Current Treatment Options for the Management of Vitreomacular Traction

Pars Plana Vitrectomy for Vitreomacular Traction Resulting in Persistent Postoperative Loculated Foveal Subretinal Fluid

Purpose: To describe a case of postoperative persistent loculated subretinal fluid (SRF) that developed after pars plana vitrectomy (PPV) for vitreomacular traction (VMT) syndrome. Methods: A case was analyzed and a literature review performed. Results: A healthy 64-year-old man with no significant ocular history presented with persistent, symptomatic VMT. Combined phacoemulsification and PPV, epiretinal membrane and internal limiting membrane peeling, and gas-fluid exchange were performed. Postoperative spectral-domain optical coherence tomography imaging showed loculated foveal SRF. The SRF persisted for 8 months, with minimal change in size and little best-corrected visual acuity improvement. Conclusions: Although persistent loculated SRF has been reported after vitrectomy for rhegmatogenous retinal detachment (RD) in high myopia and tractional RD in diabetes, it has not yet been reported postoperatively after PPV for VMT. Studies of the pathophysiology and long-term course of persistent SRF after PPV for VMT are needed to inform management decisions for this rare complication.

[Biomarkers in full-thickness and lamellar defects of the macula]

BACKGROUND

Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes.

METHODS

Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented.

RESULTS

The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis.

CONCLUSION

Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

[Vitreomacular Interface Diseases: Vitreomacular Adhesion, Vitreomacular Traction, Epiretinal Membranes, and Macular Hole]

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. This review presents the sequence of events due to complicated persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction, VMT; macular hole, MH; epiretinal membrane). Pathologic aspects, clinical features, diagnostic implications, and current management strategies are described. Observation, pharmacologic vitreolysis with Ocriplasmin, and surgical treatment are positioned as treatment options for different diseases.

[Microstructural retinal changes after pharmacological vitreolysis with ocriplasmin-an SD-OCT supported analysis]

PURPOSE

Ocriplasmin (Jetrea®) is a therapeutic option for patients with focal vitreomacular traction (VMT) with or without small full thickness macular holes (FTMH) < 400 µm. Retinal alterations after injection with ocriplasmin have been described. The purpose of this essay was to determine Ocriplasmin-associated side-effects and changes in the retinal microstructure.

METHODS

We included 70 patients with ocriplasmin treatment in our study. On all patients SD-OCT (spectral-domain optical coherence tomography) scans were performed prior to injection with Ocriplasmin. If present, adverse events were registered. The OCT scans were then evaluated taking the following into account: macular hole (MH) size, macular edema, subretinal fluid (SRF), changes in the ellipsoid zone (EZ) and the external limiting membrane (ELM).

RESULTS

Twenty of the 70 examined patients showed a preoperative FTMH. One week after ocriplasmin IVI (intravitreal injection) 8 of the 20 FTMHs were already closed. Overall 12 patients showed a FTMH closure and 4 patients developed a FTMH after ocriplasmin IVI. Twelve of the 24 MH (macular hole) patients still required an operative closure of the FTMH. We noticed a resolution of the VMT on 51 patients. Three patients developed a retinal detachment. Furthermore, after ocriplasmin IVI we detected changes in the EZ and ELM on 8 patients.

CONCLUSIONS

Ocriplasmin is a substantial minimal invasive option in the therapy of VMT with or without small FTMH. Nevertheless, there seem to be some specific ocriplasmin-associated risks, although usually transient. Severe complications like retinal detachment are rare