Macular ConditionsThe macula is an oval-shaped pigmented area located at the center of the retina that is responsible for our central vision. Its main function is to provide the high-definition visual acuity that makes it possible for us to read, see fine details, perceive color, and more.
Measuring at about 5.5 mm in diameter, the macula is incredibly delicate, making it particularly susceptible to a wide range of conditions. The most well-known macular condition is age-related macular degeneration, which is when the macula deteriorates because of aging. When the macula is damaged, it can cause a slew of vision problems, the most serious being the loss of central vision.
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Epiretinal Membrane / Macular Pucker
An epiretinal membrane, also known as a macular pucker, is a condition in which a thin layer of scar tissue forms on the macula. The scar tissue usually forms as a result of the vitreous fluid inside the eye becoming separated from the retina and tugging at the macula. Macular puckers can also develop because of a traumatic injury, inflammation, after a retinal tear or detachment, after cataract surgery, uveitis, or diabetes. It normally affects only one eye, but can eventually affect both eyes.
A macular hole is a condition in which a break or tear forms in the macula. The most common cause of macular holes is posterior vitreous detachment (PVD), which is a natural aging process where the vitreous fluid inside the eye shrinks and recedes from the retina. Most of the time, PVD causes no serious issues, but in some cases, the vitreous gel is stuck to the retina and pulls on it as it tries to recede. This can lead to strain on the macula that eventually results in a hole.
Stages of Macular Hole
Macular holes are categorized into four stages. The prognosis of a macular hole is dependent on what stage the hole has developed into.
- Stage I: In a first stage macular hole, the fovea, which is a small indentation located at the center of the macula, loses its contour. This causes small defects that set the stage for holes to start forming. Although stage I macular holes can heal on their own, about 50% of cases will end up progressing to the next stage, especially when left untreated.
- Stage II: At the second stage, the macular hole develops to partial-thickness. At this point, visual acuity begins to noticeably decline.
- Stage III: At the third stage, the macular hole develops to full-thickness. Visual acuity continues to decline even further.
- Stage IV: At the fourth stage, the macular hole has reached full-thickness and is accompanied by a complete separation of the vitreous from the macula and optic disc. At this point, your vision has become seriously compromised.
Macular edema is a condition in which fluid accumulates in the macula and causes it to swell. This is often caused by leakage coming from abnormal or damaged blood vessels in the eye. There are several risk factors that are associated with macular edemas, including:
- Retinal vein occlusion
- Macular degeneration
- Inflammatory eye diseases
- Eye injuries
- Hereditary retinal diseases such as retinitis pigmentosa or retinoschisis
Vitreomacular Traction Syndrome
Vitreomacular traction (VMT) syndrome is a complication of posterior vitreous detachment (PVD). In PVD, which generally occurs naturally as we age, the vitreous fluid that fills the inside of the eye shrinks and recedes from the retina. In some cases, the vitreous fluid remains partially connected to the retina, which pulls on the retina and creates a tractional force. This traction can lead to structural damage in the macula as well as set the stage for a variety of maculopathies, including macular holes, macular puckers, and macular edema. Common risk factors for VMT include exudative wet AMD, extreme myopia, retinal vein occlusion, and diabetic retinopathy.
Common Symptoms of Macular Conditions
Because the macula’s main function is so specific, many macular conditions have similar symptoms. The most common symptoms that patients experience for macular pucker, macular holes, macular edema, and vitreomacular traction include:
- Difficulties with central vision
- Blurring and distortion
- Difficulty reading or seeing fine detail
- Gray area in the center of vision
- Changes to perceptions in color
In addition to the above symptoms, patients with VMT may also experience photopsia, which is flashes of light in your field of vision, as well as micropsia, which is when objects appear smaller than they actually are.
How Macular Conditions Are Diagnosed
There are several tests that a retina specialist may perform to determine the type and progression of a macular condition. These tests include:
- Eye dilation: This exam is used in virtually all retinal and macular exams. Special drops are applied to the eyes to keep the pupil open, which helps your physician get a closer look at the inside of your eye and the retinal area.
- Ophthalmoscopy: In this test, the physician uses an ophthalmoscope to shine a light into the eye so they can view the macula and fovea. When you look into the light, your doctor can determine the presence of any damage or conditions in the macula region.
- Optical coherence tomography (OCT): This is a non-invasive imaging technique that uses infrared light to capture cross-sectional images of the retina and macula. OCT is frequently used to determine whether or not fluid has leaked into the macula and can help determine if the macula is damaged in some way.
