A full-thickness macular hole is repaired by pars plana vitrectomy (PPV) with ILM peel and a gas tamponade. Under local anaesthetic as a day case, the surgeon removes the vitreous gel, peels the internal limiting membrane around the fovea and fills the eye with a temporary gas bubble that holds the hole closed while it heals. Closure rates are 95–100% for small holes and 80–95% for large holes with an inverted ILM flap. Visual recovery is best when surgery is done within 6 months of symptoms.
What is a macular hole and why does it need surgery?
A macular hole is a small full-thickness defect through all the neurosensory layers at the centre of the retina (the fovea), almost always caused by the vitreous gel pulling on the macula as it separates with age. It causes a central grey or black spot, distortion of straight lines (metamorphopsia) and difficulty reading. Left untreated a full-thickness hole rarely closes on its own and central vision deteriorates, so the standard of care is to repair it surgically.
Holes are graded on macular OCT using the International Vitreomacular Traction Study (IVTS) classification by minimum linear diameter: stage 2 (less than 250 microns), stage 3 (250–400 microns) and stage 4 (more than 400 microns with a complete posterior vitreous detachment). The stage drives both the technique and the expected outcome. Related conditions on the same spectrum include vitreomacular traction and epiretinal membrane.
Surgical techniques
Every macular hole repair is a pars plana vitrectomy – the techniques differ in how the ILM is handled, which gas is used and whether cataract surgery is combined. Your consultant vitreoretinal surgeon chooses based on the hole size, how long it has been open and whether you are phakic.
Not sure which technique applies to your hole? A consultant will stage it on OCT and explain your options.
Book your assessmentHow macular hole surgery works
Surgery is a day case under sub-Tenon’s or topical local anaesthetic, with optional intravenous sedation – you are awake but the eye is fully numb, so there is no pain, just a sensation of pressure and the surgeon’s light. Three tiny valved ports are placed through the pars plana 3.5–4 mm behind the edge of the cornea.
The surgeon removes the vitreous gel (core vitrectomy), induces a complete posterior vitreous detachment if needed, then stains and peels the internal limiting membrane in a 2–3 disc-diameter ring around the fovea. For large or chronic holes an inverted ILM flap is laid across the hole as a healing scaffold. After a fluid–air exchange the eye is filled with gas – 20% SF6 for small/medium holes or 14% C3F8 for large, chronic, re-do or myopic holes. The small-gauge ports are usually self-sealing without stitches. The whole operation takes 30–50 minutes per eye.
Recovery & the gas bubble
While the gas bubble fills the eye, the operated eye sees only light and shadow; vision returns from the top of the field downwards as the bubble absorbs – over 2–4 weeks for SF6 or 6–8 weeks for C3F8. The fellow eye is unaffected throughout.
Day 0–1
Day-case surgery; pressure and bubble check the next day. Begin antibiotic and steroid drops and any prescribed posturing.
First 1–2 weeks
Operated eye sees light/shadow only. Posturing 3–5 days (SF6 small/medium) or 5–10 days (C3F8 large/chronic). 2-week OCT confirms closure.
3–8 weeks
Gas absorbs and vision returns from the top down. No flying until the bubble has gone (3 weeks SF6, 6–8 weeks C3F8). Driving once you meet the DVLA standard.
3 months & beyond
Final outcome review with OCT. Metamorphopsia keeps improving up to 12 months. Annual macular OCT from year 2 to detect rare late re-opening.
How much does private macular hole surgery cost?
UK 2026 self-pay fees at CQC-registered London vitreoretinal centres are £6,500–9,500 per eye for standard PPV + ILM peel + gas, £7,500–10,500 for the inverted ILM flap technique, and £8,500–11,500 for combined phacovitrectomy. The fee is all-inclusive: same-week consultant assessment, macular OCT and biometry, the day-case operation, the IOL where combined, and the 1-day, 2-week, 6-week and 3-month review pathway.
Macular hole vitrectomy is also commissioned on the NHS (realistic 4–12 week waits) and is generally covered by Bupa, AXA Health, Aviva, Vitality and WPA when OCT-documented – always pre-authorise in writing. See full vitreoretinal surgery pricing or the wider vitreoretinal surgery overview.
Macular hole surgery FAQs
How much does private macular hole vitrectomy cost in London in 2026?
UK 2026 self-pay macular hole vitrectomy in London costs £6,500–9,500 per eye, all-inclusive. The fee covers a same-week consultant vitreoretinal assessment, dilated fundoscopy, high-resolution macular OCT, biometry, 25G/27G day-case pars plana vitrectomy under sub-Tenon’s or topical local anaesthetic with optional sedation, ILM peel (brilliant blue G or ICG dye), 20% SF6 or 14% C3F8 gas tamponade, and the 1-day, 2-week, 6-week and 3-month review pathway. Combined phacovitrectomy (with simultaneous cataract surgery) is typically £8,500–11,500.
What is the success rate of macular hole surgery?
Anatomic closure on OCT is 95–100% for small stage 2 holes (less than 250 microns), 90–95% for medium stage 3 holes (250–400 microns), and 80–95% for large stage 4 holes (more than 400 microns) when an inverted ILM flap is used. Functional success – a 2-line or greater Snellen gain at 6 months – occurs in 70–80% of eyes overall, and distortion keeps improving up to 12 months. Visual recovery is best when surgery is done within 6 months of symptom onset.
Do I really have to lie face-down for a week?
Modern practice is more pragmatic than the strict 7–10 day protocols of the 1990s. For small or medium stage 2–3 holes filled with 20% SF6, many surgeons recommend 3–5 days of face-down posturing during waking hours, with relaxed posturing at night. For large stage 4 or chronic holes filled with C3F8, 5–10 days of stricter posturing is more common. The Cochrane review and the PIMS trial suggest prolonged strict posturing is not essential when an adequate gas fill is achieved.
How long does macular hole surgery take and is it painful?
Macular hole vitrectomy takes 30–50 minutes per eye as a day case under sub-Tenon’s or topical local anaesthetic, with optional sedation. You are awake but the eye is fully numb, so there is no pain during surgery – just a sensation of pressure and the surgeon’s light. Afterwards there is a mild dull ache for 24–48 hours, easily controlled with paracetamol. Vision in the operated eye is reduced to light and shadow for the first 1–3 weeks because of the gas bubble.
Will I need cataract surgery afterwards?
Yes, in almost all phakic patients over 55. Vitrectomy reliably accelerates cataract formation so a visually significant cataract appears within 6–12 months. For this reason most surgeons recommend a combined phacovitrectomy (cataract surgery + IOL + vitrectomy + ILM peel + gas) in the same operation in phakic eyes; it costs more up front (£8,500–11,500) but avoids a second operation, anaesthetic and recovery. Pseudophakic eyes that have already had cataract surgery do not need this and have macular hole vitrectomy alone.
When can I fly after macular hole surgery?
No air travel until the gas bubble has fully absorbed – approximately 3 weeks for 20% SF6 and 6–8 weeks for 14% C3F8. The cabin pressure drop at altitude causes residual gas to expand and raise the eye pressure to levels that can cause irreversible optic nerve damage. Your surgeon will confirm flight clearance once your post-op OCT shows the bubble has gone.