Macular Hole: Surgery, Recovery, and Where Integrative Care Fits

In short. A macular hole is a small break in the macula, the centre of the retina used for reading and recognising faces. Most full-thickness holes can be closed with an operation called vitrectomy. A thin membrane is usually peeled away and a gas bubble left in the eye. Results tend to be better when surgery is not delayed, so a new hole should be seen by a retina specialist soon. A few small holes close on their own, but no drop, pill, supplement or herb has been shown to close one. Integrative care can sit alongside surgery and recovery, but it does not replace them.

What a macular hole is. In a US population study, about 8 people in 100,000 developed a macular hole each year. Women were affected about three times as often as men [1].

Most holes appear after age 60, when the vitreous gel inside the eye shrinks and pulls on the centre of the retina. Less often a hole follows an injury, high short-sight or retinal detachment surgery.

Symptoms usually creep up in one eye. Straight lines look bent or pinched, a word in the middle of a line goes missing, and central vision blurs. Side vision is not affected, so a macular hole does not cause total blindness.

Your eye doctor may shine a thin slit of light across the centre of the retina. With a full-thickness hole the line often looks broken or narrowed. In one study this Watzke-Allen test separated true holes from look-alikes well [2].

An OCT scan, a quick light-based picture of the retina, confirms the hole and measures its narrowest width, which guides surgery [3].

How holes are described:

• Gass stages, the older clinical system [4]: stage 1 is an impending hole, a yellow spot or ring at the centre without a full break. Stage 2 is a small full-thickness hole and stage 3 a larger one. Stage 4 is a full-thickness hole with the vitreous fully separated.
• OCT size (International Vitreomacular Traction Study system) [3, 5]: small (250 microns or less), medium (over 250 to 400) or large (over 400). The report also notes whether the vitreous is still pulling on the macula. Smaller holes close more easily.
• Lamellar hole and pseudohole are different. A lamellar hole is a partial-thickness defect with some loss of foveal tissue. A pseudohole is a surface membrane that makes the centre look like a hole when it is not [6]. Both often change slowly and are managed differently, so ask which one your scan shows.

The other eye. About 12% of people in the US study had holes in both eyes [1]. In a Norwegian series of 229 people treated for a hole, 5.7% later developed one in the second eye [7]. Checking each eye on its own with an Amsler grid once a week is a sensible habit.

Treatments with good evidence

Vitrectomy. This is the standard treatment for most full-thickness holes [9]. The surgeon removes the vitreous gel and its pull on the macula, then fills the eye with gas. The bubble acts as a temporary splint while the hole seals.

In the Moorfields trial in London, 185 eyes were randomised to surgery or observation. After two years, 80.6% of operated holes had closed, against 11.5% that closed on their own. Operated eyes read about six lines better at near [10].

Peeling the internal limiting membrane (ILM). Most surgeons now peel this very thin layer from the retina's surface. In the UK FILMS trial of 141 people, 84% of holes were closed at one month with peeling versus 48% without. Repeat operations fell from 48% to 12% [11].

A Cochrane review of four trials found peeling made closure after one operation far more likely, although vision at six months was similar [12].

Not delaying surgery. A pooled analysis of 940 eyes from 12 trials found 81.5% closed after one operation. Each extra month of symptoms lowered the odds of closure and cost about one letter on the eye chart every two months [8].

Large holes and the inverted flap. At Manchester Royal Eye Hospital, standard surgery closed 90% of 258 holes larger than 400 microns. For holes of 650 microns or more, the figure was 76% [13].

For large holes, surgeons may fold a flap of ILM over the hole instead of removing it all. In a randomised trial of 101 eyes with holes over 400 microns, 98% closed with the inverted flap versus 88% with standard peeling [14].

Positioning after surgery. Many surgeons ask you to keep your face down for a few days so the bubble rests against the macula. In the UK PIMS trial of 185 people with holes of 400 microns or more, 95.5% closed with face-down advice versus 85.6% facing forward. That gap could have been chance, but vision was about two lines better in the face-down group [15].

A 2023 Cochrane review of eight trials (709 eyes) rated the evidence on positioning as low certainty [16]. A 2025 pooled analysis supported face-down positioning for holes over 400 microns, with most of the benefit in the first three days [17]. Follow your own surgeon's instructions, which depend on your hole and the gas used.

Cataract after vitrectomy. If you still have your natural lens, a cataract is very likely to develop after vitrectomy.

In one trial cohort, cataract had progressed in 98% of operated eyes within a year [18]. In the Moorfields trial, 58% of operated eyes had cataract surgery within two years [10]. Some surgeons combine cataract and hole surgery in one operation.

No flying while gas is in the eye. The bubble expands as air pressure falls and can push eye pressure up sharply. In a pressure-chamber study, eyes with a little gas had pressure rise by an average of 109% during a simulated climb [19].

Do not fly or drive over high mountain passes until your surgeon confirms the gas has gone. Do not have nitrous oxide ("laughing gas") either, as it can expand the bubble and cause permanent blindness [20].

Treatments with some evidence

Watching some small holes. A review of published cases found that 3% to 15% of holes close on their own. Closure was more likely in holes of 250 microns or less (22%) and was not reported in holes of 400 microns or more [5]. Watching is only reasonable with repeat OCT scans and a plan to operate if the hole stays open or grows.

