Macular Hole
Also known as Full-Thickness Macular Hole, Idiopathic Macular Hole, FTMH, Hole in the Retina, Stage 2 Macular Hole, Stage 3 Macular Hole, Stage 4 Macular Hole
Bottom Line
A macular hole is a small break in the center of the retina, the part of the eye that lets you see fine detail. It causes a blurry or missing spot in the middle of your vision. Most macular holes can be closed with surgery, and vision usually improves.
A macular hole is a small, full-thickness break in the macula — the central part of the retina that gives sharp, straight-ahead vision. It usually shows up as a blurry, distorted, or missing spot right in the middle of what you are looking at 1.
Most macular holes happen with no clear cause (idiopathic macular hole). They are most common in adults in their 60s and 70s, and they are 2-3 times more common in women. Population-based studies put the yearly rate at about 8 new cases per 100,000 people 2.
The main treatment is a surgery called pars plana vitrectomy with internal limiting membrane (ILM) peel and a gas bubble. Modern surgery closes more than 90% of macular holes and improves vision in most patients. Small holes occasionally close on their own without surgery 3.
Symptoms
A macular hole almost always affects one eye at first. Common symptoms include:
- A blurry or missing spot in the center of your vision. Side vision stays normal.
- Wavy, bent, or broken straight lines (metamorphopsia). Door frames, text, and tile grids look distorted.
- Trouble reading, recognizing faces, or doing fine work in the affected eye.
- A small gray or dark spot in the middle of your vision.
- Things look smaller in the affected eye than in the other eye.
Symptoms usually come on over weeks to months. People often only notice when they happen to cover the good eye. There is no pain, redness, or itching.
What Causes a Macular Hole
Most macular holes are idiopathic, meaning there is no clear underlying disease. They form when the gel inside the eye (the vitreous) pulls on the macula as it shrinks with age. The pulling tears a small full-thickness break through the central retina 1.
Risk factors include:
- Age 60-80. Macular holes are uncommon under age 50.
- Female sex. Women make up about two-thirds of all idiopathic macular hole patients.
- High myopia (very nearsighted eyes). The longer eye shape stretches the retina.
- A previous macular hole in the other eye. The risk in the second eye is roughly 10-15%.
- Vitreomacular traction seen on OCT.
- Eye injury (traumatic macular hole).
- Some retinal diseases like diabetic retinopathy, retinal detachment, or epiretinal membrane.
Macular holes are not caused by reading in dim light, watching screens, or using the eyes too much.
Treatment
Most macular holes need surgery to close. A few small holes can close on their own, especially when caught very early 3.
Vitrectomy with ILM peel and gas tamponade is the standard surgery 7:
- The retina surgeon removes the vitreous gel through three tiny ports in the white of the eye.
- A thin film called the internal limiting membrane (ILM) is gently peeled off the macula. ILM peeling clearly improves the chance the hole closes 8.
- The eye is filled with a gas bubble that presses the edges of the hole back together while it heals.
- For larger macular holes (over about 400 microns), a larger ILM peel or an ILM flap technique may be used to lift the closure rate 9.
What to expect after surgery:
- Face-down positioning for several days, so the gas bubble presses on the macula. Some surgeons now use shorter or no positioning for small holes 6.
- Drops for several weeks to prevent infection and swelling.
- No flying, scuba diving, or high altitude until the gas bubble is gone (2-8 weeks). The bubble can expand at altitude and damage the eye.
- Cataracts almost always develop or get worse within a year of vitrectomy in adults over 50. A separate cataract surgery is usually needed later.
Common Questions About Macular Holes
Next Steps
- 1If you notice a new blurry, distorted, or missing spot in the center of your vision, see an eye doctor within a few days — earlier surgery for a macular hole gives better results.
- 2Cover one eye at a time and check straight lines on a doorframe, window, or tile grid. Wavy or bent lines are an early warning sign.
- 3If you have a macular hole in one eye, watch the other eye carefully and have it checked yearly.
- 4Ask whether an OCT scan of the macula is appropriate, especially if you are over 60, female, or very nearsighted.
- 5If macular hole surgery is recommended, follow your surgeon's positioning instructions exactly — face-down time matters for closure.
- 6Do not fly, scuba dive, or go to high altitude until your eye doctor confirms the gas bubble inside your eye is fully gone.
- 7Get same-day care from a retina specialist or ophthalmologist for sudden vision loss, a curtain or shadow over the vision, many new floaters or flashes, or any eye injury — these can mean a retinal detachment or vitreous bleed. Go to the emergency room if a retina specialist is not reachable today.
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