CLINICAL COMMUNICATION

Spontaneous resolution of vitreomacular traction: a case series

Clin Exp Optom 2013; 96: 424–427 DOI:10.1111/cxo.12019

Ozlem Barut Selver* MDMelih Parlak† MDZeynep Ozbek Soylemezoglu† MDAli Osman Saatci† MD* Department of Ophthalmology, Buca SeyfiDemirsoy State Hospital, Izmir, Turkey† Department of Ophthalmology, Dokuz EylulUniversity, Izmir, TurkeyE-mail: osman.saatci@deu.edu.tr

Three patients had unilateral vitreomacular traction (VMT) syndrome and the diagnosis wasconfirmed by spectral domain-type optical coherence tomography (OCT). All patients werefemale aged 51, 55 and 62 years. All denied surgical intervention. In one patient, rapidspontaneous resolution of the vitreomacular traction with a complete posterior vitreousdetachment (PVD) and a normal foveal contour was achieved within 15 days. In theremaining two cases a complete PVD could be detected as late as seven months after theinitial presentation. In one, though the vitreomacular adhesion released spontaneously,there was a minimal residual epiretinal membrane. In all three eyes, visual acuity wasconsiderably improved. Spontaneous, uneventful resolution has been rarely reported in thenatural course of VMT but several recent studies with the aid of OCT have shown thatspontaneous resolution might be more common than previously known. In light of our cases,we believe that there is still room to search for OCT clues in eyes with VMT to predict eyeswith higher likelihood of spontaneous resolution, thereby avoiding unnecessary pharmaco-logic and/or surgical intervention.

Submitted: 22 July 2012Revised: 2 September 2012Accepted for publication: 5 September2012

Key words: macular, optic coherence tomography, posterior vitreous detachment, vitreomacular traction.

Vitreomacular traction (VMT) syndromeis an idiopathic retinal disease caused byincomplete posterior vitreous detachment(PVD). Incomplete separation of the vitre-ous at the macular area may cause maculartraction that leads to cystoid changes in theneurosensory retina. Vitreomacular tractionis characterised by a constellation of clinicalsymptoms, such as metamorphopsia, de-creased visual acuity, photopsia and micro-psia.1–3 Symptoms are usually mild andcharacterised by a slow progressive visualloss due to chronic traction. Macular sur-face wrinkling, tractional cystoid macularoedema, chronic cystoid macular changesand macular hole are among the clinicalmanifestations of VMT.4 There is no signifi-cant correlation between clinical findingsand symptoms, so even in patients withsevere macular traction visual acuity may berelatively good. Clinical examination is notsufficient to demonstrate the extent of vit-reomacular adhesion and optical coherencetomography (OCT) becomes the decisivetool to determine the extent of VMT. Inparticular, spectral domain OCT yields veryvaluable information that helps us under-stand the ultrastructural changes and func-tional implications of VMT.

Spontaneous uneventful complete PVDhas been reported rarely in the naturalcourse of VMT but several recent studiesusing OCT showed that spontaneous re-solution might be more common thanpreviously known.3,5–6 In the pre-OCT era,the prevalence of spontaneous PVD wasreported as 11 per cent in eyes with VMT,while after the introduction of spectraldomain OCT the rate was reported as highas 47 per cent.3,5 In this case series, wedescribe the clinical and OCT findings ofthree patients who experienced spontane-ous resolution of VMT.

CASE REPORTS

Case 1A 51-year-old woman with a history of visualloss in her right eye of five months’ durationwas referred to us. Her visual acuity was 6/75in the right eye and 6/7.5 in the left. Slitlampexamination and intraocular pressures werenormal. On funduscopy, there was a trac-tional maculopathy with a slight leakage onangiography in the right eye (Figure 1A).Spectral domain OCT (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg,

Germany) revealed the vitreoretinal tractionat the foveal centre and cystoid macularchanges (Figure 1B). The surgical optionwas explained in detail but the patientelected to wait. Seven months later, hervisual acuity improved to 6/12 and the VMTrelieved spontaneously as demonstratedwith OCT (Figures 2A and 2B).

Case 2A 62-year-old woman presented with a visualloss in her left eye over the last month.Her visual acuity was 6/7.5 in the righteye and 6/15 in the left. Slitlamp examina-tion and intraocular pressures were normal.Funduscopic examination revealed a signifi-cant vertical veil-like opacity attached tothe fovea at the left eye (Figure 3A). OCTconfirmed the vitreoretinal traction at thefoveola (Figure 3B). Left VMT was diag-nosed. The patient denied surgical interven-tion. Two months later, the vitreoretinaltraction persisted (Figures 3C and 3D).Seven months later, her visual acuity im-proved to 6/7.5. Although the vitreousseparated spontaneously, there was still per-sistent mild tangential traction (Figure 3E).Three years after the first visit, some cystoidchanges and minimal epiretinal membrane

C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY

Clinical and Experimental Optometry 96.4 July 2013 © 2013 The Authors

424 Clinical and Experimental Optometry © 2013 Optometrists Association Australia

persisted but visual acuity was still 6/7.5(Figure 3F).

