Vitreomacular traction syndrome

Vitreomacular traction (VMT) syndrome is a distinct vitreoretinal interface disorder that is differentiated clinically from typical ERM. Whereas ERM formation generally results from complete posterior vitreous detachment, VMT syndrome stems from anomalous, incomplete posterior vitreous separation at the macula. The fundus examination in VMT syndrome is often normal. The disorder may create focal elevation of the fovea (Fig 20-3) and, occasionally, a shallow retinal detachment. VMT syndrome is best diagnosed and differentiated from ERMs with the aid of optical coherence tomography (OCT); in eyes with this syndrome the hyaloid classically inserts onto a tractionally elevated macular retina, usually the fovea. Symptoms include decreased vision and distortion. VMT syndrome is often progressive and is associated with a greater loss of vision than are ERMs alone. Surgical treatment consists of a pars plana vitrectomy and peeling of the cortical vitreous from the surface of the retina. Intraoperative use of triamcinolone may aid visualization of the cortical vitreous. See Chapter 17 for further discussion of VMT syndrome.

• Voo I, Mavrofrides EC, Puliafito CA. Clinical applications of optical coherence tomography for the diagnosis and management of macular diseases. Ophthalmol Clin North Am. 2004; 17(1):21–31.

Idiopathic macular holes

Vitrectomy surgery is not generally recommended for stage 1 macular holes because approximately 50% of them will resolve spontaneously. It is definitely indicated for all recent full-thickness macular holes (stages 2, 3, and 4). Early intervention for full-thickness macular holes is important; shorter time intervals between the development and the closure of macular holes have been associated with improved anatomical and functional outcomes.

Surgery for full-thickness macular holes typically consists of a pars plana vitrectomy, separation and removal of the posterior cortical vitreous, optional removal of the ILM, and use of an intraocular air or gas tamponade (Video 20-2). Various studies have demonstrated that ILM peeling improves the rate of hole closure, particularly for larger stage 3 or 4 holes, and reduces reopening rates. ILM inverted flaps is a newer surgical technique used to repair macular holes, but there is no consensus on whether this technique improves visual acuity in patients with large macular holes (Video 20-3). The intraoperative use of dyes (eg, ICG, trypan blue, BBG) or other visualization techniques (eg, triamcinolone) to aid in peeling the ILM is widely practiced, despite potential toxicity. Duration of face-down positioning ranges from a few hours to 2 or more weeks. Since the early 2000s, most studies have reported macular hole closure at rates higher than 90% (Fig 20-4). After successful closure, it is uncommon for the hole to reopen; however, this may occur if severe cystoid macular edema or ERM develop.

VIDEO 20-2 Vitrectomy for macular hole repair with ILM peeling.

Courtesy of Colin A. McCannel, MD.

VIDEO 20-3 Inverted ILM flap for macular hole closure.

Courtesy of María H. Berrocal, MD.

• Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991;109(5):654–659.

• Kumagai K, Furukawa M, Ogino N, Uemura A, Demizu S, Larson E. Vitreous surgery with and without internal limiting membrane peeling for macular hole repair. Retina. 2004;24(5):721–727.

Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.