Diagnosing Macular Holes

As retina specialists, Dr. Kirsch and Dr. Hairston can diagnose a macular hole during a detailed, painless examination of the retina using special lenses and instruments. For most patients a fluorescein angiogram test is usually recommended to help determine the severity and stage of the macular hole. This test is performed in the office and involves injecting an orange vegetable dye into a vein in the arm and taking black-and-white photographs (NOT X-rays) of the macula. An Ocular Computed Tomography (OCT) test will also show the macular hole in great detail and is not invasive. A non-invasive ocular ultrasonogram will reveal whether the vitreous is attached and can also help determine the stage of the macular hole. The doctor will review the results of the fluorescein dye pictures, ultrasonogram and OCT tests with you in detail.

The Progression of Macular Holes

What effect will a macular hole have on your vision? Macular holes progress through four stages and the stage of your macular hole will be determined during your examination. The vision is generally worse as the macular hole progresses from Stage 1 to Stage 4. The loss of sight usually only involves the center portion of your vision and may progress to 20/200 or worse (“legally blind”). You will not normally lose any of the “side” or peripheral vision and therefore will not become completely blind from the macular hole itself. In very rare instances (about 1 in 10,000), a macular hole can lead to a retinal detachment that can cause severe, permanent loss of all vision if untreated.

Treatment Levels

The treatment that Dr. Kirsch or Dr. Hairston recommends for a macular hole is custom-designed for your situation. If your vision is still good and the macular hole is in Stage 1, observation is usually recommended. The patient is very carefully monitored with regular examinations every 3 to 6 months. You will also be asked to look at your Amsler Grid once or twice per week. About 50% of Stage 1 macular holes will get better without treatment because the vitreous gel spontaneously separates from the retina and relieves the pulling force on the macula. Once the macular hole reaches Stage 2 (which is a partial thickness hole in the retina), surgical treatment is seriously considered and may be offered to the patient, because about 75% of the Stage 2 holes will get worse without treatment. If a Stage 3 macular hole (a full thickness hole without vitreous gel separation) or a Stage 4 macular hole (a full thickness hole with vitreous gel separation) is present, surgery is almost always recommended. The decision whether to perform surgery is complex and depends upon the level of vision, the stage of the hole, the amount of time the hole has been present, the patient’s overall health, the status of the other eye, and most importantly, the patient’s feeling about whether to undertake the operation. Dr. Kirsch or Dr. Hairston will consider all of these factors and discuss them with you in detail so that together you can decide on the best course of action. Before discussing surgery, it is important to understand that there are no medications, eye drops, vitamins or laser therapy that can treat a macular hole; surgery is the only viable treatment.

If Surgery is Required

The operation for a macular hole is performed in the Surgery Center and is usually done under local anesthesia. You will go home the same day. The risks of this operation include: retinal detachment (occasionally), infection inside the eye (rarely) and bleeding inside the eye (rarely). These complications are treatable most of the time, although as with any surgery inside the eye, loss of eyesight can rarely result. In some patients (about 2%), the scar tissue grows back. If you already have a cataract, surgery will most likely make it worse.

The surgery is called a vitrectomy because the vitreous gel inside the eye is removed through 3 tiny incisions. The vitreous gel is replaced with salt water (the vitreous is like your appendix; you have it but you are sometimes better off without it!). The edge of the scar tissue is identified and separated from the surface of the retina. Using special microscopic forceps, the scar tissue is peeled from the surface of the retina like you would peel a label from its backing. The fluid is then removed from the eye and replaced with a special gas that lasts about six weeks. The gas will be reabsorbed and replaced by the body’s own natural salt water on its own. Two things that are special about the macular hole surgery with gas are: 1) you have to lay on your stomach or one side with your head down for 7 to 10 days after surgery and 2) you may not go above 4,000 feet in elevation or fly in an airplane until the gas is gone from the eye.

There is an alternative to placing gas inside the eye at the end of surgery. Instead, the eye can be filled with silicone oil. The major advantages of silicone oil are that you do not have to lie on your stomach after surgery (may be asked to lay on one side for one night) and that you can fly in an airplane or drive over an elevation of 4,000 feet. The main disadvantage of the oil is that the doctor has to remove it from the eye about 6 weeks after the initial surgery. If you have a cataract that grows during this time, it may be removed during the operation to take out the oil.

The surgery for macular holes is successful in the vast majority of patients, although it can take from 6 to 12 months for the vision to improve to its final level. About 90 to 95% of macular holes can be closed with the operations described here. Working with Dr. Kirsch or Dr. Hairston, you can decide which course of action is best for your situation to preserve or restore the precious gift of sight.