Although full thickness macular holes (FTMH) were originally described in the last century, in relation to trauma,inflammation, and myopia, more recent clinical studies have shown that the vast majority are idiopathic and occur with a prevalence of 1/3300 usually in the 6th and 7th decades of life. Many clinical studies have implicated vitreous traction as the cause of idiopathic FTMH formation and it is now widely accepted that traction at the level of the vitreofoveal interface is the underlying mechanism.

Recent work by Kelly and Wendel and others has shown that surgical intervention in the form of vitrectomy, cortical vitreous peeling, and gas tamponade is beneficial in the majority of eyes with FTMH in promoting anatomical closure and foveal reapposition with subsequent visual improvement. In addition, these studies have proposed rigorous face down posturing in the postoperative period as an important factor in achieving improved anatomical results. In the light of the implications of surgical intervention and prolonged face down posturing for elderly patients, the natural history of FTMH has assumed great importance, in particular with respect to fellow eye involvement. The purpose of this review is to summarise the natural history, clinical staging, and pathogenesis of idiopathic FTMH.