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Joy Efron
Joy R. Efron, Ed.D.

Here are some terms that can help to explain macular pucker/epiretinal membrane, macular pseudoholes, and the ways they differ from macular holes. I’ve also included a short summary for easier reference.


Macular Hole
Internal Limiting Membrane
Epiretinal Membrane or Macular Pucker
Pseudohole or Macular Pseudohole
To Summarize

Macular Hole

The eye is filled with a gel-like substance called the vitreous, which helps maintain the shape of the eye. As people age, the vitreous starts to shrink and pull away from the retina. This usually causes no problems. In isolated cases (about three per 1,000 people over the age of 60), some resilient fibers refuse to let go of the retina. Essentially, a tug-of-war takes place, with the body of the vitreous shrinking while the “stubborn” fibers hold tight to the retina. This tug-of-war can cause a hole in the macula, the area of clearest central vision in the retina.

A retinal hole results in visual symptoms that can range from blurriness or distorted vision to small areas of “missing” vision in the central vision to significantly decreased central vision. Peripheral (or side) vision is not affected. When the hole is only partial thickness, it is referred to as a lamellar hole. A macular hole should not be confused with macular degeneration or a retinal detachment.

A major component of surgical repair for macular hole involves removing the vitreous traction or tugging on the macula through microscopic instruments inserted through microscopic holes in the white part of the eye, called the sclera.

Please note: There are differing opinions and ongoing research regarding the preferred treatment for lamellar macular holes, ranging from observation to surgical treatment. Please be certain to have a thorough and informed discussion with your ophthalmologist and surgeon about the most appropriate treatment for your specific eye condition.

For more information about macular holes, see Surviving Recovery from Macular Hole Surgery.

Internal Limiting Membrane

The internal limiting membrane (ILM) is a thin, transparent, porous membrane lying between the retina and the vitreous and forming a boundary between them. Several years ago, retinal surgeons started peeling/removing the internal limiting membrane during surgery for most macular holes. This removal is very challenging surgery but has greatly improved anatomical and functional results.

For more information about this technique for macular hole surgery, see Meet Antonio Capone, Jr., MD, and His Pioneering Work in Face-Down Positioning after Macular Hole Surgery.

Epiretinal Membrane or Macular Pucker

An epiretinal membrane (ERM) is a thin, transparent sheet of fibrous (or scar) tissue that occasionally develops on top of, and attaches to, the surface of the internal limiting membrane. [Editor’s note: “Epi-” is a prefix that means “on,” “upon,” or “against”; in this case, the retina.]

The ERM is abnormal tissue caused by a proliferation of various types of cells from the retina and other parts of the eye. Often, an ERM is transparent and has no, or minimal, effect on vision. In some cases, it can worsen over time, causing blurring and distortion of central vision.

In other cases, however, the ERM can cause significant traction, or pulling, on the underlying retina (called macular pucker), which in turn can alter the structure of the retina enough to cause distortion in vision (such as straight lines appearing wavy), areas of central vision that are blurry, or decreased visual acuity.

Vitrectomy surgery, which involves removing the vitreous as well as peeling the ERM, is performed when the ERM is causing significant visual impairment. Some surgeons also peel the internal limiting membrane (ILM) during ERM surgery to confirm complete removal of the ERM, based on studies suggesting that ERM recurrence may be lower in eyes with a peeled ILM. An ERM can, in some cases, significantly affect vision, but it is not macular degeneration and it does not cause blindness.

The distortion of the retina by the ERM can cause damage to the peripheral, or outer, retina, or to the photoreceptors (primarily the cones) in the macula.

Photoreceptor cells convert (or process) incoming light into electrical impulses. These electrical impulses are carried by the optic nerve to the brain, which interprets them as visual images.

Cones are the specialized retinal processing cells that function in bright light levels and provide central (or straight-ahead) vision, along with sharp visual acuity, detail, and color vision. You can learn more about cones and the retina at Some Facts about the Retina.

The amount of damage to the photoreceptors prior to surgery will affect the final visual outcome. People with no, or minimal, disruption of photoreceptors prior to surgery will have better visual outcomes than those with damage to the photoreceptors prior to surgery.

To learn more about vitrectomy surgery, see Part One: Introduction to Surviving Recovery From Macular Hole Surgery.

Pseudohole or Macular Pseudohole

Sometimes the pulling or wrinkling of the epiretinal membrane (ERM) can result in a gap (a pseudohole) on the ERM. This is called a “pseudohole” because it appears similar to a macular hole.

However, a detailed examination, as well as more advanced imaging, such as optical coherence tomography (OCT), can confirm the diagnosis of a pseudohole rather than a macular hole. OCT is a type of medical imaging technology that produces high-resolution cross-sectional and three-dimensional images of the eye.

In a full-thickness macular hole, the OCT scan will confirm the absence of retinal layers, as well as a full thickness defect in the retina. In contrast, the OCT scan of a pseudohole will reveal an epiretinal membrane with contraction of the retina and sometimes compression of the retinal layers, but no loss of retinal layers. The term “pseudohole” reflects the fact that although this looks like a macular hole, it is not a hole in the retina.

Although a pseudohole sometimes develops into a macular hole, there are not definitive statistics on this occurrence.

The epiretinal membrane (ERM) that is causing the appearance of a pseudohole may cause no symptoms or may cause visual distortion or decreased vision. If the vision impairment is significant, surgery may be indicated.

As discussed in Epiretinal Membrane or Macular Pucker, the distortion of the retina by the ERM can cause damage to the peripheral, or outer, retina, or to the photoreceptors (primarily the cones) in the macula.

Photoreceptor cells convert (or process) incoming light into electrical impulses. These electrical impulses are carried by the optic nerve to the brain, which interprets them as visual images.

Cones are the specialized retinal processing cells that function in bright light levels and provide central (or straight-ahead) vision, along with sharp visual acuity, detail, and color vision. You can learn more about cones and the retina at Some Facts about the Retina.

The amount of damage to the photoreceptors prior to surgery will affect the final visual outcome. People with no, or minimal, disruption of photoreceptors prior to surgery will have better visual outcomes than those with damage to the photoreceptors prior to surgery.

An Important Distinctions in Layperson’s Terms: Shrinking and pulling away of the vitreous from the retina usually takes place without problems. However, in rare instances, the pulling away of the vitreous can potentially cause a macular hole, a macular pucker, and/or a pseudo hole. Despite the same cause, these are different entities.

To Summarize

  • A strong pull of the vitreous on the retina (traction) can create a macular hole.
  • The internal limiting membrane is a normal layer of the retina. It is the boundary between the retina and the vitreous body.
  • An epiretinal membrane is abnormal tissue (a thin transparent layer consisting of a proliferation of cells) on the surface of the internal limiting membrane of the retina.
  • If there is significant traction on the underlying retina by the epiretinal membrane, the retina develops a wrinkle or bulge or pucker, called macular pucker. Treatment of an epiretinal membrane is not initiated unless vision becomes substantially affected.
  • A pseudohole is not a hole in the macula. It is an appearance of the retina that occurs due to contraction of the retina by an epiretinal membrane. Although it appears to be a macular hole on clinical examination, a detailed exam or optical coherence tomography (OCT) imaging demonstrates that there is, in fact, no hole or loss of retinal layers. Its management is similar to that for epiretinal membrane.

A Disclaimer

I was an educator of blind and visually impaired children for 42 years. Although I have read and researched a great deal and have had extensive discussions with retinal specialists, I am not an ophthalmologist or medical doctor.

Additional Information on Macular Pseudohole

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Reviewed and edited by Mrinali Patel Gupta, M.D., VisionAware Medical Consultant