Macular holes and macular puckers are two distinct problems affecting the center of the retina, and they are discussed together because both arise from the vitreous gel interacting with the macular surface, both distort central vision, and both are diagnosed with the same test.

They are not the same condition, and they are not treated identically.

A macular pucker, more precisely called an epiretinal membrane, is a thin sheet of scar-like tissue that forms on the surface of the macula. As the membrane contracts it wrinkles the retina beneath it, in much the way cellophane stretched over a surface puckers when it shrinks.

The result is distortion. Straight lines bend, text appears uneven, and vision may be mildly blurred. Many epiretinal membranes are thin, cause minimal symptoms, and are found incidentally on imaging; these are simply monitored.

Membranes most often form after a posterior vitreous detachment, but they also follow retinal tears, retinal detachment surgery, inflammation inside the eye, and retinal vascular conditions.

A macular hole is an actual opening through the full thickness of the retina at the fovea, the precise center of the macula. It develops when the vitreous remains attached at the fovea and pulls forward, separating the tissue rather than releasing cleanly.

Because it affects the exact point of sharpest vision, the symptom is a blurred, distorted or missing spot in the very center of the visual field. Patients often notice it when covering one eye and discovering that a small central area is absent in the other.

Macular holes are described by stage, from early tractional change through to a full-thickness hole. Stage determines whether observation or surgery is appropriate, and some early holes close on their own as the vitreous separates.

• Distortion — straight lines appearing wavy, bowed or broken
• Blurred central vision that glasses do not correct
• A gray or missing patch at the very center of vision, more typical of a hole
• Difficulty reading, with letters seeming to run together or shift
• Objects appearing a different size in one eye than the other

Both conditions usually affect one eye, and peripheral vision is unaffected in both. Because the unaffected eye compensates, symptoms are frequently discovered by chance.

Optical coherence tomography is definitive for both conditions and has largely replaced other methods of diagnosis. It produces a cross-sectional image of the macula, showing a membrane on the surface and the wrinkling it causes, or the precise dimensions and stage of a hole.

The measurements matter practically: the thickness of a membrane and the diameter of a hole influence whether surgery is recommended and what to expect from it. Serial OCT scans show whether a membrane is contracting or a hole is enlarging, which is often more useful than a single snapshot.

Examination and fundus photography complete the assessment, and an Amsler grid gives a simple way to track distortion at home.

Surgery for both conditions is a vitrectomy, performed as an outpatient procedure.

For a macular pucker, the vitreous is removed and the membrane is peeled from the retinal surface with fine forceps, releasing the traction causing the wrinkling. Surgery is generally reserved for membranes causing symptoms that interfere with daily activity, since many thin membranes remain stable and asymptomatic for years.

For a macular hole, the vitreous is removed, the fine internal limiting membrane is peeled from around the hole, and a gas bubble is placed in the eye to support the edges while they close. Patients are typically asked to maintain a face-down or specific head position for a period afterward, and must not fly or travel to high altitude until the gas has absorbed.

Improvement after either procedure is gradual, often continuing over several months, and distortion may improve more slowly than blur. How much vision improves relates to how long the problem was present and how much the underlying retinal structure was affected — which your surgeon will discuss based on your own OCT rather than in general terms.

Straight lines looking wavy?

Distortion of central vision is diagnosed quickly with OCT imaging. Call (602) 613-5473 to arrange an evaluation at our Scottsdale office, or get in touch.