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Macular Hole

Macula is the centermost part of Retina concerned with most crisp vision, color vision and fine activity vision. Macular problems are associated with disturbance in above mentioned vision and is very symptomatic. Macular hole is one of such condition if not treated in time leads to severe vision loss.

What is Macular hole? 
A macular hole is a full thickness opening of the retina in the center of the fovea. Fovea is the most important part of retina which provides us reading and crisp clear vision. In simple words it is gap / breach in continuity of the centermost part of retina.
Below given images very well explains Macular hole. Image on Left side is of normal eye with sharp foveal reflex whereas on Right side is eye with macular hole seen in form of well circumscribed round lesion seen at macula. However other types of retinal holes and breaks it often does not lead to retinal detachment. 

diagrammatic representation of macular hole

Who develops Macular Hole?

Most of macular hole are idiopathic i.e. there is no specific cause for it’s development. Neither there are any risk factors for it. It is considered to be a degenerative disease of retina. 72% of the idiopathic macular holes occur in women and more than 50% of the macular holes occur in patients 65 to 74 years old. Other types of macular hole which are less common are associated with causes like Trauma/Injury, Epiretinal membranes or other retinal disorders.

Are there any stages of macular hole?
Yes depending upon amount of defect in macula, they are broadly classified into partial thickness macular hole also called as Lamellar Macular Hole (LMH) and Full Thickness macular hole (FTMH). This classification is done on the basis of findings on the retinal diagnostic test called OCT.  

oct image of retina with macular hole

What are symptoms in patients with macular hole?
Symptoms depend upon stage of macular hole. Vision in patients with lamellar macular hole is usually very good and they have complaints of distortion of images. Whereas in patients with full thickness macular hole vision is severely reduced including both distance and near vision. Besides vision reduction patients with full thickness macular hole also see a black spot in their sight. Vision impairment also depends upon duration of disease i.e. more prolonged the condition vision progressively worsens.

  lmage seen by person with macular hole                  full thickness macular hole

  Image seen by person with LMH                                      Image seen by person with FTMH


What are test done for patients with macular hole?
The only and single most important test to confirm diagnosis and to give prognosis in case of macular hole is OCT. OCT creates scan through the different Layers of the retina. This is a non-invasive imaging test which shows us the stage as well as the size of macular hole. Larger size of macular hole suggests prolong duration of problem and it carries poor visual prognosis after treatment.

What are treatment options for Macular hole?
Patients with Lamellar/Partial thickness Macular Hole (LMH) with good vision can be observed with periodic follow-up every 4-6 months. At every visit monitoring of vision and progression of hole is determined with the help of OCT. Only if the vision progressively deteriorates or macular hole progresses on OCT, is surgery indicated for LMH.
In patients with Full Thickness Macular Hole (FTMH) surgery is the only option. Surgery involves removal of jelly inside the eye(Vitreous) with removal of membrane which creates traction on retina (ERM/ILM) and putting some gas inside the eye. Purpose of gas Injection inside eye is to exert sealing pressure on retina to close macular hole. This surgery can be performed by any trained Retina specialist. 

What are Post-operative things to be remembered?
Most important post-operative care and instruction for the patient and relative is that after surgery patient must maintain head down position for 6-8 hours daily for 5-7 days. This can be done in lying or in sitting position with head rest. Purpose is to give gas sealing effect on macular hole. 

 macular hole surgery patient                               macular hole post operative


Second thing to be remembered is after surgery with gas air travel needs to be avoided for at least 6 weeks till gas completely absorbs. Road/train travel is not an issue after surgery. Other than this recovery period is short, and patient gets back to most normal day to day activities after the surgery with 1-2 weeks.