OCT with a Macular hole before vitrectomy

Macular hole

Table of Contents

What is a macular hole?

A macular hole is a small hole in the macula. The macula is the central part of the retina that helps us see fine details and small things. In most cases, it is due to the abnormal traction of the vitreous cortex which is the gel inside of the eye.

What are the symptoms?

A macular hole may occur after age 50. The most common symptom of a macular hole is the gradual decline in the central (straight-ahead) vision of the affected eye.
This can occur as:

  • Blurring
  • Distortion (straight lines appearing wavy)
  • A dark spot in the central vision
Macular hole
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After surgery closure
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What causes a macular hole?

In most people, macular holes are due to vitreous traction that’s more likely to happen with aging. Sometimes a macular hole is the result of an injury or a medical condition that affects the eye, including being very nearsighted.

You may be more likely to develop a macular hole if you have:

A very high degree of myopia (nearsightedness).
Inflammation within your eye (uveitis).
Eye trauma.

How can I know if I have a macular hole?

Your Retina Specialist will begin by asking you about your family and medical history and then do a complete eye exam, which will include a slit lamp exam. Your provider will put eye drops in your eyes to make your pupils larger and allow for retina examination. Afterwards it will be necessary to perform an optical coherence tomography (OCT). OCT can provide more detailed views of the initial changes induced in the macula during the formation of the macular hole after the vitreous traction has occurred.

Optical coherence tomography (OCT) imaging of macular hole
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Optical coherence tomography (OCT) imaging after surgical closure
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What is the treatment?

Currently, the standard treatment for a macular hole is a vitrectomy along with the removal of the internal limiting membrane. At the end of the surgery, we put a bubble of gas inside the eye to push the edges of the macular hole and facilitate its subsequent closure. It is necessary to maintain a face-down position for 1-2 days or more depending on the case.

Dr. Aureliano Moreno treats macular holes using novel surgical techniques and has more than 95% of success rate with his techniques compared to the 88% success rate reported by other surgeons using traditional methods.

Large macular hole in a patient with high myopia. Before and after inverted ILM flap technique Copyright Retina Center

Dr. Aureliano Moreno between 2017 and 2023 performed this surgery more than 300 times and is a speaker in international forums speaking on this topic.

Dr. Moreno presenting the inverted ILM flap technique for large macular holes

There are other conditions such as macular hole combined with retinal detachment. Macular hole in combination with retinal detachment typically occurs in one of two scenarios. The first of these is in the presence of high myopia and staphyloma. In these cases, the macular hole is the break that led to the retinal detachment. This detachment is typically posterior but can spread anteriorly, and generally there are no other associated breaks. Here an example of this case:

Macular hole and retinal detachment

In the second scenario there is a rhegmatogenous retinal detachment, which started with a peripheral break or breaks and subsequently spread posteriorly. The stretching of the retinal tissue over the thin fovea during detachment has led to the formation of the macular hole. Both scenarios require the macular hole to be fixed.

The surgical approach for macular hole in combination with retinal detachment is slightly different from and more challenging than surgery for a typical macular hole without concurrent retinal detachment. The primary challenge is peeling the internal limiting membrane (ILM) over the detached and mobile retina associated with surgery in high myopia include long axial length, staphyloma and, in some eyes, decreased contrast due to light pigmentation. Here an example of this case:

Retinal detachment and macular hole

This innovate technique in the hands of Dr. Moreno increase the rate of retinal reattachment and macular hole closure in 97.8% vs 82% of the conventional technique.

Additional information: National Eye Institute

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