Retina · Patient & Surgeon Series
A hole the width
of a hair, in the one place
you read with.
A macular hole is a full-thickness break in the centre of the retina. It rarely hurts, rarely announces itself, and usually starts with a straight line that no longer looks straight. Here is how the vitreous tears it open, how OCT measures it, and what vitrectomy, gas and face-down recovery actually involve.
on OCT
approx.
holes, modern surgery
Section 01 — What It Is
Not a tear at the edge.
A gap at the centre.
That changes everything.
Most retinal emergencies patients hear about — tears, detachments — happen in the periphery. A macular hole is the opposite: a small, round, full-thickness defect in the fovea, the pinpoint of the macula packed with the cone photoreceptors that carry reading, driving and face-recognition vision.
The typical patient is in their sixties or seventies, and women are affected roughly three times as often as men. In a population-based study from Olmsted County, Minnesota, McCannel and colleagues estimated an incidence of roughly 8 new macular holes per 100,000 people per year. Most are idiopathic — not caused by injury or another disease — though high myopia and blunt trauma can produce holes too.
Because the other eye usually sees normally, a macular hole often goes unnoticed until the good eye is covered. The complaints are characteristic: straight lines that bow or pinch inward (metamorphopsia), letters missing from the middle of words, and a blurred or dark spot exactly where you look. Peripheral vision stays intact, which is why a macular hole does not cause total blindness — but it can take away the vision that matters most for daily tasks.
A macular hole is a full-thickness opening in the fovea, usually created when the ageing vitreous gel separates from the retina but stays stuck to the fovea and pulls it apart. It causes central blur, distortion and a central blind spot in one eye, without pain. It is diagnosed and measured with OCT, and its size largely decides the treatment plan and the prognosis. Most established holes need surgery: a vitrectomy that removes the vitreous, peeling of the internal limiting membrane, and a gas bubble that supports the hole while it closes. Modern surgery closes the large majority of holes; the earlier and smaller the hole, the better the visual recovery tends to be.
Section 02 — Interactive
The number that shapes
the plan: hole width.
On OCT, surgeons measure the minimum linear diameter of the hole — the narrowest horizontal width across the gap. The International Vitreomacular Traction Study Group sorts holes into small, medium and large using two cut-offs. Drag the slider to widen the hole and see where it lands.
Why width matters so much: the hole's edges have to be brought back together and sealed by glial tissue for the fovea to reform. A narrow gap closes readily once traction is released and the edges are supported; a wide gap has further to travel, and its edges are often thickened and cystic. Ullrich and colleagues showed in 2002 that hole size is a strong predictor of both anatomical closure and final visual acuity after surgery, a finding repeated in many later series.
Section 03 — How It Forms
The vitreous lets go
everywhere except
the one spot it shouldn't.
The vitreous is a clear gel attached to the retinal surface. With age it liquefies and shrinks, and eventually peels away from the retina — a posterior vitreous detachment. Usually this happens cleanly. Occasionally the gel stays stuck at the fovea while the surrounding vitreous has already pulled away, and that focal, forward-and-sideways traction can split the fovea open.
Donald Gass described the biomicroscopic stages of this process, revising the scheme in 1995. With OCT now able to show the vitreoretinal interface in micron-level detail, the IVTS group proposed an anatomical classification in 2013 based on what the scan shows rather than on clinical examination alone. Both are still used, and they map onto each other roughly as follows.
| Gass stage (1995) | What is happening | IVTS OCT term (2013) |
|---|---|---|
| Stage 1 — impending hole | Foveal traction with loss of the normal foveal contour; no full-thickness defect yet | Vitreomacular traction (VMT) |
| Stage 2 | Small full-thickness hole, under about 400µm, vitreous still attached | Small or medium FTMH with VMT |
| Stage 3 | Full-thickness hole of about 400µm or more, vitreous still attached at the optic disc | Medium or large FTMH with VMT |
| Stage 4 | Full-thickness hole with complete posterior vitreous detachment | Small, medium or large FTMH without VMT |
The practical consequences of this distinction are real. A stage 1 impending hole can resolve if the vitreous releases on its own, so it is often observed with serial OCT. Once a full-thickness hole exists, spontaneous closure is uncommon, and the question shifts from whether to operate to how. The fellow eye also matters: if its vitreous has already fully detached, its risk of developing a hole is low; if it still shows focal adhesion at the fovea, it is watched more closely.
