist feels you need to posture it may be possible to get short term help from social services while you are recovering from the macular hole surgery.
How does posturing work?
Usually 45-50 minutes out of every hour needs to be spent face down, although posturing timing can vary. This allows you 10-15 minutes off from posturing every hour for things such as eating and using the bathroom. You might be able to speak with a nurse before the operation to discuss how much time you need to posture for and they may be able to give you some tips on how to manage your posturing. It is important for you to discuss any particular concerns you might have about posturing with your ophthalmologist or clinic nurse before the day of your surgery.
It is important to remember that some of your time off from posturing may also be taken up putting in any eye drops you need following the surgery.
It is not necessary to lie completely flat and many people posture whilst sitting in a chair. This means sitting in a chair and leaning forward onto some sort of support such as a stool or another chair. Obviously using pillows can make this posture much more comfortable.
Trying out different ideas to help with the posturing can help you choose the most comfortable way for you. For example:
- Sitting at a table on a hard-backed chair and leaning forwards onto the table.
- Sitting in an armchair leaning onto a small stool.
- Some people prefer to remain in bed whilst posturing, particularly if they have any kind of problems with the joints of their neck or shoulders.
It might be useful to have various places to posture so you may want to try all of them to see which one you prefer. Different positions and changing where you are sitting may help any stiffness or boredom.
Any tips to make posturing easier?
These few tips may help with your posturing.
Preparation before you go into hospital can be really useful. If you specialist wants you to posture after surgery you’ll be expected to start your posturing straight away when you come home. The following pointers, may help you think about what you might need to do to prepare around the house before you go into hospital:
- Do any house work that is necessary
- Make sure what you are going to use to posture with is in the right place.
- Move furniture and pillows into the place where you are going to posture.
- Make sure that the floor is clear of clutter, to help you get around without falling or having to move anything.
- Organise a shopping trip so that you don’t have to worry about things like food and toiletries.
- You may want to prepare some food in advance that may just need heating up, this will save time on preparing and cooking food.
- You may want to rely on ready meals just for this period, that only need heating up in the microwave.
- Arrange to pay any bills that are due and to organise any benefits to be collected if you would normally need to do this.
Preparing for posturing
Wherever you are posturing it is a good idea to have things close by that you may need.
- Things like tissues or soft drinks or fruit are good to have close by.
- If you find it difficult to drink and maintain the posture then a straw may help.
- If drinking is still difficult then ice cubes are very good at moistening the mouth without you having to swallow.
- Drinking is important though and should be encouraged on your posturing breaks.
- You may also want to have some form of entertainment. It may not be possible to watch TV so having a radio close by can help with the boredom as can music that you enjoy.
- Move the telephone too, as you will be able to answer it better if it is near you.
How do you posture when you are sleeping?
Propping pillows on either side of you can help to stop you rolling onto your back. It can also help to pop a pillow under your forehead and another one under your chest and chin. This can help you to create a breathing space which might make you feel a little more comfortable. It can be tricky to keep the right posturing position overnight whilst sleeping. As long as you are posturing throughout the day and doing what you can to posture at night then you are doing your best to give your recovery every chance.
Help at home whilst you recover from surgery
If at all possible it can help to have someone, such as a family member or friend, to stay with you after surgery whilst you are posturing. Having someone to make drinks and food can help enormously. This helps to cut down on the amount of time you spend doing these things during your time off from posturing. Having someone to help during posturing may be of particular importance if you have sight loss in your non-operated on eye or if you have another disability.
For many people it is not possible to have someone stay with them after surgery. Your hospital can arrange short-term care at home for up to 6 weeks after surgery. This might involve help with shopping, food preparation, cooking, cleaning, or looking after your personal hygiene. If you feel this kind of help would be of use then it is important to discuss it with the hospital well in advance of your surgery date so they have time to make the appropriate care arrangements for you. Through our Helpline we can provide you with further advice regarding available help and care services.
Eye care after surgery
Immediately after the surgery you will be given eye drops. You will probably have two types of drops – an antibiotic drop to prevent infection and a steroid drop to help reduce any swelling. It is important to take these drops as your ophthalmologist recommends and to complete the course. Your eye clinic should be able to give you information on how to use your eye drops. If you have problems using the drops you should let your GP know as they may be able to arrange some help for you.
After surgery, and especially once the gas bubble has dissolved, people may begin to notice an improvement in vision. If your eye is very painful, feels increasingly hot or gets increasingly red, if your vision suddenly gets a lot worse, or you get new or increased symptoms such as floaters or flashes of light after surgery then you should let the hospital know as soon as possible as this may mean they need to see you again.
After surgery, you can usually go back to your everyday activities once you have finished posturing. Apart from taking eye drops, you can usually carry on as normal but you may need to avoid the following activities for the first few weeks after surgery or until you see your specialist again and ask their opinion. The hospital should advise you before you are discharged.
- Rubbing your eye. You may have to wear an eye shield (patch) when you are sleeping to avoid rubbing your eye.