Ocriplasmin injection. This enzyme, given as an eye injection, loosens the vitreous from the macula. In the MIVI-TRUST trials it closed 40.6% of macular holes versus 10.6% with a placebo injection [21]. Side effects such as floaters and flashes were more common (68.4% vs 53.5%), and some eyes later showed reduced retinal function [21, 22].

It is no longer marketed in the United States [23], so for most people in the US surgery is the only active option.

What is not proven

• Acupuncture and herbal medicine. We found no trials of acupuncture, Chinese herbs or Ayurvedic herbs for macular hole. A full-thickness hole is a physical break held open by traction, and there is no evidence that needles or herbs close it.
• Eye drops, vitamins and "natural closure" products. None has been tested in a trial for macular hole. Holes that close on their own are mainly small ones [5].
• Anything that asks you to delay surgery. Waiting has a measurable cost in closure and vision [8].

Where Netra fits

Netra Eye Institute is an acupuncture and Oriental medicine practice. We do not diagnose or treat macular hole, and we do not replace your retina surgeon. Our role is adjunctive:

• We check that the basics are in place: an OCT measurement, a plan with your retina specialist, and a surgery date that is not drifting.
• We offer acupuncture and, where appropriate, Chinese herbal medicine within Netra Restoration Therapy (NRT), with the evidence explained before you start. Herbs are reviewed against your medicines, and we tell your surgeon and anaesthetist about every herb you take, so they can say when to stop it before surgery.
• During face-down positioning we do not ask you to lie on your back. We do not needle around the operated eye until your surgeon agrees. We plan visits around your positioning and the no-flying period.
• We share what we see with your eye doctor. If you report pain, redness or a sudden change in vision, we refer you back the same day.

For Ayurvedic approaches, see Ayurvedic treatment for macular hole.

NRT is not a treatment for macular hole and does not replace vitrectomy or your surgeon's aftercare. If you want to talk through whether integrative care makes sense alongside your treatment, request a consultation.

Questions people ask

Can a macular hole be treated without surgery?

Sometimes, as a small share of holes, mostly small ones, close on their own [5]. Ocriplasmin, an injection that closed some holes in trials, is no longer sold in the US [21, 23]. For most full-thickness holes, vitrectomy is the treatment that works.

How can I treat a macular hole naturally?

There is no natural treatment shown to close a macular hole. Diet, supplements, eye exercises, acupuncture and herbs have not been tested in trials for this. The helpful "natural" steps are an early specialist visit and careful aftercare if you have surgery.

Is there a new treatment for macular hole?

The main recent change is the inverted ILM flap, which raised closure rates for large holes in a trial [14]. Surgeons also use grafts and other flap techniques for holes that do not close the first time. Ask your surgeon which technique suits your hole size.

Will my vision come back after surgery?

Most people gain some vision, though often not back to what it was. In pooled trial data, typical vision after a successful closure was about 20/60, and results were better when surgery came sooner [8].

How long do I have to stay face down?

It depends on hole size and your surgeon. In trials, advice ranged from 3 to 10 days, and some surgeons ask for none [16]. Evidence suggests most of the benefit comes in the first three days, mainly for holes over 400 microns [17].

Will I get a macular hole in my other eye?

Most people do not. In one series about 6 in 100 later developed a hole in the second eye [7]. Check each eye separately and report changes early.

References

1. McCannel CA, Ensminger JL, Diehl NN, et al. Population-based incidence of macular holes. Ophthalmology. 2009;116(7):1366-1369.
2. Martinez J, Smiddy WE, Kim J, et al. Differentiating macular holes from macular pseudoholes. Am J Ophthalmol. 1994;117(6):762-767.
3. Duker JS, Kaiser PK, Binder S, et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120(12):2611-2619.
4. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol. 1995;119(6):752-759.
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12. Spiteri Cornish K, Lois N, Scott N, et al. Vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with no peeling for idiopathic full-thickness macular hole (FTMH). Cochrane Database Syst Rev. 2013;(6):CD009306.
13. Ch'ng SW, Patton N, Ahmed M, et al. The Manchester Large Macular Hole Study: is it time to reclassify large macular holes? Am J Ophthalmol. 2018;195:36-42.
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18. Cheng L, Azen SP, El-Bradey MH, et al. Duration of vitrectomy and postoperative cataract in the Vitrectomy for Macular Hole Study. Am J Ophthalmol. 2001;132(6):881-887.
19. Mills MD, Devenyi RG, Lam WC, et al. An assessment of intraocular pressure rise in patients with gas-filled eyes during simulated air flight. Ophthalmology. 2001;108(1):40-44.
20. Lockwood AJ, Yang YF. Nitrous oxide inhalation anaesthesia in the presence of intraocular gas can cause irreversible blindness. Br Dent J. 2008;204(5):247-248.
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23. US Food and Drug Administration. Purple Book: Jetrea (ocriplasmin) intravitreal injection, BLA 125422, ThromboGenics Inc. Approved 17 October 2012; marketing status listed as discontinued. Accessed 15 October 2026.