A macular hole is a break in the central portion of the retina this region is critical to our vision and acuity. This break leads to significant disturbances in vision. Patients will complain of a “hole” in their vision that they can not see around and through. The severity and presentation varies from patient to patient.
Macular holes are usually caused by vitreal traction. The vitreous degenerates and liquefies with age. The back portion of the vitreous or posterior hyaloid face begins to separate from the retina. An epiretinal membrane (type of scar tissue) may form where the vitreous was once attached. The epiretinal membrane is not a uniform membrane and these variations cause tugging and pulling on the retina that distorts vision and may form macular holes.
Our iVue OCT office can show a detailed view of the effect these forces have on the retina. Prior to this technology it was difficult at times to appreciate the subtle changes in the retina structure caused by these membranes. The scans at the top of the page make these changes easy to detect.
Macular holes are classified using the Gass scale.
Stage 1: the foveal pit/depression begins to be more difficult to see, and a small cyst forms below the retinal surface.
Stage 2: Partial inner retinal breaks can be seen with a lid or operculum adhering to the sides of the hole.
Stage 3: The operculum no longer adheres to the retina.
Stage 4: Hole becomes full thickness.
Treatment by a retinal surgeon is often required. They typically do a vitrectomy and membrane peel. The prognosis is much better now than even a few years ago with improving techniques.
Vitrectomy is very invasive surgery and should not be considered lightly. There has been development of a new intraocular injection that relaxes the tension the membranes apply to the retina, but these are carried out with caution. I think as data mounts on the effectiveness of these injections, they will become a increased asset in preventing full thickness holes from forming, and allow us to be more proactive and less reactive.