Macular Hole: Symptoms, OCT Diagnosis, Surgery and Recovery

Author: Dr Val Phua
Estimated reading time: 20 minutes

A macular hole is a small opening that develops in the macula—the central part of the retina responsible for sharp, detailed vision.

The macula allows you to:

Read
Recognise faces
Drive
Use a phone or computer
See fine details
Distinguish colours
Look directly at an object

When a full-thickness hole forms at the centre of the macula, the retinal tissue required for detailed central vision is interrupted. This may cause:

Blurred central vision
Straight lines appearing bent or wavy
A small dark or missing area in the centre
Distorted faces
Difficulty reading
Letters appearing broken or incomplete
Reduced central visual detail
Unequal vision between the eyes

A macular hole usually affects central rather than peripheral vision. It does not normally cause complete darkness, but an untreated hole can significantly reduce the useful vision of the affected eye.

Most idiopathic full-thickness macular holes develop because of abnormal traction between the vitreous gel and the macula. Modern optical coherence tomography, or OCT, allows the hole’s size, configuration and relationship with the vitreous to be examined in detail. OCT is central to diagnosis, treatment planning and postoperative monitoring.

Most symptomatic full-thickness macular holes are treated with vitrectomy, internal limiting membrane surgery and an air or gas bubble. Contemporary surgery has a high anatomical closure rate, although the final visual improvement depends on the hole’s size, duration, cause and the condition of the retinal photoreceptors.

The Quick Answer

What Is a Macular Hole?

A full-thickness macular hole is an opening extending through all the layers of the retina at the fovea—the central point of the macula.

The opening is not:

A hole in the entire eyeball
A tear in the cornea
A hole that allows fluid to leak out of the eye
The same as an ordinary peripheral retinal tear

The International Vitreomacular Traction Study Group defines a full-thickness macular hole as interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium.

What Are the Main Symptoms?

Possible symptoms include:

Blurred central vision
Wavy or bent lines
Distorted words
Difficulty reading
A central grey or blank spot
A missing letter within a word
Faces appearing distorted
Reduced depth perception
Unequal image size between the eyes

Symptoms are usually painless and may develop gradually over days, weeks or months.

Is a Macular Hole an Emergency?

An ordinary idiopathic macular hole does not usually require treatment within hours.

However, it should be assessed promptly because:

A smaller, more recent hole generally has a better prognosis.
Some holes enlarge over time.
Longer-standing holes may cause more permanent photoreceptor damage.
Sudden symptoms may have another urgent cause.

Seek urgent same-day assessment for:

A sudden shower of floaters
New flashes of light
A curtain or shadow
Sudden severe vision loss
Eye trauma
Eye pain or redness
Sudden clouding of the vision

These symptoms may indicate a retinal tear, retinal detachment, vitreous haemorrhage or another acute condition rather than an uncomplicated macular hole.

Can a Macular Hole Heal by Itself?

Some small macular holes close spontaneously.

Published reviews have reported spontaneous closure in approximately 3% to 15% of idiopathic full-thickness holes overall, with a higher probability among holes measuring 250 micrometres or less. Closure becomes progressively less likely as the hole becomes larger.

Observation may therefore be considered for selected:

Very small holes
Recent holes
Holes with OCT signs suggesting possible closure
Patients who cannot undergo immediate surgery
Traumatic holes in younger patients

Observation requires repeat OCT rather than simply waiting indefinitely.

Can Eyedrops Close a Macular Hole?

Eyedrops are not established first-line treatment for most full-thickness macular holes.

Small retrospective studies have reported closure in selected holes treated with combinations of topical steroid, non-steroidal anti-inflammatory and pressure-lowering drops. These results are not yet sufficient to replace vitrectomy as the standard treatment for a typical symptomatic full-thickness hole.

Medication may occasionally be considered in carefully selected cases under a retinal specialist, particularly when:

The hole is small.
Macular swelling contributes to its configuration.
Surgery must be delayed.
The patient is temporarily unable or unwilling to undergo surgery.

Steroid-containing drops should not be used without monitoring because they may raise eye pressure, accelerate cataract formation or worsen certain infections.

Does Surgery Restore Normal Vision?

Surgery often improves vision, but it does not guarantee completely normal vision.

Successful closure may improve:

Reading ability
Central clarity
Distortion
Recognition of faces
Binocular visual balance
Vision-related quality of life

Some patients retain:

Mild waviness
A small central blur
Reduced contrast
Difficulty with fine print
Unequal vision between the eyes

Long-term studies show that visual improvement after successful surgery can be substantial and sustained for many years.

Understanding the Macula

The Retina

The retina is a thin layer of light-sensitive nerve tissue lining the back of the eye.

It converts light into electrical signals that travel through the optic nerve to the brain.

The Macula

The macula is the specialised central area of the retina.

It is responsible for the detailed vision needed for:

Reading
Facial recognition
Driving
Using digital devices
Seeing fine textures
Colour discrimination
Precise hand-eye coordination

The Fovea

The fovea is the central depression within the macula.