Section 04 — The Surgery
Remove the pull,
peel the scaffold,
float a bubble against it.
Macular hole surgery was once considered impossible. In 1991, Kelly and Wendel reported that removing the vitreous and filling the eye with gas could close idiopathic macular holes — a little over half of eyes in their pilot series. Refinements since then have pushed closure rates much higher.
A modern operation is a pars plana vitrectomy, usually under local anaesthesia and often lasting under an hour. The surgeon removes the vitreous gel and makes sure it is fully separated from the retina, then peels the internal limiting membrane (ILM) — the retina's thin innermost basement membrane — from around the hole. Because the ILM is transparent, it is stained with a vital dye first so it can be seen and grasped. Peeling it removes residual tangential traction and is thought to encourage the glial response that seals the hole.
At the end, the fluid in the eye is exchanged for a gas bubble — commonly SF6, which absorbs over roughly two weeks, or the longer-acting C3F8, which can last six to eight weeks. The bubble acts as an internal splint, keeping the hole's edges dry and supported while they close.
Section 05 — The Evidence
What changes the odds
of closure.
The literature is consistent on the main levers. Smaller, more recent holes close more often and recover more vision. ILM peeling raised closure rates compared with vitrectomy alone. For large holes, the inverted flap technique has reported higher closure than standard peeling. The effect of strict face-down positioning appears to be concentrated in larger holes.
Illustrative visualisation of the direction and approximate magnitude reported across published series (see References). Only the ocriplasmin bar reflects a single trial figure (Stalmans et al., 2012); the others are rounded, not pooled meta-analytic estimates, and results vary by centre and case mix.
Closure is an anatomical result; vision is a separate one. After a successful closure, visual acuity usually improves gradually over months as the foveal photoreceptor layers reorganise, and distortion often lessens but may not disappear entirely. Patients with a small, recent hole commonly regain useful reading vision; patients with a large, long-standing hole may see less gain even when OCT shows a closed hole.
threshold
(Kelly & Wendel)
100,000 people per year
Section 06 — Risk, Honestly Stated
A well-proven operation
is still an operation.
Know the trade-offs.
Macular hole surgery has a good track record, but it is intraocular surgery with a recovery period that asks a lot of the patient. The commonest consequence is not a complication so much as an expected effect: a cataract.
| Issue | What to expect |
|---|---|
| Cataract | Most eyes that still have their natural lens develop a visually significant cataract within a year or two of vitrectomy. Many surgeons combine cataract surgery with the vitrectomy in older patients for this reason. |
| Raised eye pressure | Can occur in the days after surgery, particularly with expanding gas; checked at early follow-up visits and treated with drops if needed. |
| Retinal tear or detachment | An uncommon but serious risk of any vitrectomy; new floaters, flashes or a shadow afterwards need urgent review. |
| Failure to close or reopening | More likely with large or chronic holes; a second operation with a different technique can still succeed. |
| Gas bubble restrictions | No flying, no travel to high altitude, and no nitrous oxide anaesthesia until the bubble has fully gone. Vision is very poor while the bubble fills the eye. |
| Positioning burden | Face-down or head-tilted positioning for days can be hard on the neck and back, especially for older patients; protocols vary by surgeon and hole size. |
Section 07 — When to Act
The Amsler grid
will tell you before
the chart does.
A macular hole is not a same-hour emergency in the way a retinal artery occlusion or detachment is, but it is time-sensitive over weeks to months. The earlier it is measured, the more likely it is to be small — and small holes do better.
A woman in her late sixties notices that the grout lines on her kitchen tiles look pinched inward at one spot, but only when she closes her left eye. Her reading glasses seem to have stopped working for her right eye. Examination and OCT show a full-thickness macular hole of about 300 microns, with the vitreous still attached. She has a vitrectomy with ILM peel and gas a few weeks later, positions as instructed, and her hole is closed on OCT at follow-up; her reading vision improves over the following months. Had she waited a year, the hole would probably have been wider and her recovery more limited — the reason one-eyed distortion warrants prompt review.
Anyone with new distortion or a central blur in one eye should arrange a dilated eye examination with OCT. Covering each eye in turn while looking at a straight edge or an Amsler grid is a simple home check. Distortion is also a symptom of wet macular degeneration, epiretinal membrane and central serous chorioretinopathy, so the scan — not the symptom alone — makes the diagnosis.
