Macular Hole Causes: Why They Form and How They’re Treated

If straight lines have started to look wavy, or a small blank patch has appeared in the centre of your sight, you might be wondering what is behind it. Macular hole causes can be hard to spot at first, because the changes often come on slowly and in one eye.

Knowing why a macular hole develops and what to watch for can help you act at the right time. This guide covers the causes, risk factors, symptoms, diagnosis and treatment.

Quick Overview

• A macular hole is a tiny gap at the very centre of the retina, in the area that gives you your sharpest, most detailed vision.
• Most macular holes form when the vitreous gel inside the eye shrinks with age and pulls on the macula, creating a tear.
• Risk factors include older age, high myopia, eye trauma, swelling inside the eye, and previous eye surgery.
• The main treatment is vitrectomy surgery, and optical coherence tomography is used to diagnose the hole and plan care.

Below, we unpack why the vitreous pulling on the macula matters, who is most at risk, and what repairing a macular hole involves.

What is a macular hole?

A macular hole is a small break in the macula, the central part of the retina at the back of your eye. The macula gives you the sharp central vision you use for reading and recognising faces. When a hole forms here, that central vision becomes blurred or distorted.

Because the macula handles your sharpest sight, even a small hole here can have a noticeable effect on what you see straight ahead. The gap sits in the macular tissue at the very centre of the retinal surface, so it affects the middle of your vision while your outer, side vision usually stays intact. A macular hole is different from a tear elsewhere in the retina, and it is not the same as age-related macular degeneration. It is a treatable condition, and the way it is managed depends on how far it has progressed.

What causes a macular hole?

Most macular holes are caused by changes in the vitreous gel, the jelly-like substance that fills the eye. As you age, this gel shrinks and moves away from the retina. Where it stays firmly attached at the macula, the pulling can create a small break.

The vitreous is a clear, gel-like substance that fills the space behind the lens and helps the eye hold its shape. Over time, it becomes more watery and separates from the retinal surface, which is a normal part of ageing. In most eyes, this separation causes no problems. In some, though, the vitreous pulling on the macula is enough to open a gap in the central retina. Fluid can then collect in the break and blur your vision. This process is called macular hole formation, and it is why the condition becomes more common with age. A macular hole can form even in an otherwise healthy eye, without any injury or other eye disease.

What are the risk factors for a macular hole?

Age is the biggest risk factor, and macular holes are most common after the age of 60. Other risk factors include high myopia, an eye injury, swelling inside the eye, and previous eye surgery.

Beyond ageing, several factors that raise the risk are well recognised. High myopia, or strong short-sightedness, stretches and thins the retina and makes a hole more likely. Eye trauma, such as a blunt injury, can cause a hole to form suddenly, even in a younger eye. Eye inflammation and retinal conditions like diabetic retinopathy can also play a part. Knowing your own risk factors helps you notice early changes sooner. A hole can also develop after surgery for another retinal problem, although this is less common.

What are the symptoms of a macular hole?

The main symptoms of a macular hole are blurred and distorted central vision. Straight lines, such as door frames or lines of text, can look wavy or bent. As the hole grows, a small blank or dark patch can appear in the centre of your sight.

Because the hole sits in the centre of the retina, it affects the fine detail in the middle of your vision rather than your side vision. Many first notice distorted vision when trying to read small print or look at a printed page. One eye is usually affected. The changes often build gradually, from mild waviness in the early stages to a more noticeable gap in the centre of your vision as the hole widens. Sudden symptoms are different: a shower of new floaters, flashing lights, or a shadow or curtain across your vision can signal a retinal detachment, which needs immediate medical attention.

How is a macular hole diagnosed?

A macular hole is diagnosed with a detailed eye examination and a scan called optical coherence tomography, known as OCT. OCT takes a cross-section image of the retina, so your ophthalmologist can see the hole, measure its size and check its stage.

During a comprehensive eye examination, your ophthalmologist widens your pupils with drops to view the retina closely. A scan of the retina with OCT shows the layers of the macula in fine detail and confirms whether the break is partial or full-thickness. This also helps your ophthalmologist plan treatment and, later, check whether the hole has closed. If you notice a new distortion or a blank patch in one eye, it is worth booking an assessment so the cause can be identified early. Spotting a macular hole early also lets your ophthalmologist tell it apart from other macular conditions that can cause similar distortion.

How is a macular hole treated?

Treatment depends on the size and stage of the hole. Most full-thickness macular holes are treated with surgery, though very small holes in the early stages are sometimes watched first. Timing can matter because smaller, more recent holes are generally more straightforward to close than larger ones that have been present for many months, so it is worth having new symptoms checked promptly.

The most common treatment is vitrectomy surgery. During this surgical procedure, the vitreous gel is removed from the vitreous cavity to release the pulling on the macula. A fine layer on the retinal surface is often peeled away, and a gas bubble is placed in the eye to gently hold the edges of the hole together while it heals. The operation is usually done as day surgery under local anaesthetic.

After surgery, you may be asked to hold a face-down position for a period so the gas bubble rests against the macula. The gas is slowly absorbed by the eye over the following weeks. In most cases, the hole closes after one operation, and a smaller number of holes need a second operation to close.

Getting the Right Care for a Macular Hole

A macular hole affects the centre of your sight, so changes to your central vision are worth acting on early. Left alone, a full-thickness hole can slowly grow and make reading and fine detail harder. At Mornington Peninsula Eye Clinic, we diagnose macular holes with detailed imaging, monitor early changes, and provide retinal care and surgery as one of the retinal conditions we treat. If straight lines look wavy or a blank patch has appeared in one eye, please call us on (03) 9070 3580 to arrange an assessment.

Frequently Asked Questions

Can a macular hole heal on its own?

Small holes in the early stages can sometimes close without surgery, so we may monitor them for a short time. Larger, full-thickness holes rarely close on their own and usually need treatment. Because a hole can become harder to close as it grows, we keep a close watch on any changes.

Is a macular hole the same as macular degeneration?

No. A macular hole is a physical break in the central retina, usually caused by the vitreous pulling on it. Age-related macular degeneration is a separate condition where the macula is damaged by other changes over time. Both affect central vision, but their causes and treatment are different.

How long does recovery take after macular hole surgery?

Vision recovery is gradual and varies from person to person, often improving over several weeks to months as the eye heals. The gas bubble slowly disappears on its own during this time. While the gas bubble is still present, you cannot travel by air or to high altitude, as this can raise the pressure inside the eye, so we guide you on activity at each stage.

Can a macular hole develop in the other eye?

There is a small chance. If you have had a macular hole in one eye, the other eye carries a slightly higher risk than usual, so we keep an eye on it. Checking your vision at home with an Amsler grid, a simple square chart of straight lines that helps show up distortion, can help you pick up early changes in either eye.

What happens if a macular hole is not treated?

Without treatment, a full-thickness macular hole often stays open and can slowly enlarge, so the blank or distorted patch in your central vision may become more noticeable. Your side vision is not affected, and the eye does not become sore. Because a smaller hole is generally more straightforward to close, it is worth having any change assessed rather than waiting.

Does a macular hole cause total blindness?

No. A macular hole affects the detailed central vision in one eye, not your whole visual field, so it does not cause complete blindness. Your peripheral, or side, vision stays intact. It can, though, make tasks like reading and recognising faces harder in the affected eye.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

References

https://my.clevelandclinic.org/health/diseases/14208-macular-hole

https://www.sciencedirect.com/science/article/pii/S003962579700132X