“A Hole In My Vision” By Yasser Elshatory, MD, PhD


    Central vision is critical for many daily activities ranging from reading to driving.  Clear vision requires light be focused on a transparent tissue in the back of the eye called the retina.   The retina has different regions, but the portion of the retina responsible for our central vision is known as the macula, and within the macula, the finest acuity is provided by a specialized portion known as the fovea.  The fovea is where light is focused in our eyes to allow us to see fine details in the world around us.  Diseases involving the fovea affect our ability to perform our day to day activities.  One such condition is macular hole formation.  Macular holes develop when the clear gel inside the eye (the vitreous) tugs abnormally on the retina. This tugging creates a hole.  In rare cases, macular holes can develop after injury to the eye. Most of the time, it occurs because some people are born with abnormal attachments between the vitreous and the retina.  As we age, the vitreous naturally liquefies and pulls away from the retina.  In people born with abnormal attachments to the fovea, the gel does not peel away easily from the fovea, so when it pulls away it leaves a hole.  Unfortunately, there is no way to predict who will develop a macular hole.  When a hole develops, the central vision becomes blurry.  If one does not check vision in each eye individually, the effects of a macular hole in one eye can go unnoticed for weeks or even months.  Without intervention, the hole can enlarge, and more central vision can be affected.  Most of the time, this occurs in only one eye, but 1 out of 5 patients can have this occur in both eyes. 

Image showing a cross-section view of the macular hole.
Image showing a cross-sectional view of the other eye without the macular hole.

    Fortunately, a treatment is available.  Surgery is performed to remove the vitreous gel, peel a membrane from the surface of the retina, and replace the fluid in the eye with a gas mixture.  This along with head positioning face down, for up to a week, helps press the edges of the macular hole closed.  Face down positioning can be a challenging task.  As the gas bubble dissolves and is replaced with fluid the eye produces, the vision improves.  The improvement in vision can take weeks, even months.  Surgery can improve vision, but a macular hole may have lasting effects on one’s sight. Some retina surgeons place more gas in the eye to reduce the need for having patients position face down, but placing more gas in the eye has its own risks, including cataract formation, and increasing the likelihood that the pressure in the eye becomes high. 

    Macular holes should not be confused with macular degeneration, a condition which affects the macula as well, but arises from deposits of proteins and other molecules under the retina as one ages.  Blurry vision in one or both eyes that develops rapidly or slowly requires prompt evaluation by an optometrist or ophthalmologist.  Putting this off can affect one’s vision permanently, and decrease your chance of attaining your best vision.  If you are found to have a macular hole, you should be referred to a retina specialist to discuss treatment options. 



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