Vitreomacular traction diseases include abnormalities that arise from focal or broad vitreomacular adhesions in the presence of detaching or otherwise detached posterior vitreous. The 3 recognized categories of vitreomacular traction disease are: (1) vitreomacular adhesion (VMA), (2) vitreomacular traction (VMT) syndrome, and (3) macular hole. Table 17-1 summarizes a useful classification system for these categories that relies on OCT findings.
VMAs typically do not cause visual symptoms. They can be focal or diffuse and can lead to secondary traction disease, that is, VMT and macular hole.
Vitreomacular traction syndrome
In VMT syndrome, the posterior hyaloid is abnormally adherent to the macula (eg, a VMA). As the vitreous detaches, the posterior hyaloid remains tethered at the macula, usually the fovea, causing tractional foveal distortion, cystic edema, and, in severe cases, tractional foveal detachment. These changes lead to decreased visual acuity, metamorphopsia, and often vague reports about poor vision in the affected eye that are out of proportion to the measured visual acuity. Angiography may demonstrate leakage of fluorescein dye from macular vessels as well as from the optic nerve. OCT is useful to demonstrate the vitreoretinal interface abnormalities and the tractional effects of VMT syndrome on the foveal architecture. Chronic traction is generally understood to be harmful over the long term, particularly when cystic edema is present or when the patient’s vision is affected. Spontaneous separation of the focal vitreoretinal adhesion, with resolution of all clinical features, occurs in approximately 50% of cases, and less commonly when there is an associated ERM or the adhesion is broad (Fig 17-6).
Table 17-1 The International Vitreomacular Traction Study Classification System for Vitreomacular Adhesion, Traction, and Macular Hole
Figure 17-6 Vitreomacular traction syndrome. OCT scan of the macula through the fovea shows vitreomacular traction causing a large foveal cyst and distortion of the inner retina. An ERM is also present.
(Courtesy of Tara A. McCannel, MD, PhD.)
Intervention should be considered for VMT syndrome; it includes pars plana vitrectomy with membrane peeling or intravitreal injection of ocriplasmin. Vitrectomy surgery is highly successful in achieving resolution of VMT (see also Chapter 20).
Ocriplasmin is a recombinant protease with activity against fibronectin and laminin; it has a variable success rate. A multicenter clinical trial found that resolution of vitreomacular traction occurred in 26.5% of ocriplasmin-injected eyes compared with 10.1% of placebo-injected eyes over the same period. In a subset of patients with vitreomacular adhesions smaller than 1500 μm, the rate of resolution increased to 33.6%. Unfortunately, a small number of patients experienced permanent visual loss with electroretinogram (ERG) changes. This may be due to a disruption of the interphotoreceptor matrix, leading to ellipsoid layer attenuation.
Margo JA, Shocket LS, Kilma K, Johnson MA. Persistent retinal changes after intravitreal ocriplasmin. Retin Cases Brief Rep. 2016;10(1):48–51.
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.