It contains a very high concentration of cone photoreceptors and provides the sharpest vision.

A full-thickness macular hole forms at this foveal centre.

Peripheral Vision Usually Remains

Because the macular hole is small and central, the surrounding retina generally continues to provide peripheral vision.

A patient may therefore:

Walk around
Detect movement
See large objects
Navigate using the side vision

while being unable to read or see facial details clearly with the affected eye.

Understanding the Vitreous

What Is the Vitreous?

The vitreous is the transparent gel filling most of the inside of the eye.

In youth, it is relatively firm and attached to the retinal surface.

With age, it gradually:

Becomes more liquid
Shrinks
Separates from the retina
Forms a posterior vitreous detachment

Normal Vitreous Separation

In most people, the vitreous separates from the macula without causing a significant problem.

Abnormal Vitreomacular Traction

In some eyes, the vitreous begins separating from the surrounding retina but remains attached to the fovea.

This persistent attachment can pull on the central retina.

The sequence may include:

Vitreomacular adhesion
Vitreomacular traction
Foveal distortion or cyst formation
Partial disruption of the retinal tissue
Development of a full-thickness hole

The precise pathway differs between patients.

What Causes a Macular Hole?

Idiopathic Macular Hole

Most full-thickness macular holes in older adults are idiopathic.

“Idiopathic” means that the hole is not directly caused by trauma, high myopia or another retinal disease.

Age-related vitreous traction is believed to be the main mechanism.

Traumatic Macular Hole

A blunt impact can suddenly deform the eyeball and create mechanical stress at the fovea.

Possible causes include:

Ball injury
Racquet or shuttlecock injury
Fist or elbow impact
Airbag injury
Fall
Road-traffic accident
Sports trauma

Traumatic holes are more common in younger patients than idiopathic holes.

Some traumatic holes close spontaneously, particularly when they are small and show favourable OCT features. Observation with repeated OCT may therefore be appropriate in selected cases. Surgery is considered when the hole remains open or vision is significantly affected.

High-Myopia-Related Macular Hole

Highly myopic eyes are longer and may develop:

Posterior staphyloma
Retinal stretching
Myopic macular degeneration
Macular retinoschisis
Epiretinal traction
Macular-hole-related retinal detachment

These holes can be more complex than ordinary idiopathic macular holes.

Treatment may involve:

Vitrectomy
Internal limiting membrane techniques
Gas or silicone-oil tamponade
Macular buckling in selected eyes
Treatment of associated retinal detachment

The prognosis depends on the degree of myopic retinal degeneration and the presence of a posterior staphyloma.

Secondary Macular Hole

A macular hole may develop in association with:

Epiretinal membrane
Retinal detachment
Retinal-detachment surgery
Diabetic retinopathy
Retinal-vein occlusion
Uveitis
Macular telangiectasia
Solar or laser injury
Previous vitreoretinal surgery
Certain retinal degenerations

The outcome depends both on closure of the hole and on the underlying retinal condition.

Who Is at Risk?

Increasing Age

Idiopathic macular holes most commonly occur in older adults because age-related vitreous separation is central to their formation.

Female Sex

Idiopathic macular holes are diagnosed more frequently in women than men, although either sex can be affected.

A Macular Hole in the Other Eye

A patient with a hole in one eye has an increased risk of vitreomacular-interface abnormalities in the fellow eye.

The risk depends on whether the vitreous has already fully separated from the macula.

High Myopia

Highly myopic eyes are at risk of more complex macular-hole configurations and macular-hole-related retinal detachment.

Eye Trauma

Blunt injury can cause a traumatic macular hole at any age.

Epiretinal Membrane or Vitreomacular Traction

Additional traction on the macular surface may contribute to hole formation.

Does a Macular Hole Affect Both Eyes?

Most patients initially develop a hole in one eye.

The other eye may have:

A normal vitreomacular interface
Vitreomacular adhesion
Vitreomacular traction
An epiretinal membrane
A previous complete vitreous separation
A second macular hole

Both eyes should therefore be examined with OCT.

A complete posterior vitreous detachment in the fellow eye generally reduces the likelihood of a tractional idiopathic hole developing later, although it does not prevent all macular conditions.

Common Symptoms

Blurred Central Vision

The central image may appear:

Hazy
Soft
Smudged
Less distinct
Difficult to focus

Metamorphopsia

Metamorphopsia means visual distortion.

Straight lines may appear:

Bent
Wavy
Broken
Pinched
Pulled towards the centre
Misaligned

Patients commonly notice this when viewing:

Door frames
Window blinds
Bathroom tiles
Text
Road markings
An Amsler grid

A Central Missing Spot

A small grey, blurred or blank spot may appear where the patient is looking directly.

The spot is called a central scotoma.

Missing Letters

While reading, a patient may notice:

The centre of a word is missing.
Letters seem incomplete.
One letter disappears.
The line of print appears distorted.
Reading speed slows.