Case 3A 55-year-old woman who complained aboutvisual loss in her left eye for two weeks wasevaluated by us. Her visual acuity was 6/7.5in the right eye and 6/37.5 in the left. Slit-lamp examination and intraocular pressureswere normal. On funduscopic examination,there was a vitreal traction-induced macu-lopathy with a foveal cyst in the left eye,which was clearly delineated in OCT(Figure 4A). With the diagnosis of VMT,surgical intervention was offered but thepatient refused this. Fifteen days later a com-plete vitreous detachment was detected withthe OCT (Figure 4B). Three months later,her visual acuity was 6/9 and there was nomore vitreoretinal traction with a normalfoveal contour in the left eye (Figure 4C).

DISCUSSION

Posterior vitreous detachment is a degenera-tive process that is characterised by posteriorvitreous cortical separation from the inter-nal limiting membrane; however, PVD canlead to serious complications and thesehappen more commonly in eyes with accel-erated vitreous liquefaction before sufficientweakening of the vitreoretinal adhesionoccurs.2 During the PVD process, vitreoreti-nal traction may exist in retinal areas, wherethe posterior hyaloid is firmly attached.7 Themost adherent areas are mainly presentinside the 500 mm diameter foveolar zoneand the 1,500 mm of foveal margin.8 Persist-ent vitreoretinal adhesion causes static anddynamic tractional forces, and in time thisleads to VMT.1,9,10 The length of persistentfoveal attachment and the perifoveal detach-ment area is correlated with changes infoveal anatomy. Minute foveal attachmentareas exert significant traction and may bethe cause of severe symptoms and anatomicchanges.11

In the pre-OCT era, Hikichi, Yoshida andTrempe3 reported that spontaneous PVDrarely occurred in eyes with VMT. In a groupof 53 eyes with VMT, only in six eyes (11 percent) did spontaneous PVD develop afteran average time of 15 months. Odrobinaand colleagues5 analysed 19 eyes sufferingfrom VMT with spectral domain OCT andreported complete vitreous detachment inthe macular region in nine of 19 eyes (47 percent) at their last examination. They arguedthat vitreous surface adhesion and persist-

Figure 1. Case 1. A: Tractional maculopathy with a slight leakage on angiography.B: Cystoid changes with spectral optical coherence tomography.

Figure 2. Case 1. Seven months later, normal-appearing fundus (A) and normal opticalcoherence tomography (B).

Spontaneous resolution of vitreomacular traction Selver, Parlak, Soylemezoglu and Saatci

© 2013 The Authors Clinical and Experimental Optometry 96.4 July 2013

Clinical and Experimental Optometry © 2013 Optometrists Association Australia 425

ence of epiretinal membrane may be theprognostic factors for the natural course ofVMT and observed spontaneous resolutionof VMT in eyes with less vitreous surfaceadhesion and without epiretinal mem-branes. In eyes with higher vitreous surfaceadhesion or coexisting epiretinal mem-brane, pars plana vitrectomy with internallimiting membrane peeling should perhapsbe recommended.

Nowadays, OCT plays a pivotal role in thediagnosis of VMT.5 Some authors12,13 specu-lated that post-operative visual improvementmight have been predicted with the inter-pretation of pre-operative OCT patterns.According to Yamada and Kishi,13 two typesof vitreous traction develop in VMT: anincomplete V-shaped PVD that leads tofoveal retinal detachment, the surgical out-come of which is favourable, and partial PVDtemporal to the fovea, in which prominentcystoid macular oedema developed, whichmay result in a post-operative macular holeor macular atrophy.

Researchers have been investigating phar-macological tools to induce PVD for severalyears.14 Recently, microplasmin has becomepopular for PVD induction also in eyes withVMT and it can be used either as a mono-therapy or as an adjunct to facilitate PVD.15–17

The MIVI-TRUST programme investigatedocriplasmin treatment in symptomatic VMT.A single intravitreal injection (125 mg) ofocriplasmin (188 eyes) was compared with asimilar volume of single placebo injections(78 eyes). Ocriplasmin-treated eyes withVMT at baseline had a greater resolutionrate (29.8 per cent) on OCT, when com-pared to the placebo-treated eyes (7.7 percent). A single dose of 125 mg of ocriplasminachieved a resolution of VMT in approxi-mately 30 per cent of patients.18

In one of our three cases, there was a rapidspontaneous resolution of VMT with a com-plete PVD and a normal foveal contour wasachieved. In the remaining two cases, a com-plete PVD could be detected as late as sevenmonths after the initial presentation. In oneof them, although the vitreomacular adhe-sion released spontaneously, there was aminimal residual epiretinal membrane.

Although the microplasmin era seems tobe approaching rapidly, in light of our caseswe believe that there is still room to searchfor OCT clues in eyes with VMT to predictthe eyes with higher likelihood to undergospontaneous resolution. Thereby, unneces-sary pharmacologic and/or surgical inter-vention may be avoided.

