10.1 Features
Vitreomacular traction (VMT) is characterized by an incomplete posterior vitreous detachment and persistent adherence between the posterior hyaloid and the retinal surface causing architectural changes of the neurosensory retina and secondary visual disturbance. Optical coherence tomography (OCT) is sufficient and, in some cases, necessary to confirm the diagnosis. Therapeutic intervention can be considered in cases with significant visual disturbance and anatomic change.
10.1.1 Common Symptoms
It may be asymptomatic. Visual symptoms may include metamorphopsia, aniseikonia, photopsia, micropsia, central scotoma, or significant decrease of central vision. Natural history is difficult to predict from presenting symptomatology or anatomic appearance.
10.1.2 Exam Findings
The diagnosis of VMT can be difficult by clinical examination alone as the findings are often subtle. Slit-lamp biomicroscopy may reveal an abnormal foveal reflex and elevated fovea with a partially detached vitreous cortex. On ophthalmoscopy, VMT may be difficult to distinguish from idiopathic epiretinal membrane or cases of cystoid macular edema. Severe cases of VMT can result in retinal pigment epithelium changes from persistent traction. Significant traction may result in schisis-like changes or even localized tractional retinal detachment.
10.2 Key Diagnostic Tests and Findings
10.2.1 Optical Coherence Tomography
OCT is the critical ancillary test to confirm the diagnosis of VMT and to rule out concurrent and/or mimicking conditions. In addition, OCT can also show associated macular architecture changes resulting from the traction such as loss of foveal depression, intraretinal cystic changes, macular schisis, epiretinal membrane, and subfoveal serous retinal detachment (▶ Fig. 10.1). An OCT-based International Classification System defined VMT and subclassified it based on the diameter of the vitreomacular adhesion (VMA) on cross-sectional OCT B-scan (e.g., focal VMT [< 1,500 µm]; diffuse VMT [≥ 1,500 µm]). When associated with other macular disease such as retinal vein occlusion or diabetes, VMT is classified as “concurrent.” Otherwise, it is considered to be “primary.”
Fig. 10.1 Vitreomacular traction is characterized by an incomplete posterior vitreous detachment and persistent adherence between the posterior hyaloid and the retinal surface, which causes architectural changes of the neurosensory retina and secondary visual disturbance. (a) Optical coherence tomography shows associated macular changes, including minimal traction, (b) mild traction with outer retinal changes, (c) inner cystic changes with traction, and (d) significant traction with inner retinal cystic changes and subretinal fluid.
10.2.2 Fluorescein Angiography
Fluorescein angiography is not a key imaging modality for the diagnosis or management of VMT but may show mild leakage in the macular area.
10.2.3 Ultrasonography
B-scan ultrasonography can demonstrate movable membranes of medium reflectivity that adhere to some anatomical aspects of the fundus such as the macula and optic disc, correspondent to posterior vitreous detachment. However, due to its lower image definition, ultrasonography is not routinely performed for VMT.
10.3 Critical Work-up
Dilated fundus exam is important to evaluate the macula and peripheral retinal status, but OCT is the key tool to diagnose, monitor, and guide treatment decisions for VMT. Cross-sectional OCT can document the anatomic effects and extent of vitreoretinal adhesions, which is particularly relevant in those cases with central visual symptoms secondary to VMT. VMT should be differentiated from VMA. VMA does not cause architectural changes of the neurosensory retina nor secondary visual impairment and represents the normal “aging” process of the vitreous (i.e., not pathologic). OCT can easily discern the two entities as VMA OCTs are characterized by incomplete separation between the posterior hyaloid and the retinal surface, but with no architectural changes of the neurosensory retina (▶ Fig. 10.2). Other vitreomacular interface abnormalities that can be associated with VMT include epiretinal membrane, lamellar macular hole, or full-thickness macular hole. VMA can have variable length of adhesion and is not pathologic, but rather a normal finding of the natural evolution of vitreous separation. Other entities in the differential diagnosis for VMT include cystoid macular edema, full-thickness macular hole, diabetic macular edema, and epiretinal membrane (▶ Fig. 10.3).
Fig. 10.2 (a–d) Vitreomacular adhesion is a finding on optical coherence tomography characterized by incomplete separation between the posterior hyaloid and the retinal surface without architectural changes of the neurosensory retina or secondary visual symptoms.
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