Distorted Faces

Facial features may appear:

Compressed
Stretched
Asymmetrical
Blurred in the centre

Image-Size Difference

Objects may appear smaller or larger in the affected eye.

This can make it difficult for the brain to combine the two eyes’ images.

Monocular Double Vision

A single object may have:

A shadow
A second outline
Ghosting
Overlapping images

The effect remains when the unaffected eye is covered.

Reduced Depth Perception

Unequal central vision between the two eyes may affect:

Pouring liquids
Reaching for objects
Ball sports
Driving
Fine hand work
Walking on stairs

What a Macular Hole Does Not Usually Cause

An uncomplicated macular hole does not usually cause:

Eye pain
Marked redness
Discharge
A sudden shower of floaters
Flashes of light
A peripheral curtain
Complete blindness

The presence of these symptoms should prompt assessment for another condition.

Full-Thickness, Lamellar and Pseudoholes

Full-Thickness Macular Hole

A full-thickness hole extends through all retinal layers at the fovea.

This is the classic condition usually treated with vitrectomy and gas.

Lamellar Macular Hole

A lamellar macular hole is a partial-thickness defect.

Some inner retinal tissue is missing, but the defect does not pass completely through the retina.

Lamellar holes may be associated with:

Epiretinal membrane
Epiretinal proliferation
Foveal tissue loss
Outer-retinal disruption

Many remain stable and are monitored.

Surgery may be considered when there is:

Progressive visual loss
Increasing distortion
Significant traction
Favourable OCT anatomy

The indications and outcomes are less predictable than for an ordinary full-thickness hole.

Macular Pseudohole

A pseudohole is not a true loss of full-thickness retinal tissue.

It usually results from a contracting epiretinal membrane that steepens the foveal edges.

OCT distinguishes it from a true hole.

Macular Microhole

A macular microhole is a very small focal defect involving the outer foveal retina.

It may cause a small central spot or mild visual disturbance and is often observed.

How Is a Macular Hole Diagnosed?

Symptom History

The ophthalmologist may ask:

When the distortion began
Whether the symptoms appeared suddenly
Whether trauma occurred
Whether the vision has deteriorated
Whether the other eye is affected
Whether high myopia is present
Whether retinal surgery has been performed
Whether flashes or floaters occurred

Visual-Acuity Testing

Visual acuity measures the smallest high-contrast letters that can be identified.

The result depends partly on:

Hole size
Duration
Photoreceptor disruption
Cataract
Other retinal disease

Refraction

Refraction determines whether spectacles improve part of the blur.

Glasses cannot close the hole or eliminate retinal distortion.

Amsler Grid

An Amsler grid can demonstrate:

Central distortion
Missing squares
Bent lines
A central grey spot

Each eye should be tested separately.

Amsler-grid findings are useful for monitoring symptoms but cannot measure the hole accurately.

Dilated Retinal Examination

Dilating drops allow the ophthalmologist to inspect:

The macula
Vitreous
Peripheral retina
Optic nerve
Other retinal pathology

Small holes may be difficult to classify accurately without OCT.

Optical Coherence Tomography

OCT provides high-resolution cross-sectional images of the macula.

It can show:

Whether the hole is full thickness
The minimum hole width
The basal width
Vitreomacular traction
Cystic changes
Fluid beneath the retinal edges
Epiretinal membrane
Lamellar defects
Photoreceptor integrity
Whether the hole has closed

OCT-based classification has replaced older examination-only staging for most treatment decisions.

OCT Angiography or Fluorescein Angiography

These are not routinely required for a straightforward idiopathic macular hole.

They may be used when another disorder is suspected, such as:

Macular neovascularisation
Retinal vascular disease
Macular telangiectasia
Inflammation

OCT Classification of Full-Thickness Macular Holes

Small Hole

A small full-thickness macular hole measures 250 micrometres or less at its narrowest point.

Small holes:

Have a higher spontaneous-closure probability
Usually have high surgical closure rates
May remain associated with vitreomacular traction
Often have a favourable visual prognosis when treated early

Medium Hole

A medium hole measures more than 250 to 400 micrometres.

Surgery is generally recommended when the hole is symptomatic and the patient is medically suitable.

Large Hole

A large hole measures more than 400 micrometres.

Larger holes:

Are less likely to close spontaneously
May have a lower closure rate with basic surgical techniques
May require a larger ILM peel or flap technique
May have a less complete visual recovery

These size categories are part of the International Vitreomacular Traction Study classification.

Primary and Secondary Holes

A hole is described as:

Primary when mainly caused by vitreous traction
Secondary when directly caused by another pathology, such as trauma or high myopia

With or Without Vitreomacular Traction

OCT also records whether persistent vitreous attachment remains at the hole.

Older Clinical Staging

Stage 1

Stage 1 describes an impending hole without a complete full-thickness opening.

