Macular hole
A small full-thickness hole in the centre of the retina causes a central blind spot and distortion. Surgery closes most holes.
Quick facts
- Key signs
- Central blurred vision in one eye · Difficulty reading
- Diagnosis
- OCT
Red flags ↓
No doses: the clinician sets them by the current guideline.
What it is
A full-thickness defect in the neural retina at the fovea. Most are idiopathic, caused by traction of the vitreous on the fovea as it detaches, typically in older women. It causes central blur, distortion and a central blind spot in one eye. Vitrectomy surgery closes most holes and improves vision.
Who gets it
Most common in women in their sixties and seventies; usually one eye, with a small risk in the other.
Causes
- Vitreous traction during posterior vitreous detachment (idiopathic)
- Trauma
- High myopia
- Chronic macular oedema
Risk factors
- Female sex
- Age over 60
- High myopia
- Eye trauma
Pathophysiology
As the vitreous separates, it pulls forward on the fovea, which splits and opens. The edges of the hole lift and the photoreceptors at the centre are lost, creating a central scotoma.
Classification
- By stage, from impending hole to full-thickness hole with complete vitreous detachment
- By size of the hole on OCT
Symptoms and signs
- Central blurred vision in one eye
- Distortion of straight lines (metamorphopsia)
- A central dark or missing spot
- Difficulty reading
Diagnosis
- Clinical
- Slit lamp fundus examination shows a round red defect at the fovea; the Amsler grid shows distortion or a missing centre.
- Tests
- No laboratory tests.
- Imaging
- OCT confirms the diagnosis, measures the hole and stages it.
Differential diagnosis
- Lamellar macular hole
- Epiretinal membrane with pseudohole
- Neovascular macular degeneration
- Central serous chorioretinopathy
Goal of treatment
Close the hole to restore central vision.
Treatment
- Surgical
- Vitrectomy with peeling of the internal limiting membrane and a gas bubble, with head positioning for some days after surgery.
- Follow-up
- Observation for impending holes, some of which close spontaneously.
Complications
- Permanent central scotoma if untreated
- After surgery: cataract, retinal detachment, raised eye pressure
Prognosis
Surgery closes most holes; earlier surgery on smaller holes gives better vision.
Test yourself
Think of the answer, then tap the question to see it.
What causes most macular holes?
Traction of the vitreous on the fovea as it detaches (idiopathic).
Which test confirms a macular hole?
Optical coherence tomography (OCT).
How is a full-thickness macular hole treated?
Vitrectomy with internal limiting membrane peeling and a gas bubble.
In ophthalmology
Connections
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Macular Hole (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.