A macular hole is a small hole in the macula, which is in the centre of the retina. The macula is the part of the retina which is responsible for our sharp, detailed, central vision.
How the eye works
We need light to see what is around us and to see colour. Light bounces off the objects we look at. These reflect different amounts of light which we see as different colours.
Front of the eye
Light rays enter the front of our eye through the clear cornea and lens. It is very important that both the cornea and lens are clear as this allows the light to pass directly through the front of the eye to the retina.
The cornea and lens bends light so that it can focus on the retina at the back of our eye. This gives us a clear, precise image. The cornea focuses the light towards our retina. The lens fine tunes the focussing of this light
Our tears form a protective layer at the front of the eye and also help to direct the light coming into our eye.
The iris, the coloured circle at the front of our eye, changes the size of the pupil which allows different amounts of light into our eye.
The pupil is the dark hole in the middle of the coloured part of our eye. The pupil gets smaller in bright conditions to let less light in. The pupil gets bigger in dark conditions to let more light in
The middle of our eye is filled with a jelly-like substance called the vitreous. The vitreous is clear and allows light to pass directly from the front to the back of our eye.
Back of the eye
The retina at the back of the eye is a light-sensitive layer which consists of rod and cone cells. These cells collect the light signals directed onto them and send them as electrical signals to the optic nerve at the back of our eye.
Rod cells are concentrated around the edge of the retina. They help us to see things that aren't directly in front of us, giving us a rough idea of what is around us. They help us with our mobility and getting around by stopping us from bumping into thing. They also enable us to see things in dim light and to see movement.
Cone cells are concentrated in the centre of our retina where the light is focused by the cornea and lens. This area is called the macula. Cone cells give us our detailed vision which we use when reading, watching TV, sewing and looking at people's faces. They are also responsible for most of our colour vision.
The optic nerve is made up of thousands of nerve fibres. These fibres pass the electrical signals along to our brain where they are processed into the image we are looking at.
How we see
Seeing can be likened to the process of taking pictures on a film with a camera which you then get developed. The retina is like a camera film which stores an image of what we are looking at. The image directed onto the retina is then sent along to the brain where it is processed, like developing a camera film. Therefore we actually "see" in our brain with the light information sent to it from our eyes. This whole process happens very quickly so that everything we see is in focus.
About macular holes
A macular hole is a small hole in the macula which is in the centre of the retina. The macula is the part of the retina which is responsible for our sharp, detailed, central vision. This is the vision we use when we are looking directly at things, when reading, sewing or using a computer.
Macular holes usually only affect one eye, though there is a 10 per cent, one in ten, chance that the other eye will eventually be affected.
A macular hole is very different from macular degeneration.
Effect of a macular hole on the eye
No one knows exactly why a macular hole develops in some people and not in others.
As we get older the vitreous, the jelly that takes up the space in our eyeball, can change. It becomes less firm and can move away from the back of the eye towards the centre. When this happens the space left behind fills with aqueous fluid, a water-like substance produced by the eye. Usually the vitreous changing causes no problems to vision at all but it may cause an increase in floaters or flashing lights.
Any new floaters or flashing lights should be examined by an optometrist.
In some people the vitreous jelly is firmly attached to the retina over the macular area. As the vitreous shrinks it can pull the macula away from the back of the eye. This can cause a small tear to develop in the macula. This is the start of a macular hole. If the aqueous fluid then seeps into the hole, it can cause the sight to become blurred and distorted.
Effect of a macular hole on vision
People with a macular hole will probably have changes in the central part of their vision. These changes can range from straight lines looking wavy in the early stages to a small blank patch in the centre of vision in the late stages. People may first notice that they have trouble reading small print or that there is distortion when they look at a printed page.
There are a number of different stages to a macular hole. 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. 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 develop and distort vision. In the final stages of a macular hole most central vision will be lost. Macular hole surgery attempts to stop the macular hole developing to this stage.
An operation can be performed to help limit the sight problems a macular hole causes.
The 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 the eye. If this is successful then often sight problems can be helped.
There are two main stages to the treatment:
• Surgery to remove the vitreous and insert gas into the eye
• A recovery period when a gas smoothes the retina back flat onto the eye.
Surgery for macular hole
The operation can be performed under general or more commonly local anaesthetic.
Using delicate instruments the surgeon removes some of the vitreous jelly in your eye. The surgeon takes particular care peeling the jelly away from your retina. This leaves a space inside the eye into which a gas is inserted.