It may show:

Foveal detachment
Yellow spot or ring
Persistent vitreofoveal attachment

Some stage 1 lesions resolve when the vitreous releases.

Stage 2

A small full-thickness hole develops while vitreous attachment persists.

Stage 3

A larger full-thickness hole is present, but the vitreous is not completely detached from the optic disc.

Stage 4

A full-thickness hole is present with complete posterior vitreous detachment.

Modern OCT classification provides more useful anatomical information than this older staging system.

Can the Macular Hole Become Larger?

Yes.

An open hole may:

Remain stable
Enlarge gradually
Develop greater surrounding cystic change
Cause increasing distortion
Produce progressive photoreceptor disruption

The timing is variable.

Prompt retinal assessment is advisable after diagnosis rather than postponing review for many months without OCT monitoring.

Observation

When May Observation Be Reasonable?

Observation may be considered for:

A very small recent hole
A hole showing early bridging tissue
An impending or stage 1 hole
A traumatic hole with favourable OCT features
A patient with limited surgical suitability
A patient who understands the risks and prefers short-term monitoring

How Is Observation Performed?

Monitoring may include:

Repeat visual acuity
Repeat OCT
Amsler-grid testing
Symptom review
Dilated retinal examination

A short observation period should have a clear review schedule.

When Should Observation End?

Surgery should be reconsidered if:

The hole enlarges.
Vision deteriorates.
Distortion increases.
OCT shows worsening tissue separation.
Spontaneous closure does not occur within the planned period.

Treatment With Vitrectomy

What Is Vitrectomy?

Pars plana vitrectomy is an operation performed through very small openings in the white part of the eye.

The surgeon removes the vitreous gel and releases traction on the macula.

The Main Steps

A typical operation includes:

Anaesthetising the eye.
Creating small entry ports.
Removing the vitreous gel.
Releasing the posterior vitreous attachment.
Staining the internal limiting membrane.
Peeling or manipulating the membrane.
Replacing the fluid with air or gas.
Closing or allowing the small wounds to seal.

Internal Limiting Membrane Peeling

The internal limiting membrane, or ILM, is the innermost microscopic surface of the retina.

Peeling the ILM:

Releases residual tangential traction
Reduces the risk of reopening
Improves closure rates
Prevents an epiretinal membrane from forming over the same area

For most ordinary full-thickness macular holes, vitrectomy with ILM peeling remains the standard surgical approach.

Inverted ILM Flap

For a large, chronic, highly myopic or previously unclosed hole, the surgeon may leave part of the ILM attached and position it over or within the hole.

This is called an inverted ILM flap.

A 2025 meta-analysis found that flap techniques produced a higher overall closure rate than conventional peeling, with the greatest potential benefit among larger holes.

Other Techniques for Difficult Holes

Persistent or very large holes may require techniques such as:

Enlarged ILM peeling
Free ILM flap
Lens-capsule flap
Amniotic-membrane plug
Autologous retinal transplant
Macular hydrodissection
Silicone-oil tamponade
Macular buckling for selected highly myopic eyes

These are specialist procedures reserved for more complex cases.

Air or Gas Tamponade

Why Is a Bubble Used?

An air or gas bubble rises inside the eye and presses gently against the macula.

The bubble:

Prevents fluid from entering the hole
Brings the retinal edges into a favourable position
Supports tissue bridging
Allows the hole to seal

Common Tamponade Options

The surgeon may use:

Air
Sulphur hexafluoride, or SF6
Perfluoropropane, or C3F8
Another selected gas mixture

Shorter-acting bubbles disappear sooner.

Longer-acting gases provide prolonged support but delay visual recovery and flying.

What Will Vision Be Like?

While the bubble is large, vision is very blurred.

As it shrinks, the patient may see:

A horizontal or curved line
Clearer vision above the line
A moving bubble
Several small bubbles near the end

The bubble is gradually absorbed and replaced by the eye’s natural fluid.

Face-Down Positioning

Why Is Positioning Recommended?

Face-down positioning keeps the bubble in contact with the macula.

The surgeon may recommend:

Strict face-down positioning
Avoiding lying on the back
Sleeping on a particular side
No special daytime positioning

The instruction depends on:

Hole size
Surgical technique
Gas choice
Whether the hole is primary or complex
The surgeon’s protocol
The patient’s ability to posture safely

Is Face-Down Positioning Always Necessary?

Not always.

Randomised trials and systematic reviews suggest that prolonged face-down positioning may provide little or no closure advantage for many smaller holes treated with modern vitrectomy and ILM peeling.

For holes larger than approximately 400 micrometres, positioning may provide a modest anatomical or visual benefit. The certainty of evidence remains limited, and practices differ.

How Long Is Positioning Required?

The duration may range from:

No strict posturing
Several hours each day
Three days
Five to seven days
Longer for complex holes

Follow the operating surgeon’s specific instructions rather than applying a general rule from another patient.

Who May Have Difficulty Posturing?

Face-down positioning may be difficult for patients with:

Neck or back disease
Obesity
Severe arthritis
Breathing difficulties
Recent abdominal surgery
Neurological disease
Limited mobility
Frailty

Positioning equipment may help, but surgery should be planned with these limitations in mind.

Flying, Altitude and Anaesthesia With a Gas Bubble

Do Not Fly

A person must not fly while any intraocular gas remains.

Reduced cabin pressure can cause the bubble to expand rapidly, producing:

Severe eye pain
Dangerous pressure elevation
Retinal or optic-nerve damage
Permanent loss of vision

High-altitude travel may create a similar risk.

Do Not Use Nitrous Oxide Anaesthesia

Nitrous oxide can enter and rapidly expand an intraocular gas bubble.

Tell every doctor, dentist, paramedic and anaesthetist that gas is present in the eye.

Nitrous oxide must not be administered until the gas has completely disappeared. Severe visual loss has occurred when nitrous oxide was used in patients with residual intraocular gas.

Carry an Alert

The surgical team may provide:

A wristband
A gas-warning card
Written instructions
Documentation of the gas used

Keep this information with you until the bubble has fully absorbed.

Anaesthesia for Macular-Hole Surgery

Local Anaesthesia

Most operations can be performed using local anaesthesia, often with sedation.

The patient may notice:

Bright lights
Movement
Pressure
Touch
Fluid around the eye

Sharp pain should not be expected.

General Anaesthesia

General anaesthesia may be appropriate for:

Severe anxiety
Inability to remain still
Communication difficulties
Complex surgery
Certain medical or positional needs

The anaesthetic plan should consider any expected postoperative positioning.

Can Cataract Surgery Be Combined?

Combined Phacovitrectomy

In an eye with a cataract or natural lens, cataract surgery may be combined with macular-hole repair.

Advantages may include:

One operation
One recovery period
Clearer surgical visualisation
Avoiding rapid cataract progression after vitrectomy
Earlier visual rehabilitation after the gas disappears

Separate Surgery

The procedures may be staged when:

The natural lens is still clear.
Refractive accuracy is a high priority.
The patient is younger.
The surgeon prefers to assess the retinal result first.
The cataract is mild.

Refractive Prediction

Combined surgery can make the final prescription less predictable because:

Gas may affect lens position temporarily.
Retinal thickness and fixation may influence measurements.
The macular hole limits preoperative visual testing.
Vitrectomy may affect effective lens position.

A monofocal lens is commonly favoured when macular function is impaired.

Which Intraocular Lens Is Suitable?

Monofocal Lens

A monofocal lens is commonly recommended because it concentrates light into one main focal point.

Toric Monofocal Lens

A toric lens may be appropriate when:

Corneal astigmatism is regular.
Measurements are reliable.
The retina has reasonable visual potential.
The patient understands that retinal distortion may remain.

Multifocal or Trifocal Lens

These lenses require caution because they divide light and may reduce contrast.

A macular hole or previous macular-hole surgery may already cause:

Reduced contrast
Distortion
Incomplete central visual recovery
Unequal retinal image quality

The lens should not be expected to overcome retinal damage.

Recovery After Surgery

The First Day

Vision is usually very blurred because of:

The gas bubble
Dilating drops
Corneal surface changes
Postoperative inflammation
Ointment

The eye may feel:

Gritty
Watery
Mildly sore
Sensitive to light
Tired

The First Week

The patient may still see little detail through the bubble.

Postoperative medication commonly includes:

Antibiotic drops
Steroid drops
Pupil-dilating drops
Pressure-lowering medication when required
Lubricating drops

As the Bubble Shrinks

A moving line gradually descends through the vision.

The clearer portion of vision usually appears above the bubble.

After the Bubble Has Gone

Vision may remain:

Blurred
Wavy
Less detailed
Different from the other eye

The retina continues healing after the bubble disappears.

Three to Six Months

Central vision and distortion may improve over several months.

OCT may show gradual restoration of:

Foveal contour
External limiting membrane
Ellipsoid zone
Outer retinal layers

Long-Term Recovery

Further improvement may continue for a year or longer.

Long-term studies demonstrate that visual gains can remain stable for many years after successful closure.

Postoperative Activity

Eye Protection

Avoid rubbing or pressing the operated eye.

Use an eye shield at night when instructed.

Washing

Avoid getting:

Soap
Shampoo
Dirty water
Swimming-pool water

directly into the eye during early healing.

Exercise

Gentle walking is usually acceptable.

Avoid:

Heavy lifting
Straining
Contact sports
Swimming
Activities risking eye trauma

until the surgeon permits them.

Driving

Do not drive while:

A gas bubble remains
Vision is significantly blurred
Depth perception is impaired
The surgeon has not confirmed that vision meets legal and safety requirements

Work

Return to work depends on:

Visual demands
Positioning requirements
Type of work
Gas duration
Whether the fellow eye sees well
Exposure to dust or contamination

How Successful Is Surgery?

