Often found by chance
Because the other eye fills in, a hole is often discovered when one eye is covered, at a routine eye test, or when reading becomes oddly difficult.
Macular hole and
vitreomacular traction
What a macular hole and vitreomacular traction are, the symptoms, how an OCT scan shows them, and the choice between watching and surgery.
What a macular hole and vitreomacular traction are.
The macula is the small central area of the retina responsible for detailed vision. A macular hole is a small gap in its very centre.
Most macular holes are caused by the vitreous, the clear gel that fills the eye, pulling on the centre of the macula as it separates from the retina with age. When the gel stays attached at the centre and keeps tugging without a hole forming, the condition is called vitreomacular traction (VMT). Traction can settle on its own if the gel eventually lets go, or it can progress to a hole.
A macular hole leaves a blank or distorted spot in the middle of vision. It is not caused by anything you did, and it is not related to macular degeneration, although the two can occur in the same eye. Both a hole and traction are diagnosed and measured on an OCT scan.
In brief
- A small gap at the centre of the macula; side vision is unaffected
- Vitreomacular traction is the gel pulling without a hole, yet
- Diagnosed and measured with an OCT scan
- Most full-thickness holes need surgery to close
- Some traction, and an occasional small hole, settles without surgery
Understanding the OCT
How the centre of the macula can change.
Move through a smooth illustration of a normal macula, vitreomacular traction and a macular hole. Colour helps distinguish the retinal layers as their shape changes.
Illustrative colour OCT · not a patient scan
Normal macula
The central dip is intact. The retinal layers remain continuous.
Drag the slider, use the arrow keys, or choose a stage.
One possible sequence, not a timescale. Vitreomacular traction does not always progress to a hole; the gel can release on its own.
Normal macula
The central dip is intact. The retinal layers remain continuous.
Vitreomacular traction
The vitreous gel remains attached at the centre and pulls the macula out of shape. There is no full-thickness opening.
Macular hole
A gap extends through the full thickness of the central retina. The underlying support layer remains beneath it.
Original teaching illustration · not to scale. The colours are illustrative and do not represent measured scan signals. About vitreomacular traction · About macular holes (ASRS).
How vision changes
Symptoms of a hole or traction.
ClearWith a macular hole
Blurred area in the centre of your vision and distortion
The centre of a word or page can become blurred, while nearby lines look wavy or pinched. Traction can distort central vision even without a hole.
Slide each picture to compare typical vision with the change described. Illustrations are indicative, not a diagnostic test or a prediction of vision after treatment.
At the consultation
The OCT scan measures the hole.
An OCT scan (optical coherence tomography) shows the hole or the traction in cross-section and measures its size, which guides the decision.
After a vision test and dilating drops, the macula is examined and scanned. The scan shows whether the gel is still attached at the centre, whether there is a full-thickness hole or a partial one, and how wide it is. The state of the lens is assessed at the same time, because a cataract is often planned alongside.
Dr Chen explains what the scan shows and whether a period of watching, or surgery, is the sensible next step for that eye.
Bring with you
- Your referral and any previous OCT scans
- Current glasses
- A note of when you first noticed the change
- Someone to drive you home; the drops blur vision for several hours
Options
Watching, or surgery.
A period of observation
For vitreomacular traction, and occasionally for a very small early hole, the gel may release on its own and the retina settle. A short period of watching with repeat OCT scans is sometimes suggested before committing to surgery. The interval and the signs to watch for are explained.
Vitrectomy with gas
The operation for a macular hole. Through tiny openings the vitreous gel is removed, releasing the pull on the macula. The thin inner layer of the retina around the hole is usually peeled to help it close, and the eye is filled with a gas bubble that presses on the hole while it seals. Dr Chen performs this surgery under local anaesthetic with sedation, or general anaesthetic, usually as day surgery.
Posturing basics
Because gas rises, you may be asked to keep your head in a face-down or other position for part of each day for several days, so that the bubble sits against the hole. The exact position and duration are set for each eye and explained before you go home. Vision is very blurred while the gas is present and clears over weeks as it absorbs; no flying or travel to altitude until it has gone.
Suitability and timing are decided at the consultation. Risks include infection, bleeding, retinal tear or detachment, raised pressure, a hole that does not close or reopens, and cataract; a cataract commonly develops after vitrectomy in eyes with their natural lens and is often planned alongside. Central vision often improves as a hole closes, but the amount varies and some distortion or a small blind spot can remain. General information, not a guarantee of outcome.
Questions to ask
Useful questions for the consultation.
- Is this a full-thickness macular hole or vitreomacular traction, and how large is it?
- Is there a case for waiting and rescanning, or should surgery be arranged?
- What positioning will I need after surgery, and for how long?
- What is realistic for my central vision, and what may not return?
- Should my cataract be treated at the same operation?
- What are the risks for my eye in particular?
- When can I fly, drive and return to work?
Bring these, and anything else on your mind. Write the answers down, or bring someone who can.
Common questions
Straight answers, without replacing a consultation.
Do all macular holes need surgery?
Most full-thickness holes do not close on their own, so surgery is usually suggested once a hole is affecting vision. Some traction, and an occasional very small hole, settles without surgery, which is why a short period of rescanning is sometimes proposed.
What is the face-down positioning about?
After surgery a gas bubble is placed in the eye. Because gas rises, keeping the head down positions the bubble against the hole while it closes. The position and duration are set for each eye and explained before you go home.
Will my central vision return?
Central vision often improves after a hole closes, but the amount varies with the size of the hole and how long it has been present, and some distortion or a small blind spot can remain. What is realistic for your eye is discussed candidly before surgery.
Will I need cataract surgery as well?
Often, yes. Vitrectomy accelerates cataract in eyes that still have their natural lens. Because Dr Chen performs both, the cataract can be planned at the same operation or in sequence, whichever suits the eye.
Can I fly after surgery?
Not while gas remains in the eye. Gas expands at altitude and can raise the pressure dangerously. The team tells you when the bubble has gone, and you should tell any anaesthetist about it before other surgery.
Ready when you are.
Appointments and enquiries through Vision Eye Institute, Chatswood.
Free Chinese Patient Liaison for VEI Sydney patients. Chinese language support through VEI (02) 9052 1886