Article

Managing vitreomacular traction

Options include observation, in-office therapy and surgery.

As the eye ages, the vitreous can become liquefied and in so doing, a separation, be it complete or incomplete, can occur between the vitreous cavity and the retina. This posterior vitreous detachment (PVD) can cause trouble even before it completes the separation. One complication of an incomplete PVD is vitreomacular traction (VMT). VMT occurs as the result of persistent vitreomacular adhesion (VMA) that progresses to distort foveal anatomy.

PVD can coincide with several pathologic conditions that can have a profound impact on a patient’s vision.

Prevalence of these pathologies was not easy to come by until the arrival of OCTs. It is estimated that a complete PVD can be found in half of those over age 70.1-3

In the Beaver Dam study, 1.6% of the 1,913 participants, between the ages of 63 and 102 years, were found to have VMT; researchers used SD-OCT.4

In this article, I review potential treatment options for symptomatic VMT, which include observation, office-based procedures and surgical management.

A LOOK AT VMT

The International Vitreomacular Traction Study Group has classified vitreomacular interface disorders based on OCT features. VMA is defined as the perifoveal vitreous cortex detachment from the retinal surface with a macular attachment of vitreous cortex within a 3-mm radius of the fovea.

In VMA, the underlying foveal contour maintains its natural shape; typically, patients are asymptomatic. Visual symptoms are more common with VMT than VMA, although some patients with VMT remain asymptomatic.

By contrast, VMT is VMA with distortion of the foveal surface; however, a full thickness hole is not present.5 The decision to treat VMT, for most providers, hinges on the presence of symptoms and the risk/benefit ratio. Cost of therapy and insurance coverage are also important considerations.

OBSERVATION

The most conservative type of management for VMT is observation. In several small series, it was found that VMT spontaneously resolved in 11% to 53% of cases. While this is a wide range, it illustrates how difficult it is to determine the rate of spontaneous release.6-10 Time to spontaneous resolution is difficult to document in these studies — the mean range for release was 15 months to 18 months.6-10

Depending on the level of symptoms and the patient’s motivation, observation can be a viable option for many patients. Certainly, progressive central distortion that impairs ability to read or drive is likely to motivate a patient to pursue intervention.

IN-OFFICE VMT TREATMENT MODALITIES

  • Intravitreal ocriplasmin (Jetrea, ThromboGenics). The MIVI-TRUST trials were parallel phase 3 trials that demonstrated the efficacy of ocriplasmin for VMT resulting in the FDA approval of this enzyme in 2012. In total, 652 eyes were enrolled; 464 eyes received 0.125 mg of ocriplasmin for symptomatic VMT. At day 28 post injection, the following percentage of patients achieved: VMA release (26.5 vs 10.1% of controls, P < 0.001), complete PVD (13.4 vs 3.7% of controls, P<0.001), and macular hole closure (40.6 vs 10.6% of controls, P < 0.001.11 Certain factors predicted improved results in VMT resolution, including younger age (under 65), phakic eyes, absence of epiretinal membrane (ERM), smaller adhesions (less than 1500 mm), and presence of a full thickness macular hole with associated VMA.12 After ocriplasmin’s approval, several groups reported “real world” VMT release rates ranging from 42.1% to 50%.13-16 Ocriplasmin adoption by the retina community and sales have slowed due to reports of transient visual disturbances and OCT/ERG changes. The implications of these changes are not fully known, and visual acuity appears to be maintained or improved despite these changes.11, 17-19
  • Intravitreal gas injection or pneumatic vitreolysis. A handful of small case series have recently popularized and demonstrated the success of intravitreal gas injection. This in-office procedure involves injecting a small volume of gas through the pars plana into the vitreous cavity. The gas acts to mechanically release the vitreous traction on the macula and induce a PVD. The most commonly used gas injection is 0.2 ml to 0.3 ml of perfluoropropane (C3F8), although the use of sulfur hexafluoride (SF6) has also been reported.20 Success rates of VMT release with C3F8 intravitreal injection are between 60% and 83% with mean duration of action 13 days.21-23 Neither the presence of epiretinal membrane or status of pseudophakia appear to greatly impact success rates with pneumatic vitreolysis as with ocriplasmin. Macular hole formation and retinal detachment occurrence rates are low, but are known possible complications of pneumatic vitreolysis.23 A unique consideration of pneumatic vitreolysis includes altitudinal restrictions for the duration of the intravitreal gas, approximately one to two months.

