A macular hole is a small break that forms in the macula, the part of the retina responsible for central vision. The hole is a small but significant opening: the sharp, detailed vision you use to read, recognise faces, and see straight ahead clearly. Understanding what causes it helps make sense of a diagnosis related to retinal conditions that can feel sudden and confusing.
This guide covers what actually causes a macular hole to form, who is more likely to develop one, and what the path to treatment generally looks like.
Quick Overview
- Most macular holes form because of changes in the vitreous gel inside the eye as it pulls away from the retina with age.
- Risk factors include being over 60, being female, high myopia, eye trauma, and existing eye disease such as retinal detachment.
- Common symptoms include distorted central vision, straight lines appearing wavy, and difficulty with fine detail or small print.
- Most macular holes are treated successfully with vitrectomy surgery, though recovery and outcome depend on the size and duration of the hole.
Below, we cover what causes a macular hole, the risk factors involved, the symptoms to watch for, and what treatment generally involves.
What Actually Causes a Macular Hole
The macula sits at the very centre of the retina and gives you the fine detail in your visual field, the part of your vision you rely on for reading, driving, and recognising faces. A macular hole forms when a small break opens up in this central part of the retina. It is a separate condition from age-related macular degeneration, though the two can produce similar symptoms.
The role of the vitreous gel
Inside the eye, behind the lens, sits the vitreous: a clear, gel-like substance, sometimes described as jelly-like, that fills the vitreous cavity and gives the eyeball its shape. In younger eyes, this gel is firmly attached to the retinal surface, including the macula.
As you age, the vitreous gradually changes. It becomes more watery and starts to separate from the back of the eye, a normal process called posterior vitreous detachment. For most people, this separation happens cleanly and causes no lasting problems beyond some temporary floaters or flashes.
In some people, though, the vitreous does not separate evenly. Parts of it remain firmly attached to the macula, while the rest pulls away. This creates traction, a pulling force, directly on the macular tissue. Over time, this traction can cause a break in the macula, which is how most macular holes form.
Research from the Macular Disease Foundation Australia confirms that vitreous changes pull on macula tissue as part of the natural ageing process, and that it is not always clear why this traction affects some individuals and not others.
Eye trauma and other causes
While most macular holes develop through this gradual, age-related process, a smaller number form after eye trauma, such as a direct blow to the eye. Macular hole formation following trauma tends to happen more suddenly than the gradual traction process and can occur at any age, including in younger patients.
A macular hole can also develop secondary to other eye conditions, including retinal detachment, macular pucker, long-standing swelling in the macula, and diabetic retinopathy. Research confirms that trauma and high myopia increase the risk of macular hole formation, alongside retinal detachment as another recognised cause.
Who Is More Likely to Develop a Macular Hole
Certain factors make someone more likely to develop a macular hole, though having one or more of these does not mean a hole will definitely form.
Age is the strongest risk factor. Macular holes are most common in adults over 60, reflecting the natural vitreous changes that occur with ageing. Women are affected roughly twice as often as men, for reasons that are not fully understood.
High myopia, meaning significant short-sightedness, is another recognised risk factor. In highly myopic eyes, the eyeball is longer than average, which stretches and thins the retina and places additional stress on the macula.
Having a macular hole in one eye also raises the chance of developing one in the other eye. Existing eye inflammation, conditions affecting the blood vessels in the retina, previous retinal surgery, and a history of retinal detachment are additional risk factors worth discussing with your eye specialist if they apply to you.
Symptoms of a Macular Hole
The symptoms of a macular hole typically affect central vision specifically, while side or peripheral vision generally remains unaffected.
In the early stages, straight-ahead vision can start to look slightly off. Straight lines, such as door frames or text on a page, may appear wavy or bent. Fine detail becomes harder to make out, and small print may be more difficult to read than it used to be. Central vision often appears mildly distorted rather than completely missing at this point.
As a macular hole progresses, the distortion can develop into a small blank or blurred patch directly in the centre of your visual field. Tasks that depend on sharp, detailed central vision, such as reading, recognising faces, or threading a needle, become noticeably harder. Because the macula only affects central vision, peripheral vision remains intact even as central vision changes.
