A stage IV macular hole is an advanced full-thickness hole, with vitreous separation from the optic disc and macula.
Patients usually report a rather abrupt loss of central vision.
The surrounding retinal tissue appears gray and elevated, and often there are small yellow deposits within the hole, reminiscent of drusen. Foveal detachments and partial-thickness holes do not appear red, but rather present as a loss of the foveolar depression with the development of a central yellow spot or ring. Stage II holes are accompanied by a red, crescent-shaped retinal break at the lesion's edge. Controversy surrounds the etiology of idiopathic macular holes. Diverse mechanisms have been proposed, including systemic vascular disease, hormonal variations, cystic retinal degeneration, anterior vitreoretinal traction, and tangential vitreoretinal tractional forces.