SURGERY

Perhaps the most definitive treatment for VMT is pars plana vitrectomy (PPV). PPV has been demonstrated to be an effective solution for VMT, and for many years it has served as the gold standard.24-26 The risk/benefit profile of PPV appears improved in the current era of small-gauge vitrectomy.27 Moreover, PPV can work well in cases of pseudophakia, concurrent ERM and broad vitreomacular adhesions.

PPV is not without its disadvantages, however, which include cataract formation, ERM formation, risk of retinal detachment and recovery time. In fact, cataract formation has been reported to occur in 80% to 100% of patients within two years of vitrectomy surgery.28, 29

CONSIDERATIONS

Cost is an important consideration for each of the procedures. However, limited cost analysis data exist for VMT treatment. One recent publication used a Markov model of cost-effectiveness and utility to compare PPV, ocriplasmin and intravitreal saline for vitreomacular adhesions and macular holes. This analysis found that PPV was the most cost-effective primary procedure.30

This study did not evaluate cost effectiveness of intravitreal gas injection — given its relatively low cost and high effectiveness, one would expect that it would fare well in a similar analysis. Discussion of cost, however, is not as simple as the “face value” of the procedure.

Physicians and patients must also factor in the effectiveness of the procedure along with the number of office visits and possible or likely side effects (for example, cataract formation in the case of PPV).

Spectral domain OCT showing vitreomacular traction with associated distortion of foveal anatomy.

SUMMARY

Several therapeutic options exist for symptomatic VMT. As reviewed in this article, each of the options has its pros and cons, which should be discussed in detail with the patient. Cost and effectiveness are intertwined when considering the economics of the decision. OM

