Symptoms of a macular hole

Macular holes affect the center of vision in one eye:

Central blur that does not improve with new glasses
Distortion: straight lines bow or bend near the center
A small gray or dark spot in the very center of the vision
Difficulty reading with the affected eye
Poor depth perception with both eyes open

Causes & risk factors

As the vitreous gel separates from the retina with age, it sometimes pulls on the fovea instead of releasing cleanly. That traction, combined with circumferential traction from scar tissue on the retina, can create a small full-thickness hole. Macular holes are most common after age 60 and are somewhat more common in women. Eye injuries and high nearsightedness can also play a role.

How we diagnose a macular hole

OCT imaging and color photos of the retina are extremely helpful in diagnosing macular holes and facilitating surgical planning. The scan shows the hole’s exact size and stage in cross-section, which is what determines the best treatment and the likely visual result.

OCT scan showing a full-thickness macular hole in cross-section with cystic edges — OCT of a full-thickness macular hole: the cross-section shows the break in the central retina with lifted, cystic edges, and allows precise measurement of the hole for surgical planning.

Retina photograph showing a full-thickness macular hole at the center of the macula — A full-thickness macular hole (of a different patient than the OCT above): the small round defect at the very center of the macula. Image courtesy of the ASRS Retina Image Bank.

How is a macular hole treated?

Treatment depends on the stage of the hole:

Observation

A small, very early hole with mild symptoms is sometimes monitored closely every 1-2 months, as a minority close on their own as the vitreous releases.

Vitrectomy with membrane peel

The definitive repair: outpatient surgery removes the vitreous, releases the traction by peeling a fine membrane surrounding the hole on the surface of the retina, and places a gas bubble that helps the hole to close.

Positioning and the gas bubble

After surgery we will recommend a face-down position for several hours a day for several days. The face-down position does not need to be all at once, but is important in helping the hole to close. You cannot fly or travel to high altitude until the bubble is gone, unless silicone oil is used, and we will discuss travel plans carefully before and after surgery.

What to expect

Surgery closes roughly 9 in 10 macular holes, and vision improves gradually over weeks to months afterward. Smaller holes repaired sooner recover the most vision, and macular holes should have surgery as soon as logistically possible, ideally within a few months of diagnosis as larger, more chronic macular holes are less likely to close successfully with surgery and have a lower chance of recovering vision.

Common questions

Can a macular hole heal on its own?

A small minority of very early holes close spontaneously. Most do not, and holes that remain open tend to enlarge and cost more vision, so we monitor closely or move to surgery based on your OCT.

Does the face-down positioning need to be continuous?

No. We typically recommend about 4-5 hours of face-down positioning a day for about 4-5 days after surgery, and it does not need to be all at once; the time can add up over the course of the day. A massage table or face-down pillow can make positioning much more comfortable. At night you will sleep on either side or face down, which we will discuss after surgery.

When can I fly or drive to the mountains?

Not until the gas bubble is fully gone, which takes several weeks depending on the gas. Changes in altitude cause the bubble to expand, which can dangerously elevate the eye pressure. If silicone oil is used instead of gas, travel to higher elevations is allowed, though the oil requires a later surgery to remove. We track the bubble at each visit and will discuss your travel plans carefully before and after surgery.

Will it happen in my other eye?

There is an increased risk of developing a macular hole in the other eye, not because the hole in one eye causes a hole in the other eye, but because the vitreous is often of similar structure and attachment to the retina in each eye, and patients with macular holes in one eye are more likely to develop a macular hole in the other eye. We will monitor the other eye carefully and may have a lower threshold for performing surgery if it appears that a macular hole is developing in the other eye.

Sources & review

This page is educational and is not a substitute for an examination. Content follows guidance from the American Academy of Ophthalmology and the American Society of Retina Specialists.