What is a macular hole?
The macula is the point of sharpest vision on the retina. The retina is ultimately a thin layer of nerve cells, the so-called photoreceptors. These are particularly dense in the macula, which is why vision is particularly sharp here.
Like every tissue in the body, the retina is a vulnerable organ and very vulnerable due to its thin structure. If, due to various possible causes, the retina is pulled too much, it can only give way to a limited extent and inevitably tears at one point. If this hole is then located at the macula, it is called a macular foramen (foramen = Latin for “hole”).
The damaged region is also no longer able to absorb and process the information of the nerve cells. Fluid accumulates between the retina and the layer below. This results in a considerable reduction of vision, up to the appearance of a blind spot in the middle of the visual field (= part of a room that can be seen with the unmoving eye), a so-called central visual field defect.
Macular foramen is not a rare disease. The most common form, the idiopathic macular hole, develops without any recognizable cause and affects about 33 out of 10,000 people in the age group over 55 years. In 17% it occurs in both eyes. In general, women are affected significantly more often than men.
What are the stages of macular holes?
There are different stages and forms of macular holes. At the simplest or also lightest form one speaks of a so-called layered foramen. This is a simple defect, a kind of hole in the retina in the area of the macula.
However, this is not an actual hole in the eye (the eye as a whole remains unaffected by a macular foramen), but rather a thinning of the retinal tissue. This thinning can be of varying intensity and usually progresses relatively slowly but incessantly. A spontaneous healing without ophthalmologic treatment is not to be expected, the condition will get worse and worse in the course of time.
Sometimes a hole-like defect is formed on the retina, which is caused by a deformation of the retina. This is caused by a so-called epiretinal gliosis. Due to the pull on the retina, it deforms in the area of the macula into a hole-like shape without the retina or the macula actually thinning out.
In this case one speaks then of a pseudoforamen. After the surgical removal of the epiretinal gliosis, the retina is no longer pulled and can regain its original shape. The cells of the retina itself are not reduced or damaged by the gliosis.
Therefore, one speaks only of a “pseudoforamen”, not of a “real macular foramen”. The maximum form of a macular hole is called a pervasive macular hole. Due to the continuous thinning and pulling of the vitreous body at the retinal tissue in the area of the macula the retina finally tears at this point and the macula stands out from its underground.
No components of the macula are lost, it is figuratively speaking “only” pulled apart. The thorough macularoramina can be divided into four stages, depending on their characteristics and severity. In the later stages the edges of the macular hole can move away from each other by continuous processes.
For the patient a macular hole becomes noticeable by a relatively acute loss of visual acuity in the affected eye. This then deteriorates very quickly. A spontaneous healing is observed in individual cases sometimes in the early stages, but in the later stages it is almost impossible.
Therefore, surgery is often unavoidable and should be performed promptly if possible to prevent the hole from progressing. The early diagnosis of a macular hole is very important for the healing process. Do you have a macular hole?
This test helps you to make an assessment: Amsler Grid TestSince the processes of a macular foramen are all taking place in the area of the macula and the rest of the retina remains relatively unaffected, the occurring symptoms are relatively uniform in all patients.Since the macula is the point of sharpest vision in the retina, i.e. also the area where we see our central visual field, the symptoms occur first when trying to focus and perceive an image sharply. This is, for example, the case with A further symptom of a macular hole, which occurs mainly in more advanced stages, is a loss of the visual field, i.e. the formation of a blind spot. In the case of thorough macular holeoramas this often happens.
At the place of the hole in the macula no information about what is seen can be recorded or forwarded so that the patient perceives a dark spot at this place. This loss of visual field is also called scotoma. In the early stages of a macular hole, however, patients often perceive only a slight blurring of their visual field, primarily in the central areas.
This is initially compensated by the brain very well, so that it often remains unnoticed for a long time. An easy way to check the progression of a macular hole is to give the patient an Amsler grid to take home. The test should then be performed by the patient himself once a day.
Thus, a progression can be detected quickly and a further therapeutic procedure can be discussed with the treating ophthalmologist. The early diagnosis of a macular hole is very important for the healing process. Do you have a macular hole?
This test helps you to make an assessment: Amsler grid test A further symptom of a macular hole, which mainly occurs in more advanced stages, is a loss of the visual field, i.e. the development of a blind spot. This often occurs in case of a penetrating macular hole. At the place of the hole in the macula no information about what is seen can be recorded or forwarded so that the patient perceives a dark spot at this place.
This loss of visual field is also called scotoma. In the early stages of a macular hole, however, patients often perceive only a slight blurring of their visual field, primarily in the central areas. This is initially compensated by the brain very well, so that it often remains unnoticed for a long time.
