Macular Hole in the Eye: Definition, Causes, Symptoms, Diagnosis, and Treatment

What is a Macular Hole in the Eye?

A macular hole in the eye refers to a hole, a tear or a break in the macula. The macula is located in the centre of the retina and has nerve cells that help translate light to images and is also responsible for central vision. A macular hole is a type of retinal hole, as the macula is part of the retina. The answer to what is a macular hole in the eye is a hole or opening in the macula that may interfere with central vision.

What Part of the Eye Does Macular Hole Affect?

The part of the eye that is affected by a macular hole is the macula and the retina. A macular hole is a hole in the retina part of the eye. The retina is the layer at the back of the eye that contains photoreceptor cells. According to The Cleveland Clinic, these photoreceptor cells react to light that enters the eye, changing this light into electrical signals to send to the brain. The macula is located in the middle of the retina and assists in translating light that enters the eye into electrical signals to send to the brain.

What Does a Macular Hole in the Eye Look Like?

A macular hole, when examined by an optometrist or eye care professional using specialist equipment, may look like a circular hole, break or a tear in the surface of the macula. A macular hole will not be visible on the eye from the outside, as the macula is part of the back layer of the eye. Someone looking at the eye from the outside with no equipment will not see the hole. According to NI Direct, a macular hole may make vision look blurry or distorted in the earlier stages for those who have it, and straight lines may look wavy. In later stages, vision may have a small blank or black patch. The image below shows what a macular hole may look like when examined up close by an eye care professional using specialist equipment.

A macula with a hole in it vs a normal macula, shown on a scan

How Common is a Macular Hole in the Eye?

A macular hole is not an overly common eye condition, most often occurring in older people. According to Majumdar and Tripathy in their paper, Macular Hole, the prevalence of macular holes in Australia is around 0.2 per 1000 population. According to the NHS, macular holes are more common in those 60 years old and above as ageing contributes to changes in the eye, such as changes in the vitreous jelly, and may lead to holes in the retina or a macular hole developing.

What are the 4 Stages of a Macular Hole in the Eye?

There are four main stages of a macular hole in the eye, these are small foveal detachment, small full thickness holes, larger full thickness holes without vitreous separation and larger full-thickness holes with vitreous separation, according to the Centre for Retinal Diseases and Surgery. The four stages of a macular hole are listed below.

Small foveal detachment: Small foveal detachment is generally considered to be stage 1 of a macular hole.
Small full thickness holes: Small full thickness holes are considered to be stage 2 of a macular hole, with the break in the macular less than 400 micrometres in size, according to Majumdar S and Tripathy K in their article published in the National Library of Medicine.
Larger full thickness holes without vitreous separation: Larger full thickness holes without vitreous separation are considered stage 3 of a macular hole, with the hole in the macula greater than 400 micrometres in size, according to the National Library of Medicine.
Larger full thickness holes with vitreous separation: Larger full thickness holes with vitreous separation is the 4th stage of a macular hole.

What Causes a Macular Hole in the Eye?

One of the most common causes of a macular hole in the eye is vitreous separation due to the ageing of the eye. The vitreous is a gel-like substance that fills the eye and helps keep the shape of the eye. According to the NHS, as the eye ages, the vitreous fluid can begin to separate from the retina and macula. As the vitreous pulls away it may not do so cleanly, creating a hole or tear in the macula, which may be known as a vitreous detachment. Eye injuries and refraction errors such as myopia may also contribute to the development of a macular hole, however, this is not as common. The exact answer to what causes a hole in the retina or a macular hole, is most often a vitreous detachment, as a consequence of the eye ageing.

What are the Risk Factors of a Macular Hole in the Eye?

The main risk factor for macular holes is generally getting older. As people get older, the eye also ages and can lead to issues with the vitreous, such as vitreous detachment, which is one of the top causes of a macular hole in the eye. Risk factors for getting a macular hole in the eye can also include having shortsightedness (myopia), gender and injuries to the eye. The risk factors for a macular hole are listed below.

Getting Older: Getting older and ageing can affect parts of the eye such as the vitreous which may lead to a macular hole if it begins to separate from the retina and macula.
Short-sightedness (myopia): Short-sightedness or myopia may be a risk factor for a macular hole due to tractional forces in the eye.
Gender: Gender is a risk factor for developing a macular hole as women are more likely to develop this condition than men.
Injuries to the eye: There is a type of macular hole called traumatic macular hole, that is caused by injuries or trauma to the eye. Therefore, sustaining an eye injury can increase a person’s risk of developing a macular hole.

1. Getting Older

Getting older is a risk factor for a macular hole as an ageing eye can lead to vitreous detachment, which can cause a macular hole. According to the NHS, when the eye ages with the rest of the body, the vitreous, a gel-like substance that fills the eye and keeps its shape, can separate from the retina and macula. If the vitreous does not separate cleanly from the macula, it may tear the macula, leading to a macular hole.

2. Short-sightedness (Myopia)

Short-sightedness also known as nearsightedness or myopia, may be a risk factor for developing a macular hole due to the tractional force that high levels of myopia may cause in the eye. According to an article by De Giacinto, Pastore, Cirigliano and Tognetto called Macular Hole in Myopic Eyes: A Narrative Review of the Current Surgical Techniques, it is stated that macular holes may develop in those that have myopia due to tractional forces from various parts of the eye such as the vitreomacular interface. Myopia or nearsightedness is a refractive error, caused by either an elongated eyeball or an overly curved cornea, in which the eye is not as capable of focusing light onto the retina correctly, leading to issues with distance vision.

