Eye diseases: the macular hole

By Cristiano Antonino On May 9, 2023

When we speak of a macular hole, we are referring to an actual hole, a hole, within the macula: the central vision area of the retina

The macula – or macula lutea – appears as a yellow spot measuring 5.00-5.50 mm in diameter that – at a distance of about 4 mm from the optic nerve – is formed at the area of the retina where the greatest visual acuity is concentrated, the area where details are best focused.

Consequently, the presence of the macular hole not only interrupts the normal continuity of the retinal surface, but also causes serious visual disturbances.

Not all macular hole conditions have the same severity, however

The latter depends on the size of the opening of the macula, i.e. the extent to which the hole affects the retinal surface.

The stages of severity are as follows

Stage I – macular hole with foveal detachment

At Stage I, the macular hole is characterised by disruption of the fovea (one of the four recognised regions within the macula).

Although it is the least severe stage of macular hole, it is likely to worsen in at least half of the cases if left untreated.

In the other half of cases, however, it regresses spontaneously.

Stage II – partial thickness macular hole

In stage II the loss of retinal tissue at the macular level is partial and therefore the hole is called lamellar.

If visual acuity is low, there is an indication for treatment, otherwise in 70-80% of cases it may spontaneously worsen.

Stage III – full-thickness macular hole

Stage III represents the worst condition of the macular hole, in which there is complete retinal lift around the area of the macular aperture and retinal tissue loss at the macular level is complete down to the retinal pigment epithelium.

Patients with stage III macular hole complain of severe vision problems and – if not treated – visual acuity remains very low

Those who suffer from macular hole usually detect the pathology in one eye only, in which case they have a unilateral macular hole.

In rare cases, however, the pathology may affect both eyes at the same time, in which case we are dealing with bilateral macular hole.

What are the causes and risk factors of macular hole

The macular hole is an ocular pathology that generally affects patients over 60 years of age, particularly females in a ratio of 2:1.

One of the causes to which the formation of the macular hole can be attributed is the posterior detachment of the vitreous humour with subsequent vitreomacular traction.

The vitreous humour – or vitreous body – is the colourless substance of constant volume that, anteriorly, acts as a support for the crystalline lens and, posteriorly, acts as a support for the retina.

With advancing age, the vitreous humour tends to lose its turgid consistency, shrinking and acting less and less as a support for the retina: this process is known as ‘posterior vitreous detachment’.

This detachment can consequently lead to the phenomenon of ‘vitreomacular traction’ as the vitreous humour itself detaches from the retina and takes part of the latter with it along with the macula.

If the loss of volume occurs suddenly, almost violently, the retina and macula may be traumatised, tear or suffer a more or less important injury.

Macular hole may also be secondary to other conditions, such as diabetic retinopathy, a condition typical of diabetic patients characterised by damage to the retina’s vascular system.

Other possible causes include severe myopia, retinal detachment, retinal trauma or the presence of cystoid macular oedema or macular pucker conditions.

However, an unambiguous cause in the formation of the macular hole cannot always be recognised.

Macular hole: recognising the symptoms

Generally – unless it is a violent trauma – the macular hole presents the patient with mild symptoms, which tend to be underestimated.

With the passage of time, if the pathology in the first stage does not regress spontaneously, the opening on the macula tends to expand and, in line with its expansion, the patient will notice the exacerbation of symptoms consisting of

Blurred and/or distorted central vision
Inability to see straight lines correctly, which appear wavy to the eye
difficulty reading small texts
reduced ability to see objects and people at both short and long distances
reduced ability to recognise details
further deterioration of vision and increased blurring of vision
vision of one or more black spots in the centre of the visual field

Pain is not part of the known symptomatology associated with the macular hole.

If the patient should complain of pain, the pathology from which he or she is suffering most probably does not correspond to the macular hole

Diagnosing the macular hole

When a patient begins to experience some of the symptoms – even mild ones – among those mentioned above, it is a good idea to contact his or her ophthalmologist quickly in order to intervene promptly if the latter comes to the diagnosis of macular hole.

Only by intervening in time may one be able to fully recover one’s previous visual faculties

In order to make a diagnosis of macular hole, the ophthalmologist will immediately resort to a number of specialised tests including an ocular fundus test, an optical computed tomography scan and, if this condition is secondary to a vascular or ocular inflammatory pathology, also a retinal fluorangiography.

The ocular fundus test allows visualisation of the internal structures of the eyeball by using certain eye drops to dilate the pupil

Optical computed tomography is a test that can provide very precise scans of the various elements that make up the eye: cornea, retina, macula and optic nerve. Non-invasive and painless, it is performed thanks to an instrument that emits a laser beam free of radiation harmful to the patient.

Retinal fluorangiography is a procedure for analysing any vascular pathologies affecting the eye. By injecting a non-toxic dye – fluorescein – into a vein, it is possible to take real photographs of the circulating blood flow within the ocular blood vessels.

Once the instrumental investigations have been performed, the ophthalmologist will be able to make an accurate diagnosis and administer the most appropriate therapy for the patient’s clinical condition.

Macular hole: the most appropriate therapy

For the treatment of the macular hole, the therapy administered to the patient could include either vitrectomy or ocriplasmin injection.

Vitrectomy is when the patient undergoes total or partial surgical removal of the vitreous humour.

During the operation, which lasts a total of 2 to 3 hours, the ophthalmologist will also fix the lesion on the macula, returning the retina to its natural position.

With the injection of ocriplasmin, on the other hand, the non-violent separation between the vitreous humour and the retina is naturally promoted, reducing the need for subsequent surgery.

The indication for the most suitable treatment is given exclusively by the ophthalmologist, who will assess its appropriateness and effectiveness on the basis of the instrumental tests performed.

Prognosis

Following the operation, it will be necessary to scrupulously follow the treatment indications laid down by the ophthalmologist in order to prevent the results of the surgery from being compromised.

Visual recovery is generally slow and progressive over several months.

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