Lamellar macular hole: symptoms, monitoring and treatment

The retina is a thin sheet of nerves lining the inside of the eye that turns light into a picture for the brain. Its central part, the macula, is responsible for your best vision, including reading, recognising faces and fine detail. The Macular Society describes the macula as the small area at the centre of the retina responsible for all of our central vision, most of our colour vision and the fine detail we see.

A lamellar hole is a partial-thickness split at the very centre of the macula. That is different from the more familiar full-thickness macular hole, in which the defect goes all the way through the retinal layer. The Macular Society explains that full macular holes are thought to be due to abnormal adhesion and traction on the retina by the vitreous gel as it shrinks and detaches with age, and a similar pulling mechanism applies in the tractional form of lamellar hole.

The Plymouth leaflet describes two broad types. A tractional lamellar hole is one where there is pulling from a membrane on the surface of the retina. A degenerative lamellar hole is one where there is apparent loss of tissue within the central retina.

The difference matters because the outlook after surgery is not the same. The leaflet says the outcome of surgery is thought to be best in tractional lamellar holes and not so good in degenerative lamellar holes. Your retinal specialist will use scans to decide which type you have.

The Plymouth leaflet says people with lamellar holes most commonly experience blurred central vision, and may also notice that things look distorted near the centre. These changes develop slowly. In some cases the hole is not initially noticed and is only picked up on a routine visit to the optician.

The Macular Society describes the symptoms of a full macular hole as slight distortion or blurred vision, straight lines appearing wavy and reading becoming difficult, which overlap with lamellar holes. It stresses that peripheral vision is unaffected and that a macular hole does not lead to complete blindness.

Diagnosis is made by an eye specialist using a detailed scan of the retina. The Macular Society mentions optical coherence tomography (OCT) scans being used by the ophthalmologist to assess the macula and risk of a hole developing.

The Macular Society says that the sudden appearance of flashing lights, floaters (specks or flecks that float across the vision) or fading vision could indicate a retinal detachment, and that in this case you should seek urgent medical help. It also advises having eye tests with an optometrist at least every two years and seeing them urgently if you notice any sudden change in vision.

A lamellar hole itself usually changes slowly. A sudden, marked change in vision is therefore a reason to be seen promptly rather than waiting for the next routine appointment.

The Plymouth leaflet says that an operation is the only way to attempt to repair a lamellar hole, but that the progress of lamellar holes is very slow, so you may choose not to have any intervention in the first instance. Your specialist will advise whether it is best to monitor the hole or to consider surgery.

There is no obvious preventive action that can be taken, according to the same leaflet. If you have one macular hole, the Macular Society says you may be at higher risk of developing one in the other eye, so changes in vision in the other eye should be reported to your optometrist.

The operation described by the Plymouth leaflet is a vitrectomy. It can be done under local or general anaesthetic and involves removal of the jelly-like fluid in the eye, removal of any membranes from the surface of the macula and injection of a long-acting gas bubble. As long as there are no problems you can go home on the day of surgery.

The leaflet says that for 10 to 14 days you may have to do posturing, spending most of the day looking straight down at the floor, with a 10-minute break each hour. Your vision will be very blurred for over a month, and during the six to eight weeks that you have gas in your eye you must not lie on your back unless instructed, must not fly in an aeroplane and must tell any anaesthetist about the gas.

The main risks it gives are that all patients who have not previously had cataract surgery will develop a cataract more rapidly, a one in a thousand chance of loss of vision from severe infection, a one in a thousand chance from severe bleeding in the eye and a one in twenty chance of developing a retinal detachment. In one study the average vision improved from 6/15 to 6/10 after surgery, with significantly poorer outcomes in degenerative holes.

If your sight remains poor, the Plymouth leaflet says you can be helped to see many of the things you used to by making use of your remaining sight, and that low vision services can help with magnifiers and with advice and training. You can ask the eye specialist, optometrist, GP, social worker or a local voluntary organisation about local services, and the RNIB can also advise on help available.

The Macular Society runs a helpline and local support groups for people with macular conditions.