Anatomical Closure

Modern vitrectomy with ILM surgery and gas closes most primary macular holes after one operation.

Closure rates are generally highest for:

Small holes
Recent holes
Primary idiopathic holes
Holes without severe myopic degeneration

More complex holes may require advanced techniques or repeat surgery.

Visual Improvement

Many patients gain several lines of visual acuity after successful closure.

The amount varies widely.

Long-term data demonstrate sustained average visual improvement, with most eyes maintaining anatomical closure and a low reoperation rate.

Closure Does Not Equal Normal Vision

The hole can close anatomically while vision remains limited because the central photoreceptors have been damaged.

Factors Affecting the Visual Result

Hole Size

Smaller holes generally have better closure and visual outcomes.

Duration

A recent hole generally has a better prognosis than one that has been open for a prolonged period.

The precise date of onset is often difficult to determine because the better eye may initially compensate.

Starting Vision

Better preoperative vision is often associated with better postoperative vision.

Photoreceptor Integrity

OCT appearance of the:

Ellipsoid zone
External limiting membrane
Outer retinal tissue

helps estimate visual potential.

Type of Closure

A smooth closure with restoration of outer retinal tissue generally provides a better result than closure with a residual central retinal defect.

Cause of the Hole

Traumatic, highly myopic and secondary holes may have different outcomes from ordinary idiopathic holes.

Other Eye Disease

Vision may remain limited by:

Macular degeneration
Diabetic retinopathy
Glaucoma
Retinal vascular disease
Corneal disease
Amblyopia
Optic-nerve damage
Cataract

Possible Complications of Surgery

Cataract Progression

Vitrectomy commonly accelerates cataract formation in an eye that still has its natural lens.

The patient may later notice:

Hazy vision
Glare
Faded colours
Poor night vision
Increasing prescription

Many older phakic patients eventually require cataract surgery.

Raised Eye Pressure

Eye pressure may rise because of:

Expanding gas
Inflammation
Steroid response
Pre-existing glaucoma
Pupil block in selected eyes

Symptoms of severe pressure elevation may include:

Eye pain
Headache
Nausea
Vomiting
Halos
Sudden blur

Retinal Tear

Creating a posterior vitreous detachment may cause a peripheral retinal tear.

The tear can be treated with laser during surgery.

Retinal Detachment

Retinal detachment is uncommon but potentially sight-threatening.

Symptoms include:

New flashes
A sudden shower of floaters
A curtain
Missing peripheral vision

Infection

Endophthalmitis is a rare serious infection inside the eye.

Seek urgent care for:

Increasing pain
Increasing redness
Worsening vision
Marked light sensitivity
Discharge
Eyelid swelling

Bleeding

Minor intraocular bleeding may occur.

Severe haemorrhage is uncommon.

Failure to Close

The hole may remain open after the first operation.

Risk is greater with:

Large holes
Long-standing holes
High myopia
Significant retinal degeneration
Previous failed surgery
Inadequate tissue mobilisation

Reopening

A previously closed hole may reopen, particularly if:

An epiretinal membrane develops.
Macular traction recurs.
The eye undergoes further retinal change.
The original hole was large or complex.

Visual-Field Change

Small visual-field defects can occasionally occur after vitrectomy or ILM manipulation.

Persistent Distortion

Some metamorphopsia may remain despite successful closure.

What Happens if the Hole Does Not Close?

Repeat OCT

The retinal specialist evaluates:

Current hole size
Previous ILM peel
Retinal mobility
Outer-retinal condition
Gas response
Myopic anatomy
Associated epiretinal tissue

Repeat Surgery

Options may include:

Enlarging the ILM peel
Inverted ILM flap
Free ILM graft
Lens-capsule graft
Amniotic-membrane plug
Autologous retinal transplant
Longer-acting gas
Silicone oil
Macular buckling in selected myopic eyes

The expected benefit should be balanced against the reduced visual potential of a chronic or repeatedly treated hole.

Traumatic Macular Holes

Observation Can Be Appropriate

A traumatic hole in a young patient may close spontaneously over weeks or months.

Favourable features may include:

Small hole diameter
Early bridging tissue
No epiretinal membrane
Improving OCT configuration
Improving vision

When Is Surgery Considered?

Vitrectomy may be considered when:

The hole remains open.
Vision is significantly reduced.
The hole is large.
OCT shows no sign of closure.
Associated vitreoretinal traction is present.

A 2024 paediatric and adolescent study found that both observation and surgery could produce favourable outcomes in selected traumatic holes, supporting an individualised approach with serial OCT.

Associated Trauma

The eye should also be examined for:

Retinal tear
Retinal detachment
Choroidal rupture
Lens injury
Traumatic inflammation
Optic-nerve injury

Highly Myopic Macular Holes

Why Are They Different?

Highly myopic eyes may have:

A stretched retina
Posterior staphyloma
Macular retinoschisis
Chorioretinal atrophy
Reduced retinal elasticity
Retinal detachment

Macular-Hole Retinal Detachment

A hole in a highly myopic eye can allow fluid to pass beneath the retina and cause a central retinal detachment.