Section 08 — FAQ
Frequently asked questions
about macular holes.
A macular hole is a small, full-thickness break in the macula — the central part of the retina responsible for sharp, detailed vision such as reading and recognising faces. It usually forms when the vitreous gel pulls on the fovea as it separates from the retina with age. It causes blurred or distorted central vision and a central blind spot, while peripheral vision is typically unaffected.
The earliest signs are often subtle: straight lines looking bent or pinched (metamorphopsia), letters dropping out of words, and a blurry patch in the centre of vision in one eye. Because the other eye compensates, many people only notice when they cover the good eye. As the hole enlarges, a dark or missing spot in the very centre of vision becomes more obvious. Pain and redness are not features.
Some very early changes (impending holes and vitreomacular traction) resolve spontaneously if the vitreous releases the fovea, and a minority of small full-thickness holes close without treatment. Most established full-thickness macular holes, however, persist or enlarge without surgery, which is why an OCT scan and a retina specialist's opinion are needed rather than watchful waiting by default.
Modern vitrectomy with internal limiting membrane peeling and gas tamponade closes the large majority of idiopathic macular holes — commonly reported closure rates are around 90% or higher for small and medium holes, and somewhat lower for large or long-standing holes. Closure is not the same as perfect vision: visual recovery depends mainly on hole size and how long it has been present, and continues gradually over months.
At the end of surgery the eye is filled with a gas bubble that floats upward. Positioning the head so the bubble presses against the macula is intended to keep the hole's edges supported while they seal. The evidence suggests the benefit of strict face-down positioning is most relevant for larger holes; for small holes many surgeons use shorter or less strict positioning. Follow your own surgeon's instructions, as protocols differ.
Not while a gas bubble remains in the eye. Gas expands at altitude and can raise eye pressure dangerously, so air travel — and nitrous oxide anaesthesia — must be avoided until the surgeon confirms the bubble has fully absorbed. That typically takes around two weeks for SF6 and six to eight weeks for C3F8, depending on the gas and concentration used.
References & Evidence Base
Peer-reviewed
citations.
Continue Reading
Related guides
from Beyond Vision.
Retina · Patient & Surgeon Series
A hole the width
of a hair, in the one place
you read with.
A macular hole is a full-thickness break in the centre of the retina. It rarely hurts, rarely announces itself, and usually starts with a straight line that no longer looks straight. Here is how the vitreous tears it open, how OCT measures it, and what vitrectomy, gas and face-down recovery actually involve.
on OCT
approx.
holes, modern surgery
Section 01 — What It Is
Not a tear at the edge.
A gap at the centre.
That changes everything.
Most retinal emergencies patients hear about — tears, detachments — happen in the periphery. A macular hole is the opposite: a small, round, full-thickness defect in the fovea, the pinpoint of the macula packed with the cone photoreceptors that carry reading, driving and face-recognition vision.
The typical patient is in their sixties or seventies, and women are affected roughly three times as often as men. In a population-based study from Olmsted County, Minnesota, McCannel and colleagues estimated an incidence of roughly 8 new macular holes per 100,000 people per year. Most are idiopathic — not caused by injury or another disease — though high myopia and blunt trauma can produce holes too.
Because the other eye usually sees normally, a macular hole often goes unnoticed until the good eye is covered. The complaints are characteristic: straight lines that bow or pinch inward (metamorphopsia), letters missing from the middle of words, and a blurred or dark spot exactly where you look. Peripheral vision stays intact, which is why a macular hole does not cause total blindness — but it can take away the vision that matters most for daily tasks.
A macular hole is a full-thickness opening in the fovea, usually created when the ageing vitreous gel separates from the retina but stays stuck to the fovea and pulls it apart. It causes central blur, distortion and a central blind spot in one eye, without pain. It is diagnosed and measured with OCT, and its size largely decides the treatment plan and the prognosis. Most established holes need surgery: a vitrectomy that removes the vitreous, peeling of the internal limiting membrane, and a gas bubble that supports the hole while it closes. Modern surgery closes the large majority of holes; the earlier and smaller the hole, the better the visual recovery tends to be.
Section 02 — Interactive
The number that shapes
the plan: hole width.
On OCT, surgeons measure the minimum linear diameter of the hole — the narrowest horizontal width across the gap. The International Vitreomacular Traction Study Group sorts holes into small, medium and large using two cut-offs. Drag the slider to widen the hole and see where it lands.