An easy way to check the progression of a macular hole is to give the patient an Amsler grid to take home. The test should then be performed by the patient himself once a day. Thus, a progression can be detected quickly and a further therapeutic procedure can be discussed with the treating ophthalmologist.
The early diagnosis of a macular hole is very important for the healing process. Do you have a macular hole? This test helps you to make an assessment: Amsler-Gitter-TestThe diagnosis of a macular hole is primarily done by an ophthalmologist.
But also a family doctor should be able to recognize the characteristic symptoms and refer the affected person to a suitable colleague. The ophthalmologist will first of all use eye drops to dilate the pupil in order to be able to have a more unrestricted view into the interior of the eye and the retina. He can then use a magnifying glass and/or a special contact lens to get an initial overview.
Already now the diagnosis of a macular hole can be made. However, in order to be able to estimate the concrete extent and possible accompanying symptoms and complications, it is necessary to create an image of the retina. For this purpose the ophthalmologist has the Optical Coherence Tomography, in short the OCT at his disposal.
It can display a three-dimensional cross-section of the retina and thus make the macular foramen clearly visible in its dimensions. Additionally, it is recommended to have an angiography done. With this angiography the condition of the vessels in the retina can be assessed and possible holes or blood leaks can be located exactly.
Optical coherence tomography is completely harmless to the patient and has no other side effects. Only in the case of angiography, patients may sometimes react to the dye that is necessarily injected and complain of slight nausea or weakness. Also, the dye is subsequently excreted through the kidney, which may cause discoloration of the urine.
However, this is harmless and also only of short duration, but if not known, it can lead to irritation on the part of the patient. The early diagnosis of a macular hole is very important for the healing process. Do you have a macular hole?This test helps you to assess: Amsler Grid TestThe surgery of a macular hole is the only reasonable treatment option to effectively close the hole in the retina.
Spontaneous healings are sometimes observed, but are extremely rare and of varying duration. The surgery should be performed as soon as possible because with increasing time the macular hole can widen and expand. There is then the risk of a loss of the central visual field, which does not mean blindness but still represents a considerable impairment of vision.
However, if a macular hole is operated early there is a good chance that the patient regains his vision and can even see on a comparable level as before the formation of the macular hole. But even if the macular hole has been existing for a longer period of time an operation is still reasonable and recommended because the macula will still be able to regenerate to a certain extent. There are only few situations in which the treating ophthalmologist would advise against a surgical therapy of the macular hole.
The surgical therapy of a macular hole is the so-called vitrectomy. As before every operation which is performed under general anesthesia the patient has to appear fasting. This means that at least six hours before the operation the patient has not eaten anything and two hours before the operation he has not drunk anything.
If a patient is not able to be put under general anesthesia due to concomitant diseases or other complaints, the operation can alternatively be performed under local anesthesia. If medication is taken regularly, this must be discussed with the responsible anesthesiologist in advance. Even before the operation, the pupils are dilated with eye drops to give the surgeon the best possible view of the eye.
During the entire operation the following persons are present in the operating room: the operating ophthalmologist, an assistant ophthalmologist, one or two operating nurses and the anaesthesia team, which usually consists of an anaesthesiologist and an assistant. The surgery usually takes between 30 and 60 minutes, depending on the location, extent and complexity of the macular hole. The actual vitrectomy now consists of the surgeon carefully removing the vitreous body in the eye using various instruments and also removing any tissue deposits (for example, epiretinal gliosis) on the retina.
Then, depending on the findings, the macular foramen is additionally reattached to the surface with a laser or connected to it by cryotherapy. Finally, the eye is then filled up with a gas or an oil mixture instead of the original vitreous body. These provide a certain pressure in the eye, which presses the macula firmly to its base so that it can anchor itself there again.
In order to achieve an optimal operation result, the patient should spend the next few days in a so-called head-down position. This means that he keeps his face down as much as possible and avoids fast, jerky movements of the head or eyes. An eye bandage is only necessary in the early days.
Often a transparent protective cover is stuck over the eye to protect the eye from possible bumps, flying dust or the like. Of course, the surgery of a macular hole bears the usual risks that every operation brings with it. Since it is desirable for a smooth course and a good postoperative result to operate the patient under general anesthesia, the known side effects such as nausea, circulatory problems, allergic reactions, etc.
can occur, which are caused by the anesthetics. If it is not possible to perform general anesthesia in a patient due to already existing concomitant diseases, the operation can also be performed under local anesthesia. However, this may mean that the surgeon cannot work as precisely as he could with a sleeping patient.
