What is the recommended treatment for a macular hole?

Macular Hole Treatment

For stage 2-4 full-thickness macular holes, vitrectomy surgery with internal limiting membrane (ILM) peeling is the definitive treatment, achieving approximately 90% closure rates for holes <400 μm and significantly improving visual acuity. 1, 2

Treatment Algorithm by Stage

Stage 1 (Impending Macular Hole)

• Observation only - no surgical intervention recommended 1, 2
• Approximately 50% resolve spontaneously when vitreous detaches from the fovea 1
• Vitrectomy to prevent progression has been shown to have no effect on preventing full-thickness hole development 1
• Monitor closely and instruct patients to return immediately if symptoms worsen 1

Stage 2-4 (Full-Thickness Macular Holes)

• Vitrectomy surgery is strongly recommended as untreated holes progress to 20/200-20/400 vision 1
• Surgery includes: pars plana vitrectomy, posterior hyaloid separation, careful ILM peeling (increases closure rates without affecting visual acuity), and gas tamponade 1
• Cochrane meta-analysis demonstrates vitrectomy improves visual acuity by approximately 1.5 Snellen lines and achieves 76% closure rate versus 11% with observation 1, 3

Prognostic Factors

Hole Size Impact

• Holes <400 μm achieve ~90% closure rate with surgery 1, 2
• Larger holes have lower closure rates and worse visual outcomes 1, 2
• Early detection and intervention correlate with both higher closure rates and better postoperative visual acuity 1, 2

Timing Considerations

• Delays in repair reduce success rates and visual benefit 1
• As holes enlarge, epiretinal membranes develop and surgical success decreases 1

Alternative Treatment Options

For holes with associated vitreomacular traction (VMT):

• Intravitreal ocriplasmin or expansile gas may be considered 1
• Discuss detailed risks/benefits relative to vitrectomy 1
• These are alternatives, not replacements, for definitive vitrectomy in most cases 1

Critical Surgical Considerations

Anesthesia and Technique

• Typically monitored anesthesia care with local anesthetic 1
• Avoid nitrous oxide during final 10 minutes of air-fluid exchange to prevent unpredictable gas fill 1
• Triamcinolone acetonide can highlight posterior vitreous during surgery 1

Postoperative Management

• Face-down positioning traditionally recommended for 7-14 days to tamponade the hole 1
• Monitor for elevated intraocular pressure (can cause permanent vision loss, especially in glaucoma patients) 1
• Advise patients to avoid travel above 2000 feet altitude 1

Expected Outcomes and Complications

Visual Results

• Vision typically does not return to "normal" even after successful closure 1
• Residual metamorphopsia and visual blur commonly persist 1
• 64-80% of successfully closed holes achieve ≥20/50 vision depending on preoperative acuity 4, 5

Complications

• Cataract formation occurs in ~50% of phakic eyes at 2 years post-surgery 1, 3
• Consider combined phaco-vitrectomy in phakic patients 1
• Retinal detachment occurs in approximately 5% of cases 1, 3
• Retinal tears develop intraoperatively in 3-17% of cases 6

Common Pitfalls

• Misdiagnosing lamellar holes or macular pseudoholes as full-thickness holes delays appropriate management 1, 2
• Delaying surgery for full-thickness holes allows enlargement and poorer outcomes 2
• Fellow eye risk is 10-15% within 5 years - educate patients about monocular self-assessment and monitor the fellow eye with OCT 1, 2
• Failing to identify vitreous traction in the fellow eye misses at-risk patients 1