What is vitreo-macular traction?
The macula is the center of your retina. It is responsible for your straight ahead vision. While reading the print on this page, you are using your macula. The cornea and lens in the front of your eye focus the image of these words onto your macula. The macula converts the light from the image on this page into a neurological signal that is processed by your brain. When an extra layer of tissue forms on the retinal surface and then contracts to distort the central retina, we call it a macular pucker. A macular pucker is sometimes called an epiretinal membrane, cellophane maculopathy, a wrinkle, preretinal fibrosis or pseudomacular hole. Macular puckers are present in about 10% of people over the age of 50. They usually caused by a layer of vitreous--the gel that fills the eye--condensing on the surface of the retina and changing into a membrane. They look like a piece of scotch tape. Some macular puckers contract and pull the macula enough to cause distortion in the central vision. When this happens, patients can consider vitrectomy for macular pucker.
Video Primer on Vitreomacular Traction
Below is a video that reviews the anatomy of the eye, information on vitreomacular traction, and an example of vitrectomy surgery:
What are the symptoms of vitreomacular traction?
The most common symptoms of vitreomacular traction are distortion and vision loss. In is important to realize that other, more serious and more acute disorders can also cause distortion. If you experience new distortion in your vision, DO NOT ASSUME YOU HAVE VITREOMACULAR TRACTION. You may have something more serious. You should consult a physician as soon as possible (less than a week) if you have new onset distortion and vision loss in either eye. Sometimes when one eye has a serious vision problem the other eye will take over and you may not notice the problem. Therefore, it is important to check your eyes separately every day to make sure that each eye is seeing well.
What is a vitreomacular traction evaluation?
The diagnosis of vitreomacular traction is established by an eye examination and confirmed with ancillary testing. A dilated examination of the macula using a silt lamp (microscope) can usually establish the diagnosis of vitreomacular traction. Optical coherence tomography (OCT) is a useful tool for assessing the microstructure of the macula. A low energy laser is swept across the macula and a computer uses the reflected light to reconstruct the layers of the retina. An OCT scan will also show details of how the vitreomacular traction is affecting the layers of the retina and also can be used to follow the course of the disease.
What are the options?
If you have been diagnosed with vitreomacular traction you can follow without treatment, treat with Jetrea, treat with an intra-ocular gas bubble, have surgery, or if applicable, seek treatment of other disease affecting your vision.
Observation: Vitreomacular traction is not uncommon. As the vitreous contracts it usually pulls free of the fovea and vitreomacular traction is transient. Spontaneous resolution of vitreomacular traction occurs in about 10 to 30 percent of cases and usually takes about 18 months to occur. The smaller the area of attachment of the vitreous the center of the macula (on OCT scanning) the more likely the vitreomacular traction is to spontaneously resolve. In cases where the vitreomacular traction is symptomatic, spontaneous resolution can occur if the vitreous further contracts and pulls free of the fovea.
Jetrea (ocirplasmin) therapy: Jetrea is FDA approved as an injection for vitreomacular traction. It is highly effective in cases where the area of vitreomacular traction is not too broad. Overall, about 25 percent of eyes treated with Jetrea experience release of their vitreomacular traction. Jetrea is an enzyme and may have other affects on the vision in a small number of patients. The smaller the area of adhesion ( less than 1500 microns on OCT scanning) the more likely that Jetrea will work. There is a risk of retinal tear and retinal detachment with this treatment.
Pneumatic vitreo-lysis: This is a therapy that is new as of this writing in 2017. By injecting a small gass bubble in the eye and allowing it bounce around for a few weeks, there is a fairly high rate of release of vitreomacular traction. The release usually occurs in an average of 13 days. Small studies have shown a success rate of 80 to 90 percent. There is a small risk of retinal tear and retinal detachment with this treatment.
Vitrectomy: Vitrectomy is highly effective for vitreomacular traction. This therapy has been in widespread use since 1980. The success rate of relieving the traction is nearly 100 percent. Their are risk of vitrectomy surgery like infection, bleeding, and retinal detachment. Therefore it is best to discuss surgery and other treatment options with an experienced vitreo-retinal specialist who can outline the risk and benefits of all the possible management options currently avialable.
Video Vitreomacular Traction Spontaneous Resolution
A 70 year old woman presented with minimal blurring and distortion of vision due to vitreomacular traction syndrome (VMT). As she tolerated the symptoms well, she was observed without surgery. Over a period of four years, the traction released itself and the vision remained stable.