In addition, there are general surgical risks such as bleeding, post-operative bleeding, infection, injury to other structures in or around the eye, or the need for a post-operation if the result is not as desired. If a patient with a macular hole is still in possession of his or her original lens, it is possible that the surgery will accelerate the development of a cataract.If the patient is already suffering from cataracts at the time of the operation, the opportunity can be taken and the old lens can be replaced directly so that a second operation can be avoided. A typical side effect of macular hole surgery is the development of retinal tears or even a retinal detachment.
This can be caused by the suction of the vitreous body in the eye, which in some patients is more firmly attached to the retina and thus pulls on it. However, retinal tears or retinal detachments occur very rarely, only in 2% of all operated patients. In these cases, a second operation is necessary to apply the retina.
In addition, postoperatively there may be an increase in intraocular pressure, especially if the surgeon has introduced a gas or oil mixture into the eye instead of the old vitreous body. Therefore, the intraocular pressure should be checked regularly for a period of time after the operation. It is also possible that redness and swelling may occur in the eye as a result of the surgery, both in and around the eye.
In some cases, the retina may temporarily swell, or an inflammation may occur in the front parts of the eye, such as the conjunctiva. In these cases, anti-inflammatory and decongestant eye drops can be prescribed, which usually contain cortisone and are fast and effective. The most feared, though very rare, complication is an infection of the eye.
If left untreated, it can spread further and in the worst case lead to blindness or loss of the eye. A typical side effect of macular hole surgery is the development of retinal tears or even a retinal detachment. This can be caused by the suction of the vitreous body in the eye, which in some patients is more firmly attached to the retina and thus pulls on it.
However, retinal tears or retinal detachments occur very rarely, only in 2% of all operated patients. In these cases, a second operation is necessary to apply the retina. In addition, postoperatively there may be an increase in intraocular pressure, especially if the surgeon has introduced a gas or oil mixture into the eye instead of the old vitreous body.
Therefore, the intraocular pressure should be checked regularly for a period of time after the operation. It is also possible that redness and swelling may occur in the eye as a result of the surgery, both in and around the eye. In some cases, the retina may temporarily swell, or an inflammation may occur in the front parts of the eye, such as the conjunctiva.
In these cases, anti-inflammatory and decongestant eye drops can be prescribed, which usually contain cortisone and are fast and effective. The most feared, though very rare, complication is an infection of the eye. If left untreated, it can spread further and in the worst case lead to blindness or loss of the eye.
The causes for the development of a macular hole can be manifold. The vitreous body completely fills the interior of the eye and in some places is firmly attached to the retina. If a shrinking of the vitreous body occurs in the course of natural aging processes, the vitreous body can in some cases pull at the retina at those very connection points.
The delicate retina has only grown to a limited extent in these pulling forces running parallel to the retina. This leads to increasing tension, which ultimately causes a gradual tearing of the retina. The hole or tear causes fluid to penetrate from the inside of the eye and pushes the retina further and further away from its surface.
The macular foramen enlarges. Of course it can also occur independently of a vitreous shrinkage to a too strong pull at the retina. For example after an accident, especially in the head and neck area or after an operation on the affected eye a macular hole can develop.
In these cases however, unlike the idiopathic age-related macular hole, it is an acute event and not a gradual process. Therefore the patient also describes a sudden loss of the central visual field (= part of a room which can be seen with the unmoving eye). However, in the age-related macular holes the vision decreases only slowly.In general only the central area of the visual field is affected since the macula is the point of sharpest vision at the retina and the outer areas are not further affected by a macular foramen.
The early diagnosis of a macular hole is very important for the healing process. Do you have a macular foramen? This test helps you to assess: Amsler grid testA healing of a macular hole is absolutely possible.
However, spontaneous healings are only described in rare individual cases so that the gold standard nowadays is still the surgical treatment. Only in a few cases there are arguments which could speak against an operation. If the operation goes well and there are no complications or further diseases of the eye, the macula can regenerate completely after some time in many cases.
This healing process can take up to several months in some cases, about which the patients must be informed. However, if a patient has waited for a comparatively long time until he/she has come to an ophthalmologist with his/her symptoms, it can be assumed that the macular foramen has already existed for a long time. In these cases the chances of success are not so good anymore.
It is possible that the macula then only partially recovers from its defect. Therefore it is important to consult an ophthalmologist already at the first symptoms so that he/she can recognize a possible macular hole early and treat it accordingly. If the operation is not successful or if the patient feels an impairment of the vision afterwards, the operation can be repeated in hope to achieve a better result.
There are currently no sensible and promising alternatives to surgical therapy. The early diagnosis of a macular hole is very important for the healing process. Do you have a macular hole? This test will help you with the assessment: Amsler-Gitter-Test
