A macular hole is an eye condition that affects the central part of the retina, leading to a gradual decline in central vision, which is essential for daily tasks like reading and driving. Symptoms typically develop slowly, with straight lines appearing distorted or bent, and difficulty recognizing small text or facial details. As the condition worsens, patients may notice a dark spot or missing area in the center of their visual field. Although a macular hole does not cause pain or total blindness, it often requires surgical treatment to close the hole and restore some of the lost vision.
What is the macula?
The macula is a small area located in the center of the retina and is the most sensitive part of the retina to light. This area contains specialized photoreceptors that receive light and send signals to the brain to form an image. The macula allows humans to see clearly and see the fine details necessary for tasks that require high visual concentration, such as reading, writing, and watching TV.
The function of the macula
The macula’s function is to provide sharp central vision and accurate color discrimination. It serves as the main focal area for light that enters the lens and reaches the retina. Without a properly functioning macula, the ability to see fine details is diminished, although peripheral vision remains mostly intact. Any abnormalities in the macula directly impact vision quality, making it challenging to perform precise tasks.
What is a macular hole?
A macular hole is a tear or small gap in the tissue of this delicate area of the retina. It usually occurs due to abnormal pulling of the vitreous humor (the gel-like substance that fills the eye socket) as it shrinks with age. Normally, the vitreous gradually detaches from the retina without causing damage, but in some cases, its adhesion to the macula is so strong that it pulls away a portion of the retina, creating a hole that affects central vision. A macular hole often affects only one eye, but it can occur in both eyes over time.
Causes of macular hole
Many reasons cause a macular hole, including the following:
- Aging: The most common cause, the vitreous material inside the eye shrinks and separates from the retina, and may pull on the macula, causing its rupture.
- Vitreous traction: The remaining part of the vitreous body attached to the macula during its detachment causes pulling and tearing of its tissue.
- Severe myopia: It leads to stretching of the eye tissue and increases the likelihood of a macular hole.
- The presence of scar tissue over the macula: This can lead to wrinkling and tightening of the retinal surface, contributing to macular damage.
- After major eye surgery: Procedures such as retinal or cataract surgery may predispose the eye to the development of a macular hole.
- Chronic retinal diseases: Conditions like diabetic retinopathy or intraocular infections such as uveitis can trigger macular degeneration and hole formation.
- Additional risk factors: Older age (60-80 years) and being female increase the risk, and 5-15% of patients may develop a perforation in the other eye in the future.
- Direct eye injuries or severe trauma
Macular hole symptoms
Symptoms of macular hole vary among patients, but here are the most important ones:
- Difficulty recognizing faces or performing delicate activities such as sewing and driving
- Progressive blurring of central vision that makes it difficult to see fine details
- Straight lines are wavy or curved when looking at objects
- Difficulty reading or seeing small letters
- A dark spot or missing area in the center of the field of view
- Seeing part of the image missing or distorted in the center of the image
- No eye pain or redness despite poor vision
- Symptoms gradually worsen over time if the condition is not treated
Diagnosing a macular hole
Diagnosing a macular hole usually begins with a thorough eye examination by an ophthalmologist, which includes reviewing the patient’s medical and family history, as well as any prescription or over-the-counter medications. Next, a slit lamp examination with pupil dilation with special drops is performed to enable the doctor to examine the fundus and clearly see the retina and macula.
Optical coherence tomography (OCT) is the most important test for diagnosing a macular hole, as it uses light waves to create precise, high-resolution images of the different layers of the retina. This painless test allows the doctor to accurately identify the presence, depth, and stage of the hole, and helps distinguish it from other diseases that may present similar symptoms.
In some cases, your doctor may order additional tests, such as fluorescein fundus photography or digital retinal imaging, to assess retinal blood flow and rule out comorbidities. Most cases do not require laboratory tests because a macular hole is often spontaneous and unrelated to systemic causes.
What are the treatment options for a macular hole?
Treatment options for macular holes depend on the size, stage, and visual impact. In some small or partial cases, periodic monitoring may be sufficient as the hole may heal spontaneously without intervention. Medicated vitreous injections can also be used in some early cases to break up the adhesion between the vitreous and the macula without the need for surgery. The most effective and common treatment is microsurgery (vitrectomy), which aims to remove the tension on the macula and help the tissue heal.