3. Gender

Gender may be a risk factor for developing a hole in the macula, with women more likely to have this issue than men. According to an article by Wang J, Yu Y, Liang X, Wang Z, Qi B, and Liu W, the female to male ratio for macular hole development is 3:1. According to Hwang, S., Kang, S.W., Kim, S.J. et al, in an article called Risk factors for the development of idiopathic macular hole: a nationwide population-based cohort study, the authors discuss theories that the reason women are more likely to get a macular hole than men is due to drops in oestrogen levels when women enter menopause. It is theorised that a drop in oestrogen causes a loss of vitreous collagen and glycosaminoglycan, which may lead to premature vitreous detachment. However, this research is not supported by all who study the topic, with small amounts of epidemiological or biological evidence to support it.

4. Injury to the Eye

Injuries to the eye may be a risk factor for developing a hole in the eye due to the trauma that an injury may cause. Macular holes that are caused by an injury to the eye are called traumatic macular holes. According to the American Academy of Ophthalmology, traumatic macular holes are generally caused by blunt ocular trauma, with the macular hole either presenting as soon as the trauma has happened, or weeks later.

What are the Symptoms of a Macular Hole in the Eye?

The symptoms of a macular hole in the eye are dependent upon what stage the macular hole is at. According to the National Eye Institute, the symptoms of a macular hole in its early stages are distorted or blurry vision. Straight lines may look strange or wavy. Early signs of a macular hole can also include trouble doing everyday activities such as writing or reading. The macular hole symptoms for the later stages usually revolve around issues with central vision, such as having a blind spot or a gap in central vision. Central vision refers to what a person sees directly in front of them.

How Does an Eye Doctor Diagnose a Macular Hole in the Eye?

In Australia, an eye doctor, also known as an ophthalmologist, may diagnose a macular hole, as can an optometrist. To diagnose a macular hole, an optometrist or ophthalmologist will first begin with an understanding of your medical history and ask you to describe any symptoms you may have experienced. The tests an eye care professional may perform to diagnose a macular hole include a dilated eye test and optical coherence tomography (OCT) according to the National Eye Institute. A patient may be given eye drops to dilate the pupil in order to perform an OCT.

Can Retinal Imaging Detect Macular Hole?

Yes, retinal imaging may help detect a macular hole. Retinal imaging refers to a process in which a specialised camera takes digital images of the retina. A camera will flash or low-power lasers enter the eye through the pupil, according to The University of Edinburgh. The light reflects off of the retina and is captured by the camera.

Is a Macular Hole in the Eye Serious?

A macular hole can be a serious eye condition, as it can impact a person’s central vision and in turn their quality of life. According to the National Eye Institute, some people with macular holes may have mild symptoms in the early stages, and may not need immediate treatment. However, an optometrist may recommend ongoing observation and treatment down the line as, if a macular hole grows bigger, it can interfere with a person’s central vision and make everyday tasks such as driving and reading difficult.

What are the Treatments for a Macular Hole in the Eye?

There is one primary treatment used for macular holes which is a surgery called a vitrectomy. Some early-stage macular holes may heal on their own, according to the University of Chicago Medicine. For those with a macular hole in the early stages, eye care professionals may recommend monitoring the hole, instead of treatment straight away. If a macular hole does not heal on its own, a vitrectomy is usually required to preserve eye health and central vision. The treatment for a macular hole is listed below.

Vitrectomy: A Vitrectomy is a procedure in which a surgeon will remove the vitreous fluid from the eye and any other tissue that is causing an issue, and insert a gas bubble into the macular hole. According to the National Eye Institute, this gas bubble acts as a bandage, holding the hole together until it heals.

Can a Macular Hole in the Eye Heal Without Surgery?

Yes, in some cases a macular hole in the eye can heal without surgery. According to the Macular Disease Foundation, a macular hole that is in its early stages may heal spontaneously without the aid of treatment, but this is not always the case. While there is no way to treat a macular hole naturally, it can be treated with a type of surgery called a vitrectomy.

Can Eye Drops Help Close a Macular Hole in the Eye?

In certain cases, eye drops may help to close a macular hole in the eye. According to the University of Chicago Medicine, medicated eye drops may be prescribed to a patient to potentially help heal the macular hole in their eye. Medicated eye drops work to heal a macular hole by increasing fluid absorption in the retina and also by decreasing inflammation in the eye.

Can a Macular Hole in the Eye be Treated with Laser Surgery?

No, macular holes are not generally treated with laser surgery. According to the article, Laser treatment of macular holes, by Schocket, Lakhanpal, Miao, Kelman, and Billings, laser surgery is not often used to treat macular holes as it may cause retinal detachment.

What Happens if a Macular Hole in the Eye is Untreated?

If a person develops a macular hole, it is very important they seek advice from an eye care professional on how to proceed regarding treatment. According to the National Health Service (NHS), if a macular hole is not treated, it can lead to a decrease in central vision and affect quality of life. Therefore, it is crucial you have your eyes assessed if you believe you have a macular hole in the eye or experience any symptoms of this eye condition.

Do Macular Holes in the Eye Get Bigger?

Yes, according to the Macular Disease Foundation, a macular hole in the eye can get bigger which can lead to more vision issues. It is important to have regular eye tests if you have a macular hole as your optometrist can monitor its progression and assess if it is getting any bigger.

What to do to Prevent a Macular Hole in the Eye?

Currently, there is no way to prevent a macular hole in the eye, according to the American Society of Retina Specialists. Neither diet nor exercise have shown signs of preventing a macular hole. There are certain ways to treat and manage a macular hole such as through a type of surgery called a vitrectomy. A person can also attempt to lower their risk of developing a macular hole in the eye by having regular eye tests with an optometrist as they can monitor the health of your eye and diagnose certain eye diseases the patient may present with.