The macula is a part of the eye crucial to good vision, but as we age, it can be damaged by macular holes and macular puckers. What are the symptoms, and what are the approaches to treating and preventing these problems?
Let’s start by asking, what is the macula? The macula is the central part of the retina. It is yellowish in color. It is the part of the retina that creates clear, sharp, focused vision. And it is the part of the retina most heavily populated with cones, the type of eye cell that allows us to see in color. The retina is a thin layer at the back of the eye. It is where the lens of the eye focuses light to be interpreted and sent to the brain via the optic nerve.
In front of the retina is a layer of the eye called the vitreous. The vitreous is a squishy gel-filled area of the eye that helps to maintain its round shape. It has many small fibers that attach to the retina. As we age, the vitreous frequently dries out. As it dries, it shrinks, and the fibers attached to the retina begin to pull which can cause macular problems. Two common macular issues that can develop as we age are macular holes and macular puckers.
Usually, when the vitreous shrinks, the empty space fills with fluid without many eye complications. There may be additional floaters but no major problem develops. But sometimes, as the vitreous shrinks, the fibers do not separate from the retina and tear it. Or some fibers remain attached to the retina and then contract once the vitreous has separated and tear the retina that way. A tear in the central area of the retina is a macular hole. Fluid can then seep into this hole, created blurred and distorted vision. This condition is most common in people over age 60.
There are three stages of macular holes.
- Stage I is called a foveal detachment. About half of foveal detachments grow worse without treatment.
- Stage II is called a partial-thickness hole. About 70% of partial thickness holes will worsen if left untreated.
- Stage III is called a full-thickness hole. A full thickness hole can destroy most central vision, and, if left untreated, can lead to a retinal detachment that can destroy all vision.
The degree of visual distortion and blurring depend on the size and location of the hole.
In the early stages of a macular hole, visual changes may be subtle. People may notice that lines appear wavy in their straight-ahead vision. Reading may become difficult and objects may be a little blurred. As macular holes worsen, more and more central vision is lost, leading to noticeable differences in vision.
Macular holes are diagnosed with a thorough eye exam that checks visual ability and dilates the pupil for a close examination of the retina.
Sometimes macular holes repair themselves and no treatment is required. More frequently, surgery is performed to get the macula to reseal itself. A vitrectomy, in which the vitreous of the eye is removed is performed, helps prevent further pulling on the retina. A temporary bubble that is a mixture of gas and air is put in its place. The pressure of the bubble on the retina encourages the macula to reseal itself. The bubble is eventually resorbed by the body and the space of the vitreous fills with normal eye fluids. In order to get this to work, patients must remain lying face down so the bubble applies pressure to the retina. Usually, a patient only has to remain face-down for a day or two, but in severe cases, it can be as long as two to three weeks.
The surgery carries a risk of complications — including developing a severe cataract — and creates varying levels of vision improvement. Patients who have a macular hole that is less than six months old have a better prognosis than patients with a longer existing problem. This is a very good reason to get regular eye exams, especially in the later years of life.
Like macular holes, macular puckers are caused by a shrinking vitreous. However, in the case of a macular pucker, the retina repairs itself and the repair leads to a scar on the macula. Like macular holes, macular puckers can cause blurred and distorted vision, but usually to a lesser degree than macular holes. Unless vision loss or distortion is severe, there is typically no need to treat a macular pucker. Macular puckers are also known as epiretinal membrane (ERM) and cellophane maculopathy.
In many cases, macular puckers cause no change in vision. In some instances vision may be blurred or distorted and straight lines may appear wavy. There can also be a blind spot or a gray area in the center of the visual field.
As with macular holes, macular puckers can be easily diagnosed with a thorough eye exam that includes pupil dilation for a good view of the retina.
Unless visual issues are substantial, macular puckers require no treatment. In cases where vision has been severely affected, they are treated like macular holes, with a vitrectomy and a removal of the scar tissue. There is no need to install a reparative bubble, and instead, the vitreous is replaced with a saline solution. A typical patient regains half the vision lost from a macular pucker, but this varies from patient to patient. Vision usually does not return to normal, and eyeglasses will usually be needed.
As with all vitrectomies, the most common post-surgery complication is the development of cataracts, but retinal detachment and infection are also risks. In rare instances, the scar reforms.
Our retinal support page for macular puckers has many ideas for supporting the health of the macular surface.
While there is no definitive prevention for macular holes or macular puckers, health maintenance with a special view to the eyes may aid in prevention. Supplements such as lutein, bilberry, gingko biloba, vitamin C and glucosamine sulfate can reduce age-related eye complications. Because people tend to dry out as they age, and sensitivity to thirst declines, making sure to drink adequate fluids may also reduce problems. Exercise and a good diet also go a long way towards preventing conditions typical of age-related decline. And be sure to see your eye doctor regularly. Also, see our retina connective tissue support page, and our retinal support page for macular puckers.