If you notice a sudden change in your central vision, particularly if it is accompanied by a sudden increase in floaters or flashes of light, seek immediate medical attention. These can be signs of retinal detachment, which requires urgent treatment.
How a Macular Hole Is Diagnosed
A macular hole diagnosed early generally has more treatment options available. The process starts with a comprehensive eye examination, including a detailed look at the retina and macula. The standard tool used for this is optical coherence tomography, a non-invasive imaging scan that produces a detailed cross-sectional image of the retina. This scan shows exactly how large and how deep the hole is. Your eye specialist uses these measurements to decide how to treat a macular hole at this stage, based on your individual situation.
How a Macular Hole Is Treated
Treatment for a macular hole depends largely on its size and how long it has been present. Small holes detected early sometimes do not require immediate surgery and can be monitored over time.
For most macular holes that affect vision significantly, macular hole surgery in the form of a vitrectomy is the most common treatment. This surgical procedure is typically performed under local anaesthetic, where the surgeon removes the vitreous gel, causing traction on the macula and replaces it with a gas bubble. The gas bubble gradually presses against the macula, helping the edges of the hole come together and seal as it heals.
A face-down position is often required for several days after surgery, allowing the gas bubble to maintain consistent contact with the macula during the early healing process. The gas bubble itself dissolves naturally over several weeks, with the eye’s own natural fluid gradually replacing it as air pressure inside the eye equalises.
Vision recovery following successful surgery is meaningful for most patients, though the degree of improvement depends on how long the hole was present before treatment and its original size. In a small number of cases, a second operation may be needed if the hole does not fully close after the first procedure.
When to Seek Medical Attention
When to Seek Medical AttentionAny sudden change in central vision warrants a prompt eye examination rather than waiting to see if it resolves on its own. A macular hole itself does not typically cause pain. But sudden distorted vision, a new blank spot in your central vision, or a sudden increase in floaters and flashes is different. These symptoms should prompt immediate medical attention, as they can also indicate retinal detachment or other serious retinal conditions.
Concerned About Changes in Your Central Vision?
Distorted or blurred central vision is worth investigating properly for the sake of your overall eye health, rather than putting it off. A comprehensive eye examination, including optical coherence tomography where needed, gives a clear picture of what is happening and what your options are. Dr Edward Roufail is experienced in retinal conditions, including macular holes, and can talk you through your scan results and the most appropriate next steps for your specific situation.
To arrange a consultation, please call us on (03) 9071 0180.
Frequently Asked Questions
Can a macular hole heal on its own without surgery?
Very small holes are sometimes monitored rather than operated on immediately, and a small number of very early-stage holes can spontaneously resolve without surgery. However, most full-thickness macular holes do not close on their own and tend to enlarge gradually over time without treatment. Your eye specialist will advise whether monitoring or surgery is the appropriate next step based on the size and stage of your particular hole.
If I have a macular hole in one eye, will the same thing happen to my other eye?
About half of people with vitreous changes affecting one eye experience similar changes in the other eye over time, though this does not always progress to a full macular hole. The risk of developing a macular hole in the other eye is something your eye specialist will discuss with you, and regular monitoring of both eyes is generally recommended after a macular hole diagnosis in one eye.
How long does it take to recover after macular hole surgery?
Most people return to light daily activities within one to two weeks, though full visual recovery takes longer. While the gas bubble is present in the eye, you will need to avoid air travel and high altitudes, as changes in air pressure can cause complications. Your vision will also remain blurry while the bubble is in place, gradually improving as it dissolves and your eye adjusts over the following weeks.
What happens if a macular hole is left untreated?
An untreated macular hole generally continues to enlarge over time, with central vision becoming progressively more distorted and eventually leaving a blank patch in the middle of your visual field. Side vision is not affected by this process, so complete blindness does not result from a macular hole alone. However, the longer a hole is left before treatment, the lower the likelihood of full visual recovery once surgery is eventually performed.
Note: Surgical or invasive procedures carry inherent risks. As part of our standard practice, we thoroughly discuss these risks during the consent process before any surgical procedure. Your understanding and comfort are our utmost priority.
References
https://doi.org/10.3390/jpm13010075
https://my.clevelandclinic.org/health/diseases/14208-macular-hole
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