Symptomatic vitreomacular adhesion and vitreomacular traction
Posterior vitreous detachment, or PVD, is very common in people aged 50 years and older and is a result of two different processes1: the first is the liquefaction of the vitreous (jelly-like material in the center of the eye) and the formation of liquid-filled vacuoles; the second is when the vitreous separates from the retina (light-sensitive layer at the back of the eye). These two processes cause the vitreous to separate from the retina, leading to total PVD in a healthy eye.
Vitreomacular adhesion (VMA), where the vitreous adheres to the retina’s macular region in an abnormally strong manner, occurs as a result of pathologic posterior vitreous detachment (PVD). VMA is an asymptomatic condition and can resolve naturally.
Symptomatic VMA and vitreomacular traction
If VMA does become symptomatic, it is called sVMA. If the forces of attachment are unusually strong, VMA can cause anatomical disturbances of the macular architecture, creating pulling forces or ‘traction’ on the retinal surface. This traction is called vitreomacular traction (VMT).
OCT Image showing macular traction
This image was originally published in the ASRS Retina Image Bank. Jason S. Calhoun. Mayo Clinic Jacksonville, Florida. Macular Traction (Color). Retina Image Bank. 2015; Image Number 7637. © the American Society of Retina Specialists.
With or without macular hole
sVMA is most accurately referred to as vitreomacular traction with or without macular hole. The macula provides central vision needed for everyday tasks like driving, reading and recognizing faces. sVMA/VMT can cause symptoms like distorted or decreased vision. When the disease progresses the traction may eventually result in formation of a hole in the macula (called a macular hole)2 . sVMA may also be associated with wet age-related macular degeneration (AMD)3 , diabetic macular edema (DME)4 , retinal vein occlusion (RVO)5 , and diabetic retinopathy (DR)6 .
Retinal fundus photograph of a macular hole
This image was originally published in the ASRS Retina Image Bank. Michael P. Kelly, FOPS. Duke University Hospital. Macular Hole. Retina Image Bank. 2015; Image Number 783. © the American Society of Retina Specialists.
Diagnosis of symptomatic VMA/VMT
Careful eye examination by an ophthalmologist or retina specialist is critical for diagnosing symptomatic VMA. Imaging technologies, such as optical coherence tomography (SD-OCT), enable changes in the eye to be observed and have significantly improved the accuracy of diagnosing symptomatic VMA7.
Up till recently, the only treatment option for patients with symptomatic VMA/VMT was the surgical separation of the vitreous from the retina, called a vitrectomy. This is an invasive procedure which holds several risks and can lead to complications such as bleeding, pain, post-operative inflammation or irritation. Because of this, it is usually only undertaken when the patient’s vision has deteriorated significantly or they are at risk of central blindness.
Patients therefore undergo a period of ‘observation’ or ‘watchful waiting’ during which the patients’ symptoms go untreated until the symptoms become severe enough to warrant surgical treatment and repair of the retina. However, for many patients this is not a suitable option, as irreversible damage to the retina may have already occurred.
“The ‘watchful waiting’ approach has many more disadvantages than initially thought.”
Prof. Dr. Peter Stalmans, UZ Leuven
An alternative approach
An alternative to surgery is the intravitreal application of pharmacologic agents for the induction of vitreous liquefaction and/or vitreoretinal separation, an approach termed pharmacologic vitreolysis8 . In this option an intravitreal injection is administered to break down the protein fibers which cause the abnormal traction between vitreous and macula that causes VMA/VMT. By dissolving these proteins, the traction is released, resulting in complete detachment of the vitreous from the macula.
The same technique can also be used when VMT has progressed and caused a small hole in the macula9. If the treatment is successful, the symptomatic VMA/VMT will not recur.
People affected by VMT can suffer vision changes that have a significant impact on their lives. Until now, eye doctors have only had surgical options to treat this disease. This new treatment means that some patients can now avoid surgery, and others who might not be suitable for surgery can now be treated.
ThromboGenics is committed to advancing knowledge and understanding in the field of ophthalmology. Our research staff keeps a finger on the pulse of the latest advances in scientific research. The publications are either a result of internal collaboration or externally with academics.
1 Sebag J, Ansari RR, Suh KI. Pharmacologic vitreolysis with microplasmin increases vitreous diffusion coefficients. Graefes Arch Clin Exp Ophthalmol 2007;245(4):576-80.
2 Akiba J, Quiroz MA, Trempe CL. Role of posterior vitreous detachment in idiopathic macular holes. Ophthalmology 1990;97(12):1610-3.
3 Jackson TL, Nicod E, Angelis A, et al. Vitreous attachment in age-related macular degeneration, diabetic macular edema, and retinal vein occlusion: a systematic review and metaanalysis. Retina 2013;33(6):1099-108.
4 de Smet MD, Castilla M. Ocriplasmin for diabetic retinopathy. Expert Opin Biol Ther 2013;13(12):1741 7.
5 Akiba J, Kado M, Kakehashi A, Trempe CL. Role of the vitreous in posterior segment neovascularization in central retinal vein occlusion. Ophthalmic Surg 1991;22(9):498-502.
6 Akiba J, Arzabe CW, Trempe CL. Posterior vitreous detachment and neovascularization in diabetic retinopathy. Ophthalmology 1990;97(7):889-91.
7 Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use in evaluation of the vitreoretinal interface: a review. Surv Ophthalmol 2007;52(4):397-421.
8 Schneider EW, Johnson MW. Emerging nonsurgical methods for the treatment of vitreomacular adhesion: a review. Clin Ophthalmol 2011;5:1151-65.
9 Jackson TL, Nicod E, Simpson A, Angelis A, Grimaccia F, Kanavos P. Symptomatic vitreomacular adhesion. Retina 2013;33(8):1503-11.