A macular hole is a small break in the macula, the central part of your retina responsible for sharp, detailed vision. It develops when the gel-like substance inside your eye (the vitreous) pulls on the macula and tears through its full thickness. About 8 in every 100,000 people develop one each year, and roughly two-thirds of cases occur in women.
How a Macular Hole Forms
The inside of your eye is filled with a clear, jelly-like substance called the vitreous. As you age, this gel naturally shrinks and pulls away from the retina. In most people, it separates cleanly. But sometimes the vitreous stays stuck to the macula even as it contracts, creating traction that tugs on the delicate retinal tissue. That pulling force can lift, stretch, and eventually tear a hole through all the layers of the macula.
The process typically unfolds in stages. In the earliest phase, vitreous traction lifts the center of the macula slightly, creating a small cyst. If the pulling continues, a full-thickness break forms, initially less than 400 micrometers across. Left untreated, nearly all of these small holes enlarge to 400 micrometers or larger. In the final stage, the vitreous fully detaches from the back of the eye, but even then a thin residual layer of vitreous may remain and keep the hole open.
Most macular holes are “idiopathic,” meaning they happen on their own as part of aging. Less commonly, they result from eye trauma, high myopia, or other retinal conditions. About 80% of cases affect only one eye.
Who Is Most at Risk
Macular holes predominantly affect people over 60, when vitreous shrinkage accelerates. Women face a 64% higher risk than men after adjusting for age and other factors. The reasons for that gap aren’t entirely clear, though hormonal changes after menopause may play a role in how the vitreous ages. Having high myopia (severe nearsightedness) is another established risk factor, since a longer eyeball puts additional mechanical stress on the retina.
Symptoms to Recognize
Because the macula handles your central, detail-oriented vision, a hole there doesn’t cause total blindness. Instead, it creates a blind spot or blurry patch right in the middle of whatever you’re looking at. Reading, recognizing faces, and driving become difficult, while side vision stays intact.
One of the hallmark symptoms is a visual distortion called metamorphopsia. Straight lines look wavy, bent, or warped, similar to looking through someone else’s prescription glasses. Objects may appear smaller or larger than they actually are, or seem oddly shaped. In early stages, you might notice only a slight smudge or gray area in your central vision. As the hole enlarges, that central blind spot becomes more pronounced and harder to ignore.
A simple self-check involves looking at a grid of straight lines (an Amsler grid) one eye at a time. If lines appear wavy, broken, or missing in the center, that’s a reason to get an eye exam promptly.
How It’s Diagnosed
An eye doctor can often spot a macular hole during a dilated eye exam, but the definitive tool is optical coherence tomography (OCT). This painless imaging scan creates a cross-sectional picture of the retina, showing the exact size and depth of the hole, whether all retinal layers are involved, and how much the surrounding tissue has been affected.
OCT is also critical for distinguishing a full-thickness macular hole from two lookalike conditions. A macular pseudohole occurs when a membrane on the retina’s surface contracts and creates a steep pit, but the retina underneath remains its normal thickness. A lamellar hole, by contrast, involves partial-thickness tissue loss with an irregular, thinned center. Both can look similar through a standard examination, but OCT reveals their very different structural profiles. This distinction matters because pseudoholes and lamellar holes often don’t require surgery.
Surgical Repair: What to Expect
The standard treatment for a full-thickness macular hole is a surgery called vitrectomy. The surgeon removes the vitreous gel, then carefully peels away the internal limiting membrane (ILM), an extremely thin layer on the retina’s surface. Though only a few micrometers thick, this membrane accounts for roughly half of the retina’s rigidity and can act as scaffolding for scar tissue that prevents the hole from closing. Removing it allows the edges of the hole to relax and come together.
For larger holes (over 500 micrometers), surgeons may create a small flap from the ILM and tuck it into the hole rather than peeling it away entirely. This flap technique improves closure rates in bigger holes. At 450 micrometers, predicted success jumps from 92% with standard peeling to 98% with a flap.
After removing the vitreous and treating the membrane, the surgeon fills the eye with a gas bubble. This bubble presses against the macula, holding the edges of the hole flat while it heals. The gas gradually absorbs on its own over days to weeks.
Recovery and Face-Down Positioning
The gas bubble only works if it’s in the right position, which means you’ll likely need to keep your head face-down for a period your surgeon specifies, ranging from several days to a couple of weeks. This applies when you’re standing, sitting, eating, walking, and sleeping. It’s one of the more physically demanding parts of recovery, and many people use rental equipment like special face-down chairs and sleeping supports to make it more manageable.
Failing to maintain proper positioning can allow the bubble to press on other parts of the eye, potentially causing new problems and reducing the chance of successful closure. You also cannot fly or travel to high altitudes while the gas bubble is in your eye, because changes in air pressure can cause the bubble to expand dangerously.
Success Rates and Vision After Surgery
Macular hole surgery has a strong track record. About 85% of holes close after a single operation, and with a second surgery when needed, the overall closure rate climbs to around 92%. Separate data on the ILM flap technique shows success rates reaching 99% for holes around 400 micrometers.
Anatomical closure doesn’t always mean perfect vision, but most people see meaningful improvement. In one large study, 63% of patients gained more than two lines on a standard eye chart, and a third achieved 20/40 vision or better, which is sharp enough for most daily activities including driving. Vision improvement tends to continue gradually for several months after surgery as the retinal tissue heals and reorganizes. Smaller holes and shorter symptom duration before surgery generally predict better visual outcomes.
Potential Complications
The most common side effect of vitrectomy is accelerated cataract development in the operated eye. A full vitrectomy combined with gas tamponade increases the rate of a specific type of cataract (nuclear sclerosis) by about 60%. Most patients who haven’t already had cataract surgery will need it within a year or two. Some surgeons combine cataract removal with the macular hole repair in a single procedure, though this approach can cause a shift in the eye’s focus that needs to be accounted for when choosing a lens implant.
Retinal detachment is a less common but more serious risk. Swelling in the macula after any subsequent cataract surgery can also, in rare cases, cause a previously closed macular hole to reopen. Your surgeon will monitor for these possibilities during follow-up visits in the weeks and months after the procedure.