VITREOMACULAR TRACTION

I WAYAN ARDY PARIBRAJAKA

VITREORETINA DIVISION OF BALI MANDARA EYE HOSPITAL
DEFINITION
 Disorder of the vitreo-retinal interface
 Characterized by :
1. an incomplete posterior vitreous detachment (PVD)
2. an abnormally strong adherence of the posterior hyaloid face to
the macula and
3. anteroposterior traction exerted by the syneretic vitreous
pulling at adherent sites on the macula causing morphologic
and often functional effects
ANATOMY

• The vitreous gel is a transparent extracellular matrix that fills the cavity
behind the lens of the eye
• It occupies an average volume of 4.4 ml in adulthood
• The outer cortex of vitreous which is made up of dense collagen (Type
II) is firmly attached to internal limiting membrane (Type IV collagen).
VITREOUS ATTACHMENTS

Vitreous Base
Peripheral margin of the Optic Nerve Head Posterior pole
– margin of the fovea
– retinal veins in the mid-periphery
• The VITREORETINAL INTERFACE is an adhesive sheet that facilitates the
connection of the posterior vitreous cortex of the vitreous body to the
internal limiting membrane of the retina
• The vitreoretinal interface consists of matrix proteins including laminin,
fibronectin, and collagen IV, and it is thought that these may act as an
extracellular matrix 'glue'
CLASSIFICATION
VITREOMACULAR ADHESION
• VMA in symptomatic patients has been graded based on
SD-OCT :
• Grade 1 : incomplete cortical vitreous separation with
attachment at the fovea
• Grade 2 : Grade 1 findings plus intraretinal cysts or clefts
• Grade 3 : Grade 2 findings plus subretinal fluid
VITREOMACULAR TRACTION
• VMT has also been classified on the basis of the morphology of the
traction and it divides VMT into V type and J type
• In the V type there is incomplete vitreous detachment nasally and
temporally causing a V-shaped pattern due to persistent attachment at the
fovea
• In the J type, there is an incomplete posterior vitreous detachment with
persistent nasal attachment but detachment temporal to the fovea
• V-shaped and focal VMT were found to lead to tractional CME and
macular hole while J-shaped and broad VMT were related to ERM and
diffuse retinal thickening
MACULAR HOLE
PATHOGENESIS

• The vitreous gel forms pockets of fluid within the vitreous (synchysis)
which leads to a contraction or condensation (syneresis) of the vitreous
• As the age advances vitreous detaches from retina, a process known as
Posterior vitreous Detachment (PVD)
SYMPTOMS AND SIGNS

• SYMPTOMS
• VMA : Asymptomatic
• VMT : Symptomatic with blurred or reduced vision,
metamorphopsia, micropsia, scotoma, and difficulties with daily
vision-related tasks such as reading
• Onset and progression of symptoms are usually gradual, except in a
few cases of sudden onset of vision loss/scotoma due to severe
traction causing foveal detachment
SIGNS
1. Cystic changes in the macula, including tractional CME
2. Epiretinal membrane: 40-100% eyes with VMT have an ERM
(depending on whether the ERM is detected by biomicroscopy, OCT
or electron microscopy)
3. Thickened posterior hyaloid
4. Subretinal/subfoveal fluid
COMPLICATIONS

• Complications can include :

1. Full thickness macular hole
2. Tractional macular schisis
3. Tractional foveal/macular detachment
SUPPORTING EXAMINATION

• OCT
• In VMT syndrome, the posterior hyaloid space usually appears
hyperreflective and thickened on OCT, firmly adherent to the foveal region,
causing morphological alterations
• Dynamic B-scan ultrasonic examination of VMT syndrome may
demonstrate the peripherally detached hyaloid with attached hyaloid over
the posterior pole, differentiating this syndrome from idiopathic macular
pucker in which a complete PVD and Weiss ring is usually present
• Ultrasonic B-scan has higher sensitivity and specificity for evaluating
the vitreoretinal relationship as compared to stereoscopic slit lamp
biomicroscopy, and can be useful in eyes with opaque media,
where OCT is not possible, or when OCT devices are not available
DIFFERENTIAL DIAGNOSIS

The differential diagnosis can include:

• Early full thickness macular hole
• Pseudophakic CME
• Other causes of CME (uveitis, diabetic macular edema,
exudative age related macular degeneration, macular
telangiectasia)
• ERM
MANAGEMENT

• OBSERVATION
• In patients of VMT with good visual acuity and mild to moderate
symptoms the first approach is to observe for 3 months and re-
examine the patients using OCT
• Patient should be advised to perform periodic self examinations with
the Amsler grid or monocular reading tests.
• In case intensity of symptoms or disability increases they can
be reassessed earlier
PHARMACOLOGICAL

• Pharmacologic vitreolysis though carrying a lower success rate than

vitrectomy, provides an alternative for patients who have overriding travel
needs that preclude a gas injection; difficulties with surgery and
postoperative management, such as positioning
• Its relatively lower invasiveness (compared with PPV) might prompt
expanded treatment indications for patients with lesser degrees of
symptoms
• At present its high cost per dose and low success rate are also limiting
factors for its worldwide acceptance as a treatment modality for VMT
SURGERY

• Patients of VMT with :

 decreased visual acuity
 good visual acuity with severe metamorphopsia and
 moderately symptomatic VMT that fail to improve with observation, or
demonstrate progression of the traction effects are indications for PPV

• There is no consensus on level of visual acuity that should be considered

significant but usually a visual acuity of 6/12 or worse is taken as an
indication for PPV
• Vitrectomy may be combined with one or more additional
interventions including stripping of the posterior hyaloid, ERM
peeling, ILM peeling, air-fluid exchange, and gas or air
endotamponade
• Complications of surgery include cataract, new or residual ERM,
full thickness macular hole, lamellar macular hole, persistent
CME, persistent subretinal fluid, macular atrophy, retinal breaks,
retinal pigment epithelial damage, visual field defects, glaucoma,
endophthalmitis, and hypotony
POOR PROGNOSTIC FACTORS

• Macular schisis
• prominent CME
• chronic retinal detachment, and
• premacular fibrosis
• Duration > 6 months
• Pre op visual acuity worse than 20/100
THANK YOU