- Swimming (until your ophthalmologist says you can), to avoid contact with dirty water while your eye is healing.
- Strenuous exercise, contact sports and heavy lifting. Everyday lifting like light shopping is usually fine, but heavy lifting like moving furniture is best avoided.
- Wearing eye makeup until the hospital is happy with your recovery.
- You must not fly or travel to high altitude on land until your gas bubble has fully absorbed which can take up to 12 weeks. The gas bubble expands at altitude, causing very high pressure and can cause permanent sight loss.
- You will need time off work to recover and your ophthalmologist is best placed to advise you how long to take off. This may depend on the type of work you do and also on how you recover.
You also need to take extra care:
- when it is windy or dusty outdoors, in case something blows in your eye, but you don't need to stay indoors – sunglasses or glasses will help to protect your eyes
- washing your hair. Avoid soapy water in your eye.
Usually, you will see your ophthalmologist about 3-6 weeks after the operation. At this appointment you can ask them about returning to all your usual activities. Some patients may need to wait a bit longer before returning to normal activities depending on how their eye is recovering.
Is there anything I can do to avoid or improve a macular hole?
There is nothing that can be done to avoid a macular hole. Diet or exercise are not thought to contribute to the problem. Having an eye test at least every two years is the best way to make sure your eye is healthy and that no new eye conditions are developing. There is no evidence that taking any kind of action or medicine can help fix a macular hole. In most cases the best treatment is Jetrea or surgery if recommended by your ophthalmologist.
What can be done if my sight is seriously affected?
It is rare to have problems with macular hole in both eyes, so even if the operation is not very successful most people have good vision in their other eye. Your ophthalmologist would be able to tell you what your risk is of developing a macular hole in your other eye.
If after surgery vision is still affected then magnifiers and large print may help you cope with the sight problems. RNIB can give you information and advice on the kinds of help and products that are available for people with sight problems.
Sources of help
Many people who have macular hole surgery have some visual improvement afterwards in that eye. However, if you do not get much improvement, experience sight problems or develop complications after surgery which affect your sight in that eye, then there are lots of things you can do to make the most of the vision you have. This may mean making things bigger, brighter or using colour to make things easier to see. Ask your ophthalmologist, optician or GP to refer you to your local low vision service. However, most people only have macular hole in one eye and have useful vision in their other eye which can help to compensate.
Being diagnosed with an eye condition can be very upsetting. You may find that you are worried about the future and how you will manage with a change in your vision. All these feelings are natural.
Some people may want to talk over some of these feelings with someone outside their circle of friends or family. RNIB can help, with our telephone Helpline and our emotional support service. Your GP or social worker may also be able to help you find a counsellor if you think this would help you.
Sometimes it can help to talk about your feelings or share your experience with people who may have had similar experiences.
Help to see things better
Ask your ophthalmologist, optometrist or GP about low vision aids, like a magnifier, and ask for a referral to your local low vision service. You should also ask whether you are eligible to register as sight impaired (partially sighted) or severely sight impaired (blind). Registration can act as your passport to expert help and sometimes to financial concessions. Even if you aren’t registered a lot of this support is still available to you.
Local social services should also be able to offer you information on staying safe in your home and getting out and about safely. They should also be able to offer you some practical mobility training to give you more confidence when you are out.
Our Helpline can also give you information about the low vision services available, and our website offers lots of practical information about adapting to changes in your vision and products that make everyday tasks easier.
105 Judd Street
Helpline: 0303 123 9999
The RNIB Helpline can:
- Put you in touch with one of our specialist advice service such as welfare benefits and rights, education, employment, legal rights, emotional support, daily living help and residential care.
- Send you free information and leaflets.
- Give you details of support groups and services in your area.
Call us Monday to Friday 8:45 am – 5:30pm.
Low Vision Services can help people make the most of their sight. They:
- are normally located within the hospital eye departments
- are usually accessed through a referral from the hospital eye consultant or your GP
- offer a thorough assessment of vision and prescribe the appropriate magnifier for the individual
- provide training on how to best use the magnifier
- give advice on lighting which can be important in getting the most benefit out of the magnifiers
- give advice on maximising the use of peripheral vision.
Are there any specialist sources of help?
At the moment RNIB is not aware of any particular support group for people affected by a macular hole. However the Macular Society deals with people affected by macula problems.
BEAVRS (British and Irish Vitreo-Retinal Surgeons) promote high quality patient care by supporting and representing British and Irish Vitreo-Retinal Surgeons through education, research, audit and revalidation. You can find their information leaflet on macular hole at the following link: www.beavrs.org/about/patient-information/macular-hole.
RNIB is aware of two companies in the UK which rent equipment which may help some people with face down posturing. They can be contacted at:
The Massage Table Store
Lichfield Road Industrial Estate
t: 01827 318236
f: 01827 316623
Face Down Support Hire
Onward Business Park
t: 0845 017 0533
These are the only companies RNIB is aware of that offer this service, however if you have come across another then please let us know and we can add their information here.
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