This requires specialist vitreoretinal treatment.

Surgical Options

Treatment may include:

Vitrectomy
ILM flap or graft
Gas
Silicone oil
Macular buckle
Combined approaches

Visual improvement may be limited by underlying myopic macular degeneration even when the retina is successfully reattached.

Macular Hole Versus Epiretinal Membrane

Macular Hole

A macular hole represents an actual central retinal defect.

It commonly causes:

A central missing spot
Broken letters
Central distortion
Reduced detailed vision

Epiretinal Membrane

An epiretinal membrane is a sheet of tissue on the retinal surface that wrinkles or pulls on the macula.

It commonly causes:

Waviness
Image-size difference
Central blur
Retinal thickening

Both may occur together.

Macular Hole Versus Age-Related Macular Degeneration

Macular Hole

The problem is a central structural opening, usually related to traction.

Age-Related Macular Degeneration

AMD involves changes such as:

Drusen
Retinal pigment epithelium damage
Atrophy
Abnormal leaking blood vessels
Macular bleeding

OCT and retinal examination distinguish the conditions.

Macular Hole Versus Retinal Tear

Macular Hole

A macular hole affects the central retina and usually causes central distortion or blur.

Peripheral Retinal Tear

A retinal tear usually occurs in the peripheral retina.

It may cause:

Flashes
New floaters
A shower of spots
Retinal detachment

A peripheral tear is generally treated with laser or freezing treatment rather than macular-hole surgery.

Can Glasses Help?

Glasses may correct:

Short-sightedness
Long-sightedness
Astigmatism
Presbyopia

They cannot:

Close the hole
Restore missing retinal tissue
Fully correct central distortion

A new prescription may still improve the non-retinal component of the blur.

Can Eye Injections Treat a Macular Hole?

Anti-VEGF injections do not close an ordinary tractional macular hole.

They may be used for an accompanying condition such as:

Wet macular degeneration
Diabetic macular oedema
Retinal-vein occlusion

Intravitreal gas injection without full vitrectomy has been studied for selected small holes associated with vitreomacular traction, but it is not appropriate for every patient and may cause retinal tears or detachment.

Can Laser Treat a Macular Hole?

No routine external laser treatment can seal an idiopathic macular hole.

Laser may be used for:

A peripheral retinal tear
Retinal detachment
Diabetic retinopathy
Another associated retinal condition

YAG laser is used for posterior capsule opacification after cataract surgery and does not treat a macular hole.

Macular Hole and Driving

Driving ability depends on:

Vision in both eyes
Central acuity
Distortion
Depth perception
Contrast
Local licensing standards

A patient may legally meet the minimum acuity requirement but still struggle with:

Reading signs
Judging distance
Recognising hazards
Night driving
Rain
Unequal images between the eyes

Stop driving and seek assessment when vision no longer feels safe.

Common Myths

“A Macular Hole Means There Is a Hole Through the Eyeball”

False.

The defect is limited to the central retinal tissue at the back of the eye.

“The Eye Will Leak”

False.

A macular hole does not allow fluid to leak out of the eyeball.

“A Macular Hole Is the Same as Macular Degeneration”

False.

They are different macular conditions with different causes and treatments.

“Laser Can Seal the Hole”

False.

The standard treatment is vitrectomy with membrane surgery and a bubble.

“The Gas Bubble Permanently Replaces the Vitreous”

False.

The bubble gradually disappears and is replaced by natural fluid produced within the eye.

“Everyone Must Lie Face Down for Two Weeks”

False.

Positioning varies according to hole size, surgical technique and surgeon preference.

“Once the Hole Closes, Vision Immediately Returns to Normal”

False.

Visual recovery is gradual, and some permanent distortion may remain.

“The Other Eye Will Definitely Develop a Hole”

False.

The fellow eye has an increased risk but may never develop a macular hole.

“Cataract Surgery Causes Every Macular Hole”

False.

Most idiopathic holes arise from age-related vitreomacular traction. A hole may occasionally become apparent after cataract surgery because of vitreous changes or because the cataract had previously hidden the macular symptoms.

Frequently Asked Questions

How Quickly Should a Macular Hole Be Operated On?

A full-thickness hole should be assessed promptly.

Surgery is not usually required within hours, but delaying a symptomatic hole for many months may reduce visual potential.

The appropriate timing depends on:

Hole size
Duration
OCT appearance
Visual function
General health
Surgical availability

Can a Small Hole Be Watched?

Yes, in selected cases.

Repeat OCT should confirm whether it is closing, stable or enlarging.

How Long Does Surgery Take?

The surgical time varies according to:

Lens status
Hole size
Need for ILM flap
Presence of an epiretinal membrane
Retinal tears
Combined cataract surgery
Previous retinal procedures

The operation is generally performed as day surgery.

Is Macular-Hole Surgery Painful?

The eye is anaesthetised.

