Macular Hole:
What It Is, Who Gets It &
Face-Down Recovery

The macula is a small but extraordinary structure — roughly 5 millimetres in diameter — at the centre of the retina. It is responsible for everything you rely on for detailed, central vision: reading, recognising faces, driving, threading a needle. The fovea, at its very centre, contains the highest concentration of cone photoreceptors in the entire eye.

A macular hole is exactly what it sounds like: a full-thickness defect in this central tissue. It develops when the vitreous gel pulls away from the macular surface imperfectly, exerting traction that tears through the fovea. The result is a blank, dark, or distorted spot precisely in the centre of vision — making tasks that depend on central acuity disproportionately difficult.

Who Gets a Macular Hole

Idiopathic macular holes — those without an identifiable secondary cause — are the most common variety. They occur predominantly in patients aged 60 and above, with a clear female preponderance (women are approximately two to three times more likely to be affected). The incidence increases with age and with conditions that alter vitreoretinal adhesion.

Risk factors include:

• Age 60+ — the primary risk factor; the posterior vitreous detachment process that causes most macular holes becomes near-universal in this decade
• Female sex — hormonal factors may influence vitreoretinal adhesion strength
• High myopia — myopic macular holes have a somewhat different mechanism (posterior staphyloma and tangential traction) and can be more difficult to close surgically
• Previous macular hole in the fellow eye — the risk to the second eye is approximately 10–15%, higher if the posterior vitreous has not yet detached in that eye
• Trauma — blunt ocular trauma can cause traumatic macular holes, particularly in younger patients

Staging: How Macular Holes Develop

Macular holes develop progressively through four stages, classified by the Gass system and assessed on OCT imaging. Understanding the stage helps determine urgency and likely surgical outcome.

Surgery: Vitrectomy and ILM Peel

The surgical treatment of macular hole — pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade — is one of the most technically demanding procedures in vitreoretinal surgery, yet yields highly reliable results when performed by an experienced surgeon.

The Face-Down Requirement: Practical Advice

This is the aspect of macular hole surgery that most patients find daunting — and rightfully so. Following surgery, patients must maintain a face-down posture for 5–7 days (sometimes longer for large holes), keeping the gas bubble pressed against the fovea for the critical healing period. The hours spent upright or face-up effectively waste the tamponade and dramatically reduce the chance of hole closure.

Compliance is the single most modifiable factor affecting surgical outcome. Preparation before surgery makes all the difference:

Outcomes and Recovery Timeline

Visual recovery after macular hole surgery is gradual, and the trajectory varies by hole size, duration, and patient age.

• Week 1–2: Vision is dominated by the gas bubble — a black arc at the bottom of the visual field moving upward as the bubble absorbs. Do not judge vision at this stage.
• Weeks 2–6: The bubble clears progressively. Vision begins to emerge — often described as looking through frosted glass initially. A watery, moving visual interface is normal as the bubble dissipates.
• Months 1–3: Most significant improvement phase. Reading vision returns. The central scotoma from the hole gradually fills in as the closure consolidates.
• Months 3–6: Continued but slower improvement. Final acuity is often not reached until 6 months post-surgery.
• 12 months: Some patients continue improving for a full year. Final acuity depends on pre-operative hole size, duration, and the degree of photoreceptor recovery.

Frequently Asked Questions

How soon after diagnosis do I need surgery?

Unlike retinal detachment, macular hole surgery is not an emergency — but it is urgent. Surgical outcomes are substantially better when the hole is smaller (Stage 2) and of shorter duration. Prolonged untreated holes allow the retinal edges to stiffen and the photoreceptors to degenerate further, reducing the chance of meaningful visual recovery. A delay of weeks is acceptable to arrange surgery; a delay of months is not ideal.

Do I really need to be face-down for the full duration?

Yes — and the more consistently you maintain the position, the better the outcome. The gas bubble must press against the macula continuously during the healing period. Brief interruptions (trips to the bathroom, short walks) are acceptable, but any prolonged deviation from face-down significantly reduces the tamponade effect. Patients who report poor positioning compliance have measurably lower closure rates.

What is my risk for the other eye?

The fellow eye risk of developing a macular hole is approximately 10–15%, and higher (up to 20%) if a posterior vitreous detachment has not yet occurred in the second eye. An anomalous (incomplete) PVD in the fellow eye on OCT further increases risk. Your surgeon will examine the fellow eye at follow-up appointments and advise on monitoring intervals.

Can I have cataract surgery at the same time?

Combined phacoemulsification and vitrectomy for macular hole is a well-established approach for patients with concurrent cataract. It avoids two separate procedures and eliminates the accelerated cataract that vitrectomy alone would cause. The tradeoff is a slightly longer operation and the need to select the IOL power in advance of the macular hole closure, without knowing the final refractive shift.

How long do I need to stay face-down after macular hole surgery?

Most surgeons recommend face-down posturing for five to seven days after surgery, though this can vary. Your surgeon will give you specific instructions based on the size and characteristics of your macular hole. Brief breaks for bathroom use and meals are usually permitted.

What is the success rate of macular hole surgery?

Modern vitrectomy with ILM peeling achieves closure in over 90% of cases with a single surgery. For smaller holes treated early, the closure rate approaches 95–100%. If the hole does not close after the first surgery, a second operation can be considered.

Will my vision return to normal after macular hole surgery?

Most patients experience meaningful improvement in central vision, but the final result depends on the size of the hole and how long it was present before surgery. Smaller holes that are treated promptly have the best outcomes. Some patients may notice subtle residual distortion even after successful closure. Visual improvement is gradual and can continue for up to a year.

Can a macular hole heal on its own without surgery?

Stage 1 macular holes (where the hole has not yet fully formed) sometimes resolve spontaneously as the vitreous releases its traction on the macula. However, full-thickness macular holes (stages 2 to 4) very rarely close on their own and typically require surgery to prevent further vision loss.

Can I get a macular hole in my other eye?

Yes. The risk of developing a macular hole in the other eye is estimated at around 10–15%. Your doctor will monitor both eyes during follow-up visits. Knowing the warning signs (distortion or blurring of central vision) and checking your vision regularly with an Amsler grid can help detect any changes early.