The gas is inserted to help the macular hole heal in the correct place. This gas is lighter than air so it floats upwards. The gas acts like a bandage pressing the macula hole flat onto the back of the eye, repairing the hole and making sure that there is no risk of further damage or retinal detachment.
To make sure that the gas is putting pressure on the correct part of the retina, it is usually necessary for the patient to have their head positioned face downwards. The gas puts a small amount of pressure on the macular hole which encourages the hole to close and repair itself. The correct posture is important because it makes sure that the pressure is applied in the right place. This part of the process is often just called "posturing". Normally people have to posture for between 7 to 10 days, although some ophthalmologists are now recommending shorter periods.
During this time the gas bubble is slowly getting smaller so that eventually it 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.
While the gas is in place there may still be some distortion to sight, but when this gas has been absorbed and the aqueous fluid has taken its place, sight should be improved.
In many people there is some improvement in vision following the surgery and recovery time. However in others the operation's main effect is to stop the sight becoming any worse.
Importance of posturing
The head down posturing following macular hole surgery is very important. Managing it well can help the results of the operation on vision. If the gas does not put pressure on the correct part of the retina, the macular hole could continue to develop.
Staying face down for a long time can be difficult. It may be made more difficult if someone has other problems such as arthritis. It is important to discuss any other medical problems that may affect your ability to posture with your ophthalmologist. In some cases it may be possible to get short term help from social services while you are recovering from the macular hole surgery.
How posturing works
Usually 50 minutes out of every hour need to be spent face down. Time off from posturing is usually allowed for things such as eating and using the bathroom. Nurses usually discuss how much time needs to be spent posturing before the operation. 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 in 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.
Tips for making posturing easier
These few tips may help give you some ideas on making life more simple during this time.
Preparation before you go into hospital can be really useful. When you come home you'll be expected to start your posturing straight away. 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 housework 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.
• Keep tissues, soft drinks or fruit close by.
• If you find it difficult to drink and maintain the posture then a straw may help.
• If drinking is still difficult then ices 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.
Posturing when sleeping
Propping pillows on either side of you can stop you rolling onto your back.
If at all possible have someone to stay with you. 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.
Improvement and prevention
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 the operation.
When to have surgery
Once your macular hole has been discovered the ophthalmologist would normally want to operate within a 6 month period. Some studies suggest that the best results from the operation occur within 6 months of the hole developing.
Prognosis for vision
In many cases surgery can stop the visual disturbances getting worse and can help sight to recover to a high standard. The operation also removes the chance of the retina detaching and so can be important in stopping more sight loss.
Complications of macular hole surgery
There are two main complications associated with the operation.
Almost everyone that has this operation will develop a cataract. A cataract is a clouding of the lens of the eye. Usually the cataract can be removed in the usual way once it starts to affect vision, this may be months or years after the macular hole surgery. Please see our information on cataracts for more details.
When the ophthalmologist peels the jelly from the retina there is a chance that the retina may detach away from the back of the eye. If this happens then usually steps will be taken to reattach the retina as soon as possible, sometimes during the surgery. Please see our information on retinal detachment for more details.
Long term effects
It is very 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.
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.
Talk to someone
The RNIB Helpline is your direct line to the support, advice and products you need. We'll help you to find out what's available in your area and beyond, both from RNIB and other organisations.
Whether you want to know more about your eye condition, buy a product from our shop, join our library, find out about possible benefit entitlements, be put in touch with a trained counsellor, or make a general enquiry, we're only a call away.
Telephone: 0303 123 9999
We are ready to answer your call Monday to Friday 8.45am to 5.30pm. Outside these times leave us a message and we'll get back to you as soon as possible.
Unfortunately, RNIB can only answer email enquiries from the UK.
Our pages on information for everyday living offer ideas for people with sight problems on making life easier and ways of getting the most out of life.
At the moment RNIB is not aware of any particular support group for people affected by a macular hole. However the Macular Disease Society deals with people affected by macular problems. They can be contacted at:
Macular Disease Society
Macular Disease Society
PO Box 1870
Tel: 01264 350 551
RNIB is aware of two companies in the UK which rent equipment which may help some people with face down posturing.
Massage Table Store
Lichfield Road Industrial Estate
Tel : 01827 60013
Fax : 01827 314519
Face Down Support Hire
32 Sovereign Street
Tel: 0845 0170533
These are the only companies RNIB is aware of that offer this service. However, if you have come across another, please let us know and we can add their information here.
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