REFERENCES

  1. Foos RY, Wheeler NC: Vitreoretinal juncture. Synchysis senilis and posterior vitreous detachment. Ophthalmology 1982, 89:1502-1512.
  2. Hikichi T, Hirokawa H, Kado M, Akiba J, Kakehashi A, Yoshida A, Trempe CL: Comparison of the prevalence of posterior vitreous detachment in whites and Japanese. Ophthalmic Surg 1995, 26:39-43.
  3. Weber-Krause B, Eckardt C: [Incidence of posterior vitreous detachment in the elderly]. Ophthalmologe 1997, 94(9):619-623.
  4. Barrio-Barrio J1, Ruiz-Canela M1, Noval S2, Galdós M3. Retinal Thickness Measured by Spectral-Domain Optical Coherence Tomography in Eyes Without Retinal Abnormalities: The Beaver Dam Eye Study. Am J Ophthalmol. 2015 Jul;160:209-10.
  5. Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, Sadda SR, Sebag J, Spaide RF, Stalmans P: The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology 2013, 120:2611-2619.
  6. Hikichi T, Yoshida A, Trempe CL: Course of vitreomacular traction syndrome. Am J Ophthalmol 1995, 119:55-61.
  7. Odrobina D, Michalewska Z, Michalewski J, Dziegielewski K, Nawrocki J: Long-term evaluation of vitreomacular traction disorder in spectral-domain optical coherence tomography. Retina 2011, 31:324-331.
  8. John VJ, Flynn HW, Jr., Smiddy WE, Carver A, Leonard R, Tabandeh H, Boyer DS: Clinical course of vitreomacular adhesion managed by initial observation. Retina 2014, 34:442-446.
  9. Charalampidou S, Nolan J, Beatty S: The natural history of tractional cystoid macular edema. Retina 2012, 32:2045-2051.
  10. Tzu JH, John VJ, Flynn HW, Jr., Smiddy WE, Jackson JR, Isernhagen BA, Carver A, Leonard R, Tabandeh H, Boyer DS et al: Clinical Course of Vitreomacular Traction Managed Initially by Observation. Ophthalmic Surg Lasers Imaging Retina 2015, 46:571-576.
  11. Stalmans P, Benz MS, Gandorfer A, Kampik A, Girach A, Pakola S, Haller JA, Group M-TS: Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med 2012, 367:606-615.
  12. Haller JA, Stalmans P, Benz MS, Gandorfer A, Pakola SJ, Girach A, Kampik A, Jaffe GJ, Toth CA, Group M-TS: Efficacy of intravitreal ocriplasmin for treatment of vitreomacular adhesion: subgroup analyses from two randomized trials. Ophthalmology 2015, 122:117-122.
  13. Singh RP, Li A, Bedi R, Srivastava S, Sears JE, Ehlers JP, Schachat AP, Kaiser PK: Anatomical and visual outcomes following ocriplasmin treatment for symptomatic vitreomacular traction syndrome. Br J Ophthalmol 2014, 98:356-360.
  14. Kim BT, Schwartz SG, Smiddy WE, Doshi RR, Kovach JL, Berrocal AM, Moshfeghi AA, Fortun JA: Initial outcomes following intravitreal ocriplasmin for treatment of symptomatic vitreomacular adhesion. Ophthalmic Surg Lasers Imaging Retina 2013, 44:334-343.
  15. Sharma P, Juhn A, Houston SK, Fineman M, Chiang A, Ho A, Regillo C: Efficacy of intravitreal ocriplasmin on vitreomacular traction and full-thickness macular holes. Am J Ophthalmol 2015, 159:861-867 e862.
  16. Warrow DJ, Lai MM, Patel A, Raevis J, Berinstein DM: Treatment outcomes and spectral-domain optical coherence tomography findings of eyes with symptomatic vitreomacular adhesion treated with intravitreal ocriplasmin. Am J Ophthalmol 2015, 159:20-30 e21.
  17. Quezada-Ruiz C, Pieramici DJ, Nasir M, Rabena M, Steinle N, Castellarin AA, Dhoot D, Couvillion S, See RF, Avery RL: Outer retina reflectivity changes on sd-oct after intravitreal ocriplasmin for vitreomacular traction and macular hole. Retina 2015, 35:1144-1150.
  18. Hahn P, Chung MM, Flynn HW, Jr., Huang SS, Kim JE, Mahmoud TH, Sadda SR, Dugel PU: SAFETY PROFILE OF OCRIPLASMIN FOR SYMPTOMATIC VITREOMACULAR ADHESION: A Comprehensive Analysis of Premarketing and Postmarketing Experiences. Retina 2015, 35:1128-1134.
  19. Shah SP, Jeng-Miller KW, Fine HF, Wheatley HM, Roth DB, Prenner JL: Post-Marketing Survey of Adverse Events Following Ocriplasmin. Ophthalmic Surg Lasers Imaging Retina 2016, 47:156-160.
  20. Claus MG, Feron E, Veckeneer M: Pneumatic release of focal vitreomacular traction. Eye (Lond) 2017, 31:411-416.
  21. Rodrigues IA, Stangos AN, McHugh DA, Jackson TL: Intravitreal injection of expansile perfluoropropane (c(3)f(8)) for the treatment of vitreomacular traction. Am J Ophthalmol 2013, 155(2):270-276 e272.
  22. Steinle NC, Dhoot DS, Quezada Ruiz C, Castellarin AA, Pieramici DJ, See RF, Couvillion SC, Nasir MA, Avery RL: Treatment of Vitreomacular Traction with Intravitreal Perfluoropropane (C3f8) Injection. Retina 2017, 37:643-650.
  23. Chan CK, Crosson JN, Mein CE, Daher N: Pneumatic Vitreolysis for Relief of Vitreomacular Traction. Retina 2017.
  24. Smiddy WE, Michels RG, Glaser BM, deBustros S: Vitrectomy for macular traction caused by incomplete vitreous separation. Arch Ophthalmol 1988, 106:624-628.
  25. Davis RP, Smiddy WE, Flynn HW, Jr., Puliafito CA: Surgical management of vitreofoveal traction syndrome: optical coherence tomographic evaluation and clinical outcomes. Ophthalmic Surg Lasers Imaging 2010, 41:150-156.
  26. Jackson TL, Nicod E, Angelis A, Grimaccia F, Prevost AT, Simpson AR, Kanavos P: Pars plana vitrectomy for vitreomacular traction syndrome: a systematic review and metaanalysis of safety and efficacy. Retina 2013, 33:2012-2017.
  27. Neffendorf JE, Gupta B, Williamson TH: Intraoperative complications of patients undergoing small-gauge and 20-gauge vitrectomy: a database study of 4,274 procedures. Eur J Ophthalmol 2017, 27:226-230.
  28. Do DV, Gichuhi S, Vedula SS, Hawkins BS: Surgery for post-vitrectomy cataract. Cochrane Database Syst Rev 2013:CD006366.
  29. Cheng L, Azen SP, El-Bradey MH, Scholz BM, Chaidhawangul S, Toyoguchi M, Freeman WR: Duration of vitrectomy and postoperative cataract in the vitrectomy for macular hole study. Am J Ophthalmol 2001, 132:881-887.
  30. Chang JS, Smiddy WE: Cost evaluation of surgical and pharmaceutical options in treatment for vitreomacular adhesions and macular holes. Ophthalmology 2014, 121:1720-1726.

About the Author