Why width matters so much: the hole's edges have to be brought back together and sealed by glial tissue for the fovea to reform. A narrow gap closes readily once traction is released and the edges are supported; a wide gap has further to travel, and its edges are often thickened and cystic. Ullrich and colleagues showed in 2002 that hole size is a strong predictor of both anatomical closure and final visual acuity after surgery, a finding repeated in many later series.
Section 03 — How It Forms
The vitreous lets go
everywhere except
the one spot it shouldn't.
The vitreous is a clear gel attached to the retinal surface. With age it liquefies and shrinks, and eventually peels away from the retina — a posterior vitreous detachment. Usually this happens cleanly. Occasionally the gel stays stuck at the fovea while the surrounding vitreous has already pulled away, and that focal, forward-and-sideways traction can split the fovea open.
Donald Gass described the biomicroscopic stages of this process, revising the scheme in 1995. With OCT now able to show the vitreoretinal interface in micron-level detail, the IVTS group proposed an anatomical classification in 2013 based on what the scan shows rather than on clinical examination alone. Both are still used, and they map onto each other roughly as follows.
| Gass stage (1995) | What is happening | IVTS OCT term (2013) |
|---|---|---|
| Stage 1 — impending hole | Foveal traction with loss of the normal foveal contour; no full-thickness defect yet | Vitreomacular traction (VMT) |
| Stage 2 | Small full-thickness hole, under about 400µm, vitreous still attached | Small or medium FTMH with VMT |
| Stage 3 | Full-thickness hole of about 400µm or more, vitreous still attached at the optic disc | Medium or large FTMH with VMT |
| Stage 4 | Full-thickness hole with complete posterior vitreous detachment | Small, medium or large FTMH without VMT |
The practical consequences of this distinction are real. A stage 1 impending hole can resolve if the vitreous releases on its own, so it is often observed with serial OCT. Once a full-thickness hole exists, spontaneous closure is uncommon, and the question shifts from whether to operate to how. The fellow eye also matters: if its vitreous has already fully detached, its risk of developing a hole is low; if it still shows focal adhesion at the fovea, it is watched more closely.
Section 04 — The Surgery
Remove the pull,
peel the scaffold,
float a bubble against it.
Macular hole surgery was once considered impossible. In 1991, Kelly and Wendel reported that removing the vitreous and filling the eye with gas could close idiopathic macular holes — a little over half of eyes in their pilot series. Refinements since then have pushed closure rates much higher.
A modern operation is a pars plana vitrectomy, usually under local anaesthesia and often lasting under an hour. The surgeon removes the vitreous gel and makes sure it is fully separated from the retina, then peels the internal limiting membrane (ILM) — the retina's thin innermost basement membrane — from around the hole. Because the ILM is transparent, it is stained with a vital dye first so it can be seen and grasped. Peeling it removes residual tangential traction and is thought to encourage the glial response that seals the hole.
At the end, the fluid in the eye is exchanged for a gas bubble — commonly SF6, which absorbs over roughly two weeks, or the longer-acting C3F8, which can last six to eight weeks. The bubble acts as an internal splint, keeping the hole's edges dry and supported while they close.
Section 05 — The Evidence
What changes the odds
of closure.
The literature is consistent on the main levers. Smaller, more recent holes close more often and recover more vision. ILM peeling raised closure rates compared with vitrectomy alone. For large holes, the inverted flap technique has reported higher closure than standard peeling. The effect of strict face-down positioning appears to be concentrated in larger holes.
Illustrative visualisation of the direction and approximate magnitude reported across published series (see References). Only the ocriplasmin bar reflects a single trial figure (Stalmans et al., 2012); the others are rounded, not pooled meta-analytic estimates, and results vary by centre and case mix.
Closure is an anatomical result; vision is a separate one. After a successful closure, visual acuity usually improves gradually over months as the foveal photoreceptor layers reorganise, and distortion often lessens but may not disappear entirely. Patients with a small, recent hole commonly regain useful reading vision; patients with a large, long-standing hole may see less gain even when OCT shows a closed hole.
threshold
(Kelly & Wendel)
100,000 people per year
Section 06 — Risk, Honestly Stated
A well-proven operation
is still an operation.
Know the trade-offs.