- Amsler grid test: The Amsler grid test uses a simple grid printed on plain white paper to assess visual acuity. There are many variations of the grid but the most common is a 10 cm by 10 cm grid that consists of 0.5 cm by 0.5 cm squares. At the center of the grid is a black dot. The patient holds the Amsler grid about 14 to 16 inches away from their eyes while covering one eye at a time so that both eyes can be tested individually. As they focus on the dot in the center, the patient is asked a series of questions about what they see, which will help determine whether or not there are any irregularities in their vision.
- Ultrasound: This non-invasive imaging method uses high-frequency sound waves to produce an image of the retina and macula. It can be used to identify tissue irregularities as well as structural issues.
- Fluorescein angiography: In this test, a colored dye is injected into the patient’s bloodstream via the arm. The dye migrates towards the ocular blood vessels and highlights if there are any abnormalities in the macula or blood vessels. A specialized camera is used to capture these images. This is a common diagnostic method for identifying macular edema and VMT.
- Indocyanine green angiography: This test is similar to fluorescein angiography in that it also uses an intravenous injection of colored dye and a special camera to capture images of blood flow in the eye. The main difference is the dye used. In indocyanine green angiography, the dye illuminates when exposed to infrared light, making it easier to see the deeper blood vessels in the retina.
Macular Conditions Treatment
There are several ways in which macular conditions can be treated or managed. The most common methods include:
- Managing underlying conditions and risk factors: Some macular conditions, such as mild macular puckers or mild VMT, are not treated at all beyond monitoring the condition and managing any underlying conditions or risk factors. Some of the most important risk factors to keep in mind are diabetes, high blood pressure, high cholesterol, smoking, aging, and cataract surgery.
- Anti-vascular endothelial growth factor (anti-VEGF) medications: Anti-VEGF injections help to prevent abnormal blood vessel growth in the eyes. Common examples of these injectable medications include Avastin, Lucentis, and Eylea. The eye is first numbed and then the medications are injected directly into the eye. This is a common treatment for macular edema.
- Focal laser therapy or surgery, also known as photocoagulation: This procedure uses a high-energy laser beam to seal off any abnormal blood vessels so that they stop bleeding and causing further damage to the macula. This is a common treatment for macular edemas.
- Vitrectomy: In this surgical procedure, the vitreous humor fluid is removed from the inside of the eye so that the macula can be repaired. The vitreous is then replaced with a similar fluid, such as saline. This technique is commonly used in the treatment of advanced macular puckers, macular holes, and VMT.
- Corticosteroid injection: Used to treat macular edema, steroid injections can help improve visual acuity for a short period of time.
- Preventative eye drops: After cataract surgery, some physicians may prescribe eye drops that help to prevent macular edemas from forming.
- Ocriplasmin injections: Known commonly by the name Jetrea, ocriplasmin is a recombinant truncated form of human plasmin, which is a type of enzyme that dissolves blood clots. This medication is injected directly into the eye to treat vitreomacular adhesions.
- Pneumatic vitreolysis: In this procedure, a gas bubble is injected into the vitreous cavity, which induces a full posterior vitreous detachment that ultimately provides relief for patients diagnosed with VMT.
In addition to the above treatments, there are also a number of experimental treatments that are in various stages of being developed or tested. Some of these treatment options include eye drops, gene therapy, and the usage of human amniotic membranes to help seal macular holes.
Macular Conditions: FAQ
If you have a risk factor associated with macular conditions, you can improve your macular health by making adjustments to your lifestyle, getting your eyes examined on a regular basis, and keeping vitals such as blood sugar and cholesterol levels in check. This will also help you be proactive in getting diagnosed earlier on, which can improve your chances of preserving your vision.
After vitrectomy surgery, you may need to keep your head positioned in a specific way for a specified period of time. This may require you to keep your head in a facedown position. For sleeping, you may be able to sleep on your side as long as you keep your face leaning downward. Your retina specialist will give you specific instructions on this matter.
Once an epiretinal membrane or macular pucker forms, it will never go away on its own. However, if it’s mild or doesn’t interfere with your vision, it likely will not require any treatment.
A pseudo macular hole is not a hole but is a retinal lesion that resembles a macular hole. While it may resemble a macular hole during a regular eye exam, advanced diagnostic techniques such as OCT will reveal that there is no hole and no loss of tissue.
Macular edema is most commonly caused by diabetes. Aside from diabetic macular edema, the condition can also be caused by other factors. Non-diabetic cases are referred to as cystoid macular edema. A specific example is pseudophakic cystoid macular edema, which is when swelling occurs as a result of cataract surgery.
VMT is not common in people with healthy eyes. However, it is common amongst older adults, especially if they have other retinal issues, such as age-related macular degeneration and diabetic retinopathy.
For more information, please visit the American Society of Retina Specialists website: