A hole can spontaneously develop in the center of the macula, causing loss of central vision. It occurs usually in the sixth through eighth decades of life. The etiology of the hole is thought to be related to the tractional forces associated with vitreous gel separation that occurs naturally. Retinal exam and optical coherence tomogram are used to diagnose and stage the hole. The formation of macular hole goes through several stages:
- Stage 1: Patients experience onset of visual symptoms with distortion and decreased vision. Exam reveals evidence of cystic elevation in the center of the macular causing a tiny circular yellow spot with a full thickness hole.
- Stage 2: A full thickness defect start to develop as a break forms in the roof of the cyst further deterioration of vision.
- Stage 3: A fully developed hole is present along with a rim of subretinal fluid. The vitreous gel is still attached to the macula.
- Stage 4: The hole is fully developed and the vitreous gel has become detached from the macula.
Treatment
Patients with a stage 1 hole are usually observed, as approximately 50% of the patients may experience spontaneous resolution according to some studies. However, most patients with more advanced stage 2- 4 macular hole do not improve and should consider vitrectomy. The surgery is performed by removing the gel and injecting gas bubble into the vitreous cavity. The patient is required to maintain his/her face down up 1 to 2 weeks to allow the gas bubble to be in contact with the hole and allow the hole to close. The rate of success can be as high as up to 70 to 90% in closing the hole and improving the vision.