Macular hole surgery has a good track record, but it is intraocular surgery with a recovery period that asks a lot of the patient. The commonest consequence is not a complication so much as an expected effect: a cataract.
| Issue | What to expect |
|---|---|
| Cataract | Most eyes that still have their natural lens develop a visually significant cataract within a year or two of vitrectomy. Many surgeons combine cataract surgery with the vitrectomy in older patients for this reason. |
| Raised eye pressure | Can occur in the days after surgery, particularly with expanding gas; checked at early follow-up visits and treated with drops if needed. |
| Retinal tear or detachment | An uncommon but serious risk of any vitrectomy; new floaters, flashes or a shadow afterwards need urgent review. |
| Failure to close or reopening | More likely with large or chronic holes; a second operation with a different technique can still succeed. |
| Gas bubble restrictions | No flying, no travel to high altitude, and no nitrous oxide anaesthesia until the bubble has fully gone. Vision is very poor while the bubble fills the eye. |
| Positioning burden | Face-down or head-tilted positioning for days can be hard on the neck and back, especially for older patients; protocols vary by surgeon and hole size. |
Section 07 — When to Act
The Amsler grid
will tell you before
the chart does.
A macular hole is not a same-hour emergency in the way a retinal artery occlusion or detachment is, but it is time-sensitive over weeks to months. The earlier it is measured, the more likely it is to be small — and small holes do better.
A woman in her late sixties notices that the grout lines on her kitchen tiles look pinched inward at one spot, but only when she closes her left eye. Her reading glasses seem to have stopped working for her right eye. Examination and OCT show a full-thickness macular hole of about 300 microns, with the vitreous still attached. She has a vitrectomy with ILM peel and gas a few weeks later, positions as instructed, and her hole is closed on OCT at follow-up; her reading vision improves over the following months. Had she waited a year, the hole would probably have been wider and her recovery more limited — the reason one-eyed distortion warrants prompt review.
Anyone with new distortion or a central blur in one eye should arrange a dilated eye examination with OCT. Covering each eye in turn while looking at a straight edge or an Amsler grid is a simple home check. Distortion is also a symptom of wet macular degeneration, epiretinal membrane and central serous chorioretinopathy, so the scan — not the symptom alone — makes the diagnosis.
Section 08 — FAQ
Frequently asked questions
about macular holes.
A macular hole is a small, full-thickness break in the macula — the central part of the retina responsible for sharp, detailed vision such as reading and recognising faces. It usually forms when the vitreous gel pulls on the fovea as it separates from the retina with age. It causes blurred or distorted central vision and a central blind spot, while peripheral vision is typically unaffected.
The earliest signs are often subtle: straight lines looking bent or pinched (metamorphopsia), letters dropping out of words, and a blurry patch in the centre of vision in one eye. Because the other eye compensates, many people only notice when they cover the good eye. As the hole enlarges, a dark or missing spot in the very centre of vision becomes more obvious. Pain and redness are not features.
Some very early changes (impending holes and vitreomacular traction) resolve spontaneously if the vitreous releases the fovea, and a minority of small full-thickness holes close without treatment. Most established full-thickness macular holes, however, persist or enlarge without surgery, which is why an OCT scan and a retina specialist's opinion are needed rather than watchful waiting by default.
Modern vitrectomy with internal limiting membrane peeling and gas tamponade closes the large majority of idiopathic macular holes — commonly reported closure rates are around 90% or higher for small and medium holes, and somewhat lower for large or long-standing holes. Closure is not the same as perfect vision: visual recovery depends mainly on hole size and how long it has been present, and continues gradually over months.
At the end of surgery the eye is filled with a gas bubble that floats upward. Positioning the head so the bubble presses against the macula is intended to keep the hole's edges supported while they seal. The evidence suggests the benefit of strict face-down positioning is most relevant for larger holes; for small holes many surgeons use shorter or less strict positioning. Follow your own surgeon's instructions, as protocols differ.
Not while a gas bubble remains in the eye. Gas expands at altitude and can raise eye pressure dangerously, so air travel — and nitrous oxide anaesthesia — must be avoided until the surgeon confirms the bubble has fully absorbed. That typically takes around two weeks for SF6 and six to eight weeks for C3F8, depending on the gas and concentration used.
References & Evidence Base
Peer-reviewed
citations.
Continue Reading
Related guides
from Beyond Vision.
Start writing here...
Macular Hole: Symptoms, Stages, Surgery & Face-Down Recovery (2026 Guide)