44
QUESTION
SHOULD I USE JETREA OR A GAS BUBBLE OR JUST DO A VITRECTOMY FOR A VITREOMACULAR TRACTION?
Michael N. Cohen, MD
Caroline R. Baumal, MD
In 2013, the International Vitreomacular Traction Study Group introduced an optical coherence tomography (OCT)-based classification system to characterize the vitreomacular interface (VMI) (Table 44-1).1 The term vitreomacular adhesion (VMA) defines non-pathological perifoveal vitreous separation with residual vitreomacular attachment and preserved foveal architecture (Figure 44-1). In contrast, vitreomacular traction (VMT) is a pathological state defined on OCT by persistent vitreous attachment inducing anatomic distortion of the fovea (Figure 44-2). Full-thickness macular hole (FTMH) demonstrates central interruption of all retinal layers on OCT and is classified as primary (due to VMT) or secondary (resulting from another pathologic process) and subclassified by size as small (≤ 250 μm), medium (> 250 and ≤ 400 μm), or large (> 400 μm) and by the presence or absence of concurrent VMT. Use of this classification system across clinical trials has allowed analysis of medical and surgical treatment options for VMT and FTMH.
The initial step when evaluating a patient with VMT is to assess visual acuity and symptoms. Patients who are truly symptomatic by VMT complain of metamorphopsia or central blurred vision, often stating that they have to close the affected eye when reading or driving. If the patient is asymptomatic and/or visual acuity is 20/40 or better, observation may be indicated with periodic re-evaluation for a drop in visual acuity or the onset of symptoms. Individuals with reduced acuity and/or symptomatic metamorphopsia should be presented with the available options, including observation, intravitreal Jetrea (ocriplasmin), intravitreal injection of an expansile gas bubble, or pars plana vitrectomy (PPV). Even for those who are symptomatic, it is reasonable to offer a brief period of observation using OCT to track for potential changes. The natural history of VMT is variable (see Figure 44-2). It can persist with a stable level of retinal disruption or it may progress with increased retinal distortion or develop into a FTMH. Spontaneous release of VMT may also occur, leading to either complete resolution of VMT or development of a FTMH. Rates of spontaneous resolution of VMT are not universally agreed upon, but reported release rates have ranged from 6% to 10% over a 1-month period to 17% to 32% over 18 to 24 months.2 Close follow-up over weeks to months can allow a patient to consider all options and make an informed decision, while at the same time observing for potential spontaneous resolution of traction.
Table 44-1
Optical Coherence Tomography of the Vitreomacular Interface
| Vitreomacular Interface Finding | Optical Coherence Tomography Finding |
| VMA | Evidence of perifoveal vitreous detachment from the retinal surface with residual macular attachment and no change in foveal contour or retinal architecture |
| VMT | Evidence of perifoveal vitreous detachment from the retinal surface with residual macular attachment with associated distortion of foveal surface or retinal architecture |
| FTMH | Full-thickness foveal interruption from the ILM to RPE |
| LMH | Irregular foveal contour with inner retinal defect, or splitting, but intact outer retina/ellipsoid zone |
| Macular Pseudohole | Heaped foveal edges with concomitant ERM with no loss of retinal tissue |
ILM = internal limiting membrane; RPE = retinal pigment epithelium; ERM = epiretinal membrane; LMH = lamellar macular hole
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