Patients commonly experience:

Pressure
Touch
Bright lights
Mild postoperative grittiness

Severe increasing pain after surgery is not normal.

Will I Need Stitches?

Modern small-gauge vitrectomy wounds commonly seal without stitches.

A stitch may be placed when a wound leaks or requires added security.

Will I Need Face-Down Positioning?

Possibly.

The requirement depends on the size and type of hole and the surgeon’s protocol.

How Long Will the Gas Last?

The duration depends on the gas and concentration used.

Air disappears relatively quickly, while SF6 and C3F8 last progressively longer.

Your surgeon should tell you which bubble was used.

Can I Fly When Only a Tiny Bubble Remains?

No.

Flying is prohibited until the bubble has disappeared completely and the surgeon confirms that travel is safe.

Can I Have General Anaesthesia for Another Operation?

Not with nitrous oxide while gas remains in the eye.

Tell the anaesthetist about the intraocular gas.

When Can I Read Again?

You may attempt reading when comfortable, but the bubble and healing retina will limit clarity initially.

Improvement may take weeks to months.

Can Reading or Screen Use Reopen the Hole?

Ordinary reading and screen use do not generally pull the repaired hole open.

Follow activity and positioning instructions during early healing.

When Can I Exercise?

Light walking is commonly permitted early.

Heavy lifting, swimming and contact sports should be resumed only when the surgeon approves.

Will Cataract Develop?

Cataract progression is common after vitrectomy in an eye with a natural lens.

Can the Hole Reopen After Cataract Surgery?

Reopening is uncommon but possible.

New central distortion after cataract surgery should be assessed with OCT.

Can the Hole Close but Vision Remain Poor?

Yes.

Possible reasons include:

Photoreceptor damage
Long duration
Large initial size
Macular ischaemia
High-myopia-related degeneration
Another eye condition

Is a Closed Hole Completely Healed?

Anatomical closure is an important success, but microscopic retinal recovery may continue for months.

Some outer-retinal defects may remain visible on OCT.

Can Surgery Be Repeated?

Yes.

Repeat surgery may close a persistent or reopened hole, although the expected visual benefit may be lower than after successful primary surgery.

Can a Macular Hole Cause Complete Blindness?

An isolated macular hole usually damages central vision without eliminating all peripheral vision.

It does not generally cause complete darkness.

When to Seek Urgent Eye Care

Seek immediate ophthalmic review after surgery for:

Increasing eye pain
Increasing redness
Sudden deterioration in vision
Severe headache or nausea
Vomiting
Marked light sensitivity
Thick discharge
A new curtain or shadow
A sudden shower of floaters
Trauma
Loss of the expected red reflex or unusual eye appearance

Possible causes include:

Raised eye pressure
Infection
Retinal tear
Retinal detachment
Bleeding
Gas-related complication

A Macular-Hole Assessment Checklist

Symptoms to Report

Central blur
Wavy lines
Missing letters
A central grey spot
Distorted faces
Image-size difference
Recent eye trauma
New flashes or floaters

Tests That May Be Used

Visual acuity
Refraction
Amsler grid
Dilated retinal examination
OCT
Fundus photography
Ultrasound when the retina cannot be seen

Questions to Ask

Is this a full-thickness or lamellar hole?
What is the minimum hole diameter?
Is vitreomacular traction still present?
Is spontaneous closure reasonably possible?
Should the hole be observed or operated on?
Will the ILM be peeled or used as a flap?
Which gas or air bubble will be used?
Do I need face-down positioning?
How long must I avoid flying?
Can cataract surgery be combined?
What improvement is realistic?
What are the chances of needing repeat surgery?
Is the other eye at risk?

The Bottom Line

A macular hole is an opening at the centre of the macula, the retinal area responsible for sharp central vision.

Common symptoms include:

Blurred central vision
Wavy lines
Missing letters
Distorted faces
A small central blank spot
Difficulty reading

Most idiopathic holes develop because the ageing vitreous pulls abnormally on the fovea.

OCT determines:

Whether the hole is full thickness
Its size
Whether vitreomacular traction is present
The condition of the photoreceptors
Whether observation or surgery is more appropriate

Some small and traumatic holes close spontaneously, but most symptomatic full-thickness macular holes are treated surgically.

The standard operation generally involves:

Pars plana vitrectomy
Release of vitreomacular traction
Internal limiting membrane peeling or flap surgery
Air or gas tamponade
Positioning when indicated

Modern surgery closes most primary macular holes and frequently improves central vision.

However:

Vision may not return completely to normal.
Recovery may take months.
Cataract commonly progresses after vitrectomy.
Larger and longer-standing holes generally have a less favourable prognosis.
Flying and nitrous oxide anaesthesia are prohibited while gas remains in the eye.

Early diagnosis provides the best opportunity to treat a smaller hole before prolonged retinal damage develops.

References

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American Academy of Ophthalmology. What Is a Macular Hole? Updated January 12, 2026.