Macular hole: symptoms, vitrectomy surgery and recovery

The retina is the light-sensitive film at the back of the eye, and the macula is its centre. The macula is what lets you read small print, recognise faces and see fine detail straight ahead. A macular hole is a small break in this central area. It is not a hole through the whole eye, and it does not affect the side (peripheral) vision, which is why people keep their ability to get about even when reading becomes hard.

The NHS says macular holes usually develop because of changes in the vitreous, the clear jelly that fills the middle of the eye. As we get older the vitreous starts to pull away from the retina. If part of it stays attached to the macula as it shrinks, it can pull a section of the retina away, leading to a hole. This is known as vitreomacular traction.

RNIB also says a macular hole is linked with being slightly long-sighted, being very short-sighted, a severe eye injury, previous retinal detachment, long-lasting macular swelling (cystoid macular oedema) and vitreous gel pulling on the macula.

The NHS says that in the early stages a macular hole can cause blurred and distorted vision. Straight lines may look wavy or bowed, and you may have trouble reading small print. After a while you may see a small black patch or a missing patch in the centre of your vision. RNIB describes the same picture, with a range from slight to more noticeable changes depending on the size and depth of the hole.

• Blurred central vision in one eye, often noticed when reading or watching television.

• Straight lines, such as door frames or text lines, looking wavy, bowed or bent.

• A small blank or black patch in the centre of what you are looking at.

• No pain and no redness of the eye.

The NHS advises that if you have blurred or distorted vision, or a black spot in the centre of your vision, you should see an optician or a GP as soon as possible, and that you will probably be referred to an eye specialist (ophthalmologist). If you do have a macular hole and do not seek help, your central vision will probably get gradually worse, and relatively early treatment, within months, may give a better outcome.

Sudden new floaters, flashes of light or a curtain or shadow across the vision are different symptoms and can signal a retinal tear or detachment. These should be treated as an eye emergency and assessed the same day through an eye casualty department or NHS 111.

An optician may first notice the problem, or a GP may suspect it from the symptoms, and you will probably be referred to an eye specialist (ophthalmologist) who examines the back of the eye. The hole is a gap at the centre of the retina, so the diagnosis rests on a specialist looking at the macula. Moorfields Eye Hospital describes the symptoms as often starting slowly, with some people barely noticing them and others having slight blurring, distorted or wavy vision, difficulty reading and a dark or blind spot as the hole gets bigger.

The NHS says sometimes the hole may close and heal by itself, so your ophthalmologist may want to monitor it before recommending treatment.

RNIB says that if the ophthalmologist feels you need treatment, they will usually suggest an operation. The NHS explains that macular hole surgery is a form of keyhole surgery performed under a microscope. Small incisions are made in the white of the eye and very fine instruments inserted. The vitreous jelly is removed (vitrectomy) and then a delicate layer, the inner limiting membrane, is peeled off the surface of the retina around the hole to release the forces that keep it open. The eye is then filled with a temporary gas bubble, which presses the hole flat onto the back of the eye so it can seal.

The operation usually lasts about an hour and can be done awake under local anaesthetic or asleep under general anaesthetic. Most patients opt for a local anaesthetic, with a numbing injection around the eye.

RNIB says that in the months after surgery 80 to 90 per cent of people have some degree of improvement in their vision, although this depends on the size and age of the hole and the level of vision beforehand. The NHS says your vision will never completely return to normal but it is usually improved by surgery, and that even if the hole does not close, vision usually at least becomes stable. In a minority of people the hole does not close, and a second operation can still be successful.

The NHS lists the main complications. The hole may fail to close. You will almost certainly get a cataract after the surgery, usually within a year if you have not already had a cataract operation. There is a risk of retinal detachment, which is usually repairable in a further operation, and very rare bleeding or infection. Pressure inside the eye is quite common in the days after surgery because of the expanding gas, usually short-lived and controlled with drops.

Contact your ophthalmologist immediately or go to an eye A&E department if you have severe pain, if your vision becomes worse than it was on the day after surgery, or if you have a shadow across your vision.

The NHS is very clear that you must not fly or travel to high altitude on land while the gas bubble is still in your eye, which can be up to 12 weeks after surgery, because the bubble can expand and cause severe pain and permanent loss of vision. You must also tell any anaesthetist or dentist about the gas, and avoid nitrous oxide gas and air (Entonox), because it can make the bubble expand.

It also advises not driving while the gas bubble is still present. It is an offence to drive a car if your ability to drive safely is affected. You may need to avoid rubbing your eye, swimming, strenuous exercise and eye make-up for the first few weeks. Most people need some time off work, which depends on the job and recovery.

The NHS notes that in some people there is a 1 in 10 chance of developing a macular hole in the other eye, so it is very important to monitor any changes in the vision of the healthy eye and report them urgently.

Macular hole surgery is provided in NHS hospital eye services, usually by a vitreoretinal surgeon after referral from an optician or GP. Waiting times vary by area, and because outcomes are better when surgery is done earlier, it is reasonable to ask the clinic how soon an operation can be arranged.

Some people choose private vitreoretinal surgery to be treated sooner or to choose their surgeon. The operation itself is the same keyhole vitrectomy described above. The details to ask any provider about are who will do the operation, what posture is advised afterwards, and who to call urgently if vision worsens.