Macular Conditions

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Macular Holes and Macular Puckers

Macular holes and macular puckers both target the structure of the macula, the retina’s center, which allows for central vision.

Should you develop an opening, or a hole, this is known as a macular hole. In most cases, macular holes occur due to vitreous traction, in which the vitreous (also called vitreous gel or humor) applies pressure to the macula, pulling or stretching it. An opening may form, allowing fluid or liquefied vitreous to seep in and gather under the retina. This can cause visual symptoms, such as blind spots and linear distortions. With a macular hole, vision loss generally occurs from the inside out, while the outside border remains intact.

A macular pucker, also known as an epiretinal membrane, involves a thin, semi-transparent layer of scar tissue growing over the macula. As the pucker grows and spreads, it may contract, causing the retina to become very puckered or wrinkled. This scarring may cloud your vision, making everything appear distorted and blurred, although this effect may not be immediate. Macular puckers may also occur when cellular debris accumulates in the vitreous.

Generally, with both disorders, only monitoring is needed, as total blindness doesn’t occur. But should your diminished central vision affect your quality of life, surgical options are available.

Demographics

Macular holes are more common for patients in their 50s or 60s, as well as women. In addition, if you have a macular hole in one eye, there’s a significant chance that the second eye will end up affected as well. While the cause of macular holes is typically unknown, certain risk factors increase the chances of having one, including:

• Trauma
• Laser treatment
• Macular edema
• Macular pucker
• Retinal detachment

For macular puckers, anyone can develop them, even those who have never had eye or vision issues. However, the risk for development increases with age, as well as underlying issues, such as eye disease or trauma.

Clinical Appearance & Symptoms

In most cases, macular holes are characterized by an opening in the central retina, which are encircled by a cuff of fluid. At this stage of the process, patients generally describe themselves as having blurred central vision, along with associated blind spots and distortions.
It’s been found that the duration of the macular hole dictates such factors as the degree of visual loss, the blind spot’s size, and the level of distortion.

In some cases, patients with a macular hole in only one eye may not realize they are experiencing any symptoms because they are unknowingly relying on their vision from the unaffected eye. However, over time, and particularly if only one eye is affected, you may eventually experience difficulty with in-depth perception. Patients also report issues when performing fine motor tasks and close-up activities, such as cooking and seeing faces.

Generally, a macular pucker will not interfere with your ability to see. However, you may experience distorted and blurred vision. With this condition, total blindness doesn’t usually develop. Most patients find only their central vision affected, leaving the peripheral vision intact. Rarely, macular puckers can progress into macular holes.

Diagnosis

Macular Hole

Both macular holes and macular puckers are generally diagnosed with a comprehensive, clinical dilated examination of the central retina. A retinal specialist can employ multiple diagnostic methods in their efforts to diagnose a suspected or discovered macular hole, allowing them to:

• Determine if a macular hole exists
• Detect and identify possible underlying causes
• Establish the hole’s characteristics
• Plan a potential treatment course

One effective diagnostic technique is optical coherence tomography (OCT). A safe and non-invasive method, OCT requires only a few minutes and leaves your eyes untouched. An added benefit of OCT is that no radiation, sound, or radiofrequency waves are involved, unlike other imaging techniques. This advanced imaging technique is typically used to check on patients’ blood vessel health. For macular holes, OCT is used to take high-resolution images, including those for associated retinal traction and vitreous fluid.

Retinal specialists employ OCT to determine the stages of macular holes, which is a key part in the planning of possible treatments and the determination of the ultimate prognosis. Previously, it was discussed that macular holes are generally caused by vitreous traction on the central retina. With a stage I hole, traction results in the elevation of the central macula, also called the fovea, but a full-thickness hole does not form within the retina. This is an important point to note, with 55-60% of stage I holes resolving on their own, as the vitreous traction releases naturally; as such, these cases are generally followed closely, without the need for treatment.

With OCT, retinal specialists shine a laser light on the retina to scan it and develop an accurate, cross-sectional image. This helps them to confirm if a full-thickness defect is present in the macula. It’s been shown that OCT is adept at identifying areas of retinal traction that may be responsible for the macular hole. This technique is also useful for detecting fluid that has accumulated both within and under the retina.

Should you experience continued traction, the remaining stage I holes progress to stage II. This is distinguished by having a full-thickness defect or hole in the central vision. Stage II symptoms are much more significant, and if untreated, holes often grow larger over the next several months. Generally, this will result in additional visual loss and progression to stage III. Finally, in 20-40% of patients with untreated macular holes, the vitreous will suddenly separate over the hole, as the condition advances to stage IV.

Another diagnostic technique, fluorescein angiography may be employed in the diagnosis of macular holes. You’ll have a yellow dye injected into your arm vein, which makes its way through the circulatory system to the eye. The dye serves as a tracer and is photographed as it passes through the retinal circulation. Fluorescein angiography is effective when evaluating underlying macular hole causes. It may also be instrumental when trying to differentiate a macular hole from other conditions, like macular edema, macular pucker, and macular degeneration. In this image, fluorescein angiography of a macular hole shows a focal bright area in the central retina, which corresponds to the defect.

Macular Pucker

In addition to a comprehensive dilated eye exam, to diagnose a macular pucker, your ophthalmologist may employ an Amsler grid, a simple, black-and-white paper tool. Patients can use the Amsler grid in their own homes daily to determine if they have specific types of visual distortions. For example, if you see straight lines appearing wavy, this may indicate macular issues.

Should you see any broken, curved, or distorted lines, you need to quickly alert your ophthalmologist. Doing so allows them to properly diagnose and treat macular puckers at an earlier stage, which allows them to better preserve your long-term retinal health.

Treatment

Macular Hole Treatment

In most cases, stage I macular holes will be monitored periodically to check if the condition suddenly resolves itself or if it progresses to stage II. If you have a highly symptomatic stage I hole, you and your retinal specialist will have a thorough discussion regarding whether you’re a surgical candidate. In the event of a stage II or higher macular hole, surgical intervention is usually advised.

Without surgery, patients with stage II or higher macular holes can expect their vision to worsen until it reaches about 20/200. While this level of central vision loss is considered severe, your side vision in the affected eye should remain. Patients also find that they’re able to make up for the lost vision with their unaffected eye.

Vitrectomy Surgery

With a macular hole, surgery is often the only treatment option that will enable vitreous traction to be removed. In addition, this will allow the central defect to be sealed, while trying to restore lost central vision. With this procedure, known as a vitrectomy, part or all of the vitreous is removed from the back of the eye through tiny incisions.

Macular Pucker Treatment

As with macular holes, the majority of macular puckers will not cause any vision problems, and treatment may not be necessary. Patients may need to have their vision regularly checked to monitor their macular health. Your ophthalmologist may recommend patients wear eyeglasses or update their current prescription to improve affected vision.

However, should your central vision deteriorate, and your ability to perform close-up activities, such as reading, driving, or seeing faces, be affected, you may need to undergo surgery. Typically, retinal specialists would perform a vitrectomy to treat macular puckers.

Depending on the severity of the membrane, you may need an accompanying procedure, known as a membranectomy. It involves a surgeon grasping and peeling away the membrane from the retina, using such tools as extremely fine forceps, diamond-dusted instruments, and sutures to close the incision. A safe and effective procedure, taking less than 30 minutes, a membranectomy procedure has potential complications similar to a vitrectomy. Research shows that 80% to 90% of patients typically experience visual improvement following this procedure.