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.
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.
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.
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
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).
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
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