Vitreoretinal traction leads to a macular hole

A 51 year-old female presented with recent-onset “distorted” vision in the right eye. The duration was described as 3 days and specifically, she used the terms “fragmented” and “pulsing” to describe her symptoms. She did say that she experienced slight headache just prior to the vision change. At the visit, there was no report of pain. Her medical history is significant for rheumatoid arthritis (RA). She was oriented as to person, place, and time. 

Visual acuity was correctable to 20/60 (OD) and 20/25 (OS) with -4.00-0.75X039 and -5.75-0.25X150, respectively. Except for a cyst on the lower temporal lid and a mild papillary bulbar conjunctival response in each eye, the anterior segment was unremarkable. The IOP was 13 mm Hg @ 10:38 AM, in each eye.

Dilated fundus examination revealed clear lenses in each eye. Evaluation of the optic nerve head showed a distinct scleral ring with well-perfused rim tissue and an estimated C/D ratio of 0.5 in each eye. The macula in the right eye was significant for full-thickness macular hole with associated vitreomacular traction (Figure 1). The retinal vasculature was intact, and the periphery showed no signs of pre-disposing conditions to retinal detachement in either eye. The left macula was uninvolved (Figure 2).

An optical coherehnce (OCT) study was ordered and showed considerable traction at the macula of the right eye consistent with clincial obercvation (Figures 3 A-C).

A retinal consultation was obtained. Given the recent onset of symptoms, the patient was offered the option of being re-evaluated in one month or sooner if symptomatic vision decrease occurred. In addition, a surgical option of intravitreal ocriplasmin (Jetrea, Thrombogenics) injeciton was reserved for the case of non-spontaneous resolution in the context of further visual acuity reduction. 

Discussion

This case illustrates vitreomacular traction (VMT) causing macular hole formation.  Recently two developments in the realm of VMT have emerged. First, development of a classification scheme for VMT based on OCT.¹ Briefly, vitreomacular adhesion is perifoveal separation of the vitreous with remaining  vitreomacular attachment but preserved foveal tissue structure as seen on OCT. This situation is recognized as part of the normal course of vitreous aging but has the potential to lead to patholgoical consequences. Vitreomacular traction represents anatomic disruption of the fovea secondary to posterior vitreous detachment and may include pseudocysts, macular schisis, cystoid macular edema, and subretinal fluid. The foveal disruption can be quantitated from OCT measurements as greater (broad) or less than 1500 mµ (focal). Finally, full-thickness macualr hole (FTMH) is a foveal lesion with interruptoin of all retinal layers from the internal limiting membrane to the retinal prgment epithelium. Subclassifications of FTMH are reported, as well.¹

The clinical classification of macular hole would categorize the present case as a Stage 1B macular hole, according to the revised biomicroscopic staging scheme of Gass.² In a spectral-domain characterization, there is foveal pseudocyst with outer retinal separation and evidence of perifoveal PVD.³

Next, the FDA approval of ocriplasmin intravitreal injection based on a clinical trial conducted in Belgium.⁴ The recommendation in this case illustrates the results from that clinical trial in which about 15% of 188 patients in the sham-treated group experienced spontaneous release of VMT, while about 28% of the 464 patients administered ocriplasmin had release of their VMT. Interestingly in each group, the vast majority of resolution occurred within the first month following intervention of initial observation.⁴

The receommendation to the patient appears to be perfectly consistent with the guidance from interpretation of the study results.ODT

References

1. Duker JS, Kaiser PK, Binder S, et al. The international vitreomacular traaction study group classification of witreomacular adhesion, traction, and macular hole. Ophthalmology. 2013 Dec;120(12):2611-9.

2. Gass JDM. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Arch Ophthalmol. 1995;119:752-759.

3. Takahashi A, Yoshida A, Nagaoka T, et al. Idiopathic full-thickness macular holes and the vitreo-macular interface: A high-resolution spectral-domain optical coherence tomography study. Am J Ophthalmol. 2012;154:881-892.

4. Stalmans P, Benz MB, Gandorfer, A, et al; MIVI-TRUST Study Group. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012 Aug 16;367(7):606-15.