What is a Macular Hole?

The eye is essentially a camera, its camera film is known as the retina, a very specialised structure that senses and processes light. The central part of the retina is known as the macula, which is responsible for detailed central vision including reading and recognising faces. In most people the vitreous gel, which fills most of the eye, naturally and gently separates away from the retina with ageHowever in some people, it can be abnormally strongly attached to the macula causing pulling or traction (known as vitreomacular traction). If the traction is sufficient, it can cause a small fullthickness hole (FTMH) to form in the very centre of the macula. Because of this location, even a very small hole can cause symptoms. If the hole does not involve the full-thickness of the macula, we term it as a partial thickness or lamellar hole, and generally does not affect the vision as much as a FTMH 

Why have I Developed a Macula Hole?

Macular holes affect about 1 in 500 people, and effects women more than men. FTMHs are more common after the age of 60 and in slightly long-sighted and very short-sighted patients. It is not entirely clear why some people develop macular holes and why others don’t. Most FTMHs occur due to excessive pulling on the macula by the vitreous gel (see vitreomacular traction section). FTMHs may also develop due to eye trauma or inflammation, or if there is a history of previous eye surgery or retinal problems. Genetics, environmental factors, and systemic causes so not seem to be important in macular hole formation. 

 

macular hole

What are the Symptoms of a Macular Hole?

In the early stages of VMT, many patients will not have symptoms. However, by the time a full-thickness macular hole has developed, most patients will be aware of reduced central vision and distortion when looking at words or people’s faces. Straight lines may also appear crookedand you may also be aware of a blind spot in the middle of your vision. Occasionally, some patients may only notice these symptoms when covering their good, unaffected eye or at routine review by their optometrist. Conversely, some patients are aware of symptoms even when both eyes are open together (interference) 

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What Tests are Required?  

Macular holes are often visible when your eye is examined by your optometrist or ophthalmologist doctor. Macular holes can also often be seen on photographs of your retina. Macular holes are however best detected and classified with the use of specialist retinal imaging equipment known as an OCT scannerYour optometrist or ophthalmology doctor may already have performed this for you. This is important in differentiating full-thickness from partial thickness holes, as these are often treated differently. The OCT scan also helps to measure the size of the hole, which influences success rates and visual prognosis, and determines whether additional steps are advised during the operation to maximise chances of success.  

Benefits of Surgery

Although some very early FTMHs can occasionally just be monitored, surgery, which is the only treatment available, is advised for the vast majority of FTMHs and aims to improve your vision by closing the FTMHIt is well established that the chances of closing the FTMH and improving your symptoms of reduced vision and distortion are greater the smaller the FTMH, and the shorter the duration of symptoms. Therefore, prompt diagnosis and early surgery favour maximal gains in vision, and is generally considered gold-standard in the treatment of FTMHsIf left for a considerable time, the prognosis for visual improvement and hole closure are substantially reduced.  

Macular hole surgery in my hands has a 98-100% chance of closure with one procedure, which exceeds national standards. Typically, most patients can expect their symptoms of distortion to improve or their vision to stabilise rather than progressively get worse. If operated on early enough, about 75% of patients can expect improvement in their vision by 2-3 lines of letters on the vision chart, and some may have even greater gain. Much of the improvement occurs within the first 2-3 months following surgery, but macular function can continue to improve for up to a year. Even if vision does not improve, it is much more likely to stabilise and not further deteriorate, and surgery will allow your two eyes to work better together without interference.  For a small minority of people, vision could be worse and may require further surgery.  It is important to appreciate that even with fully successful closer, your vision will not be as good as before you developed a macular hole. The vast majority of people who have undergone surgery are pleased that they did so.  

 

What does Surgery for Full-thickness Macular Hole Involve?  

Before Surgery

After Surgery

Surgery for the repair of a FTMH is called vitrectomy. I exclusively use the latest generation micro-incisional keyhole surgical equipment to perform this operation. Through just 3 tiny incisions, each only approximately 0.5mm in length, the vitreous gel is delicately removed from the eye allowing access to the FTMHUsing very delicate forceps, a very fine retinal membrane which is only 1/400th of a millimetre thick is gently lifted and peeled from around the FTMH. This is the most critical and delicate part of the procedure.  Following this, a gas bubble is injected into the eye which naturally absorbs over a period of a 2-8 weeks, depending on which gas was used in your operation (see gas in the eye FAQ)Removing the vitreous gel and retinal membrane, in combination with gas injection allow the FTMH to close. Because the incisions required using this specialised keyhole equipment are so small, sutures will not be required in most cases. Routine surgery is usually performed under local anaesthetic and can be performed in as little 20-40 minutes. If you feel you will be very anxious during the procedure, I have access to an excellent team of private anaesthetists who will be able to administer additional sedation or even general anaesthesia as required, in order to make the procedure as comfortable as possible for you. (See anaesthesia options FAQ) 

Macular Hole Surgery FAQs

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Advantages of Private Macular Hole Surgery

“Your surgeon is the biggest factor in the outcome of your treatment”

  • I am an experienced full-time NHS Consultant who specialises in complex vitreoretinal and cataract surgery.

  • I have performed approximately 3000 vitreoretinal procedures, and personally perform and supervise approximately 300 retinal operations a year, including routine and complex retinal detachments.

  • My success rate for primary retinal detachments is above national averages.

  • I am one of the most highlytrained Vitreoretinal Surgeons in the Midlands, having completed 2 years of subspecialist high-volume vitreoretinal training fellowships at Moorfields Eye Hospital in London, one of the World’s Top Eye Hospitals. I am the Director of Vitreoretinal Surgery in my current NHS Hospital.

  • I will personally perform your initial and post-operative assessments, and will provide you with all the time you require in order to answer your questions and alleviate any fears and anxieties.

  • I will personally perform your surgery, rather than a trainee surgeon which is not uncommon in non-private settings (in particular in Teaching Hospitals).

  • You will have direct access to me from the outset, thereby circumventing some of the more traditional route requiring you to be seen by an optician and general ophthalmologist prior to being reviewed by vitreoretinal surgeon.

  • As a private patient you may bypass any local NHS waiting lists for urgent surgery, resulting in accelerated curative treatment. This is particularly important if you have very recently developed a macular-off retinal detachment where surgery could still restore good central vision, but only if performed promptly. Such cases usually receive lower priority compared with macular-on retinal detachments in busy vitreoretinal departments.

  • At all stages of your treatment pathway, you will receive my direct access telephone number. This will negate the need to go via any third party, such as a secretary or the hospital, in order to obtain any routine or urgent advice. I will be available 7 days a week for you in this regardThis is a very important aspect to the service I pride myself in providing, giving you the reassurance and confidence to make your journey through this difficult time as smooth and anxiety-free as possible. 

  • This and all other aspects of the service I provide have resulted in very high satisfaction levels from my former patients, rating my service an average of 4.9/ 5 on Trustpilot.

Macular Hole FAQs

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