Macular hole

Disease Description (Causes and Symptoms)

• Definition: A disease in which a full-thickness defect (hole) develops in the center of the macula, the central part of the retina, resulting in reduced central vision.
• Causes and pathophysiology:
  • In older adults, idiopathic cases are common (occurring due to age-related posterior vitreous detachment and traction on the retinal surface).
  • In younger patients, it may occur due to trauma.
  • As the vitreous pulls on the macula, a full-thickness defect may develop in the center of the retina, or a hole may form due to damage to the intraretinal structures.
• Main symptoms:
  • Reduced central vision (difficulty reading books or recognizing people's faces)
  • Central scotoma or distorted appearance of objects (metamorphopsia)
  • May be asymptomatic initially, but rapid worsening of central vision may occur as it progresses

Treatment Methods and Precautions

• Standard treatment:
  • Pars plana vitrectomy + internal limiting membrane (ILM) peeling (or a modified peeling technique) + gas tamponade (such as C3F8 or SF6).
  • While gas remains after surgery, patients are generally advised to remain face down (or maintain a specific position) (often recommended for approximately 1–2 weeks; the duration varies depending on the patient's condition).
  • The postoperative anatomical success rate (hole closure) is approximately 70–90%, varying according to the literature and cases. The provided material reports approximately 80%; even when anatomical success is achieved, visual improvement does not occur in all patients (visual improvement has been reported in approximately 50–60%).
• Non-surgical/adjunctive treatment:
  • In cases of a very small hole in the early stage or gradual changes in vitreous attachment to the anterior retina, spontaneous closure may be possible with observation.
  • In selected cases, pharmacological treatment (e.g., ocriplasmin) may be considered when vitreomacular adhesion is clearly present and the indications are met, but its effectiveness is limited and the eligible patient population is narrow.
  • In a small number of cases, pneumatic vitreolysis (inducing vitreous separation with gas injection alone) may be attempted.
• Medication/outpatient care:
  • Topical antibiotics and steroids before and after surgery, and intraocular-pressure-lowering medication if necessary.
• Main complications and precautions:
  • Cataract progression (especially common after surgery in older adults)
  • Retinal detachment, infection (endophthalmitis), increased intraocular pressure, recurrent macular hole
  • Do not fly or enter high-pressure environments while the gas remains in the eye (gas expansion can cause a severe increase in intraocular pressure)
  • It is necessary to confirm in advance whether the patient can follow postoperative positioning instructions (such as remaining face down).
• Self-care:
  • Follow the prescribed positioning before and after surgery, follow the instructions for applying medication, and visit the hospital immediately if abnormal signs such as changes in vision, pain, or redness occur after surgery.

Outpatient Visit Checkpoints (Items to Bring · Example Questions)

• Items/materials to bring:
  • List of currently taken medications (including anticoagulants and antiplatelet agents)
  • Previous ophthalmic examination results (visual acuity charts; copies of previous OCT, fundus photographs, fluorescein angiography, or other images, if available)
  • History of previous eye surgery (e.g., cataract surgery or retinal surgery) and systemic diseases (diabetes or hypertension)
  • Record of when symptoms began and how they have progressed (when they started, sudden/gradual, one eye/both eyes)
  • Allergy history (medications, anesthetics, etc.)
  • Whether face-down positioning is possible after surgery, and occupation and daily activities (driving, flying, etc.)
• Items to tell the doctor first during the outpatient visit:
  • Recent rapid decline in vision or new metamorphopsia (objects appearing distorted)
  • Whether there has been any direct trauma to the eye
  • Whether anticoagulants are being taken (important when planning surgery)

Examples of General Questions to Ask the Doctor

• In my case, what is the probability that the hole will close with surgery (the anatomical success rate)?
• If I undergo surgery, how much is my vision likely to improve? How long will improvement take?
• What are the main complications of surgery, and how likely are they to occur?
• When can I resume daily activities after surgery (driving and returning to work)?
• What medications will be needed during or after surgery, and what are their side effects?
• Can non-surgical treatments (observation, drug injection, etc.) be attempted, and what are their advantages and disadvantages?

Examples of Disease-Specific Questions

• What are the surgical success rate and visual prognosis according to the size of my macular hole (μm) and its stage (e.g., Gass stage or OCT findings)?
• Why should ILM peeling be performed, and could an additional surgical technique such as an inverted flap help in my case?
• How are the type of gas (C3F8 vs SF6) and the required postoperative positioning (duration of face-down positioning) determined?
• I have future plans involving air travel or anesthesia; what precautions and time restrictions are needed before and after surgery?

(Note: Examinations such as dilated fundus examination, OCT (optical coherence tomography), and fluorescein angiography are useful for diagnosis and follow-up.)