Macular hole

What is a macular hole?

The macula is the tiny central part of your retina that lets you see fine detail. A macular hole is a small break that develops right in this crucial spot. Unlike general ageing changes, a macular hole can directly reduce your sharpest vision. People often notice blurriness, distortion, or even a small dark patch in the centre of sight.

What causes a hole in the macular?

The most common cause is age-related changes in the vitreous gel, the clear jelly that fills the eye. As we age, the vitreous naturally shrinks and pulls away from the retina. If it tugs too firmly, a tear can form in the delicate macula.

Other causes include:

• Eye injury or trauma
• High myopia (short-sightedness)
• Previous retinal surgery or detachment
• Scar tissue (epiretinal membrane)

Most patients have no control over the cause.

Macular hole symptoms

Patients often describe:

• Blurred central vision that glasses don’t fix
• Distortion: straight lines looking bent or wavy
• A central patch of missing vision (a blank spot)
• Faded or washed-out detail in words or faces

Because the change is gradual, some people don’t realise there’s a problem until it affects reading, phone use, or driving.

How fast does a macular hole progress?

Progression varies. Some holes worsen slowly over months, while others enlarge more quickly, especially in the early stages. Without treatment, most macular holes get larger and central vision declines further.

Macular hole diagnosis

Diagnosis is usually made with:

• Dilated eye examination, to look directly at the retina.
• OCT scan, to confirm the presence and size of the hole, and rule out lookalikes (e.g. pseudohole).

Many patients are reassured to know that OCT gives a very clear, reliable picture, so the diagnosis is certain.

OCT macular hole stages

The OCT allows the specialist to see the layers of your retina in detail. This shows the stage of the hole:

1. Impending macular hole (stage 1): Vitreous pulls on the macula, but no full hole yet.
2. Small full-thickness hole (stage 2): A tiny opening forms.
3. Moderate hole (stage 3): The hole enlarges, vision worsens.
4. Large full-thickness hole (stage 4): The vitreous has detached fully and the hole is established.

This staging helps predict how urgent surgery is and what recovery can be expected.

How to treat a macular hole?

The main treatment is vitrectomy surgery with membrane peel and gas bubble:

• The vitreous gel is removed.
• Any fine scar tissue is peeled away.
• A temporary gas bubble is placed to support the macula as it heals.

At first, the gas blocks vision in that eye. Over weeks, it shrinks, you’ll see a dark line moving down your vision, and eventually it disappears. About 90–95% of holes close successfully. Vision often improves, though not always back to previous clarity.

How urgent is macular hole surgery?

Surgery is not usually an emergency, but timing matters. Results are best if surgery is done within a few months of the hole forming. Waiting too long can mean permanent damage to the macula and less chance of vision recovery. Most specialists recommend prompt surgery once a full-thickness hole is diagnosed and vision is affected.