Macular hole surgery (Vitrectomy)
Macular hole surgery (Vitrectomy) is performed under a surgical microscope using very fine instruments to remove the vitreous that is holding the macula in place. The doctor then peels the thin inner limiting membrane (ILM) around the hole to relieve the mechanical tension that prevents healing. A special gas (such as SF6 or C3F8) is then injected into the eye, acting as a temporary bandage that pressurizes the macula to help it heal.
The procedure usually takes 45 to 60 minutes and is performed under local or general anesthesia, depending on the case. After surgery, the patient is asked to remain in the face-down position for several days to keep the gas bubble in place. Airplane travel is prohibited until the gas is completely gone to avoid high intraocular pressure. The patient needs to use anti-inflammatory and anti-infectious eye drops, and vision gradually improves over weeks to months.
Macular hole surgery (Vitrectomy) success rates
Studies show that the success rate of macular hole surgery exceeds 90% with early surgical intervention. The earlier the procedure is performed within the first few months of symptoms, the more likely it is to close the hole and restore a significant portion of central vision. Even when the hole does not close completely, vision often stabilizes or shows fewer visual distortions. In some rare cases where the hole does not close after the first surgery, a second operation can be performed with high success rates.
Possible complications after macular hole surgery
Macular hole surgery, like any delicate eye surgery, carries some risks, although they are rare. Potential complications include:
- Formation of cataracts, which is the most common issue after any retinal surgery
- Retinal detachment, which can occur if there is an unintended tear during the procedure
- Endophthalmitis, a rare but serious infection
- Temporary elevated eye pressure, which may result from a gas bubble or postoperative inflammation
- In a small percentage of patients, the macular hole may reopen or fail to close completely
However, these risks are minimal when compared to the significant benefits of stabilized and improved vision following the procedure
Recovery after macular hole surgery
After surgery, vision in the eye is temporarily impaired by the gas bubble, and the sensation is similar to looking underwater. The patient is asked to remain in the face-down position for several days, or even up to 2 weeks, as recommended by the doctor, to ensure the bubble remains in place over the macula until it is completely healed.
Vision gradually improves as the gas bubble recedes and the eye refills with normal fluid. It usually takes a few months for the patient to regain the best possible vision, and they may notice continued improvement in image clarity and reduced visual distortion. Eye drops are used to reduce inflammation and prevent infection, and regular medical follow-up is performed during the first few weeks after surgery.
Macular hole surgery (Vitrectomy) aftercare tips
The patient is advised not to rub or apply pressure to the eye in the first weeks after surgery, to avoid swimming to prevent infection, and to refrain from traveling by plane or using laughing gas (Nitrous oxide) until the gas bubble has completely disappeared. You should also avoid strenuous activities and heavy lifting, use the prescribed eye drops regularly, and attend all follow-up appointments to ensure complete healing and optimal visual results.
When should you see a doctor immediately?
The patient should see an ophthalmologist immediately if they experience any of the following symptoms after the procedure: Severe pain or an apparent increase in redness of the eye, sudden deterioration of vision after being stable, the appearance of a shadow or dark curtain in the field of vision, which may indicate retinal detachment, abnormal discharge from the eye or swelling of the eyelid. Regular follow-up and early detection of these signs can help prevent complications and protect your eyesight.
The cost of macular piercing in Turkey compared to other countries
The cost of macular hole surgery in Turkey is relatively low compared to European and American countries, while maintaining an advanced medical level. The price depends on the surgeon’s experience, the technique used, post-operative follow-up, and hospitalization. The average cost of the operation in Turkey is between $2,000 and $3,500, and usually includes microsurgery, peeling of the inner membrane, and intraocular gas injection. In Germany, the cost ranges from $4,000 to $6,000; in the UK, from $5,000 to $7,000; and in the United States, it can reach more than $9,000. This significant price difference makes Turkey a favorite choice for patients seeking high-quality care at a reasonable cost.
In conclusion, a macular hole is a retinal condition that can be treated with high success rates due to modern microsurgical advancements. Timely diagnosis and early surgical intervention are key to restoring vision and preventing irreversible central vision loss. With major advances in retinal procedures across Turkey, macular hole surgery is now safer, more precise, and more effective than ever. Bimaristan Medical Center provides expert consultations and connects patients with top-tier surgeons and hospitals in Turkey, offering comprehensive pre- and post-operative care to ensure optimal visual recovery.
Sources:
- American Academy of Ophthalmology. (2024). Macular Hole Surgery Overview.
- National Eye Institute (NEI). (2023). Macular Hole Factsheet.
- NHS. (2024). Macular hole: Diagnosis and treatment.