Figure 3. Case 2. A: Fundus photograph with significant vertical veil-like opacity attachedto the fovea. B: Vitreoretinal traction at the foveal centre on optical coherence tomogra-phy (OCT). Two months later, (C) vitreoretinal traction was still persistent in a fundusphotograph (D) and OCT. Seven months later, (E) spontaneous vitreous detachmentoccurred and three years later, (F) OCT exhibited minimal cystoid changes.

Spontaneous resolution of vitreomacular traction Selver, Parlak, Soylemezoglu and Saatci

Clinical and Experimental Optometry 96.4 July 2013 © 2013 The Authors

426 Clinical and Experimental Optometry © 2013 Optometrists Association Australia

REFERENCES1. Smiddy WE, Michels RG, Green WR. Morphology,

pathology, and surgery of idiopathic vitreoretinalmacular disorders. A review. Retina 1990; 10: 288–296.

2. Sebag J. Anomalous posterior vitreous detach-ment: a unifying concept in vitreo-retinal disease.Graefes Arch Clin Exp Ophthalmol 2004; 242: 690–698.

3. Hikichi T, Yoshida A, Trempe CL. Course of vitreo-macular traction syndrome. Am J Ophthalmol 1995;119: 55–61.

4. Bottós JM, Elizalde J, Rodrigues EB, Maia M.Current concepts in vitreomacular traction syn-drome. Curr Opin Ophthalmol 2012; 23: 195–201.

5. Odrobina D, Michalewska Z, Michalewski J, Dzi-egielewski K, Nawrocki J. Long-term evaluation ofvitreomacular traction disorder in spectral-domainoptical coherence tomography. Retina 2011; 31:324–331.

6. Snead DR, James S, Snead MP. Pathologicalchanges in the vitreoretinal junction 1: epiretinalmembrane formation. Eye (Lond) 2008; 22: 1310–1317.

7. Sebag J. Anatomy and pathology of the vitreo-retinal interface. Eye (Lond) 1992; 6: 541–552.

8. Johnson MW. Posterior vitreous detachment: evo-lution and complications of its early stages. Am JOphthalmol 2010; 149: 371–382

9. Smiddy WE, Green WR, Michels RG, de la Cruz Z.Ultrastructural studies of vitreomacular tractionsyndrome. Am J Ophthalmol 1989; 107: 177–185.

10. Smiddy WE, Maguire AM, Green WR, Michels RG,de la Cruz Z, Enger C, Jaeger M et al. Idiopathicepiretinal membranes. Ultrastructural characteris-tics and clinicopathologic correlation. Ophthalmol-ogy 1989; 96: 811–820.

11. Spaide RF, Wong D, Fisher Y, Goldbaum M.Correlation of vitreous attachment and fovealdeformation in early macular hole states. Am JOphthalmol 2002; 133: 226–229.

12. Sonmez K, Capone A Jr, Trese MT, Williams GA.Vitreomacular traction syndrome: impact of ana-

tomical configuration on anatomical and visualoutcomes. Retina 2008; 28: 1207–1214.

13. Yamada N, Kishi S. Tomographic features andsurgical outcomes of vitreomacular traction syn-drome. Am J Ophthalmol 2005; 139: 112–117.

14. Gallemore RP, Jumper JM, McCuen BW 2nd, JaffeGJ, Postel EA, Toth CA. Diagnosis of vitreoretinaladhesions in macular disease with optical coher-ence tomography. Retina 2000; 20: 115–120.

15. Schneider EW, Johnson MW. Emerging nonsurgi-cal methods for the treatment of vitreomacularadhesion: a review. Clin Ophthalmol 2011; 5: 1151–1165.

16. de Smet MD, Gandorfer A, Stalmans P, VeckeneerM, Feron E, Pakola S, Kampik A. Microplasminintravitreal administration in patients with vitreo-macular traction scheduled for vitrectomy: theMIVI I trial. Ophthalmology 2009; 116: 1349–1355.

17. Stalmans P, Delaey C, de Smet MD, van Dijkman E,Pakola S. Intravitreal injection of microplasmin fortreatment of vitreomacular adhesion: results of aprospective, randomized, sham-controlled phase IItrial (the MIVI-IIT trial). Retina 2010; 30: 1122–1127.

18. Kuppermann BD. The Phase III MIVI-TRUSTClinical trial data: subgroup responder analysisof a single intravitreal injection of ocriplasminin patients with vitreomacular traction. ARVOAbstracts 2012: 2754.

Figure 4. Case 3. Vitreous-related tractional maculopathy with (A) a foveal cyst; (B) a complete vitreous detachment 15 days later,which was detected with optical coherence tomography and (C) normal foveolar contour was present after three months.

Spontaneous resolution of vitreomacular traction Selver, Parlak, Soylemezoglu and Saatci

© 2013 The Authors Clinical and Experimental Optometry 96.4 July 2013

Clinical and Experimental Optometry © 2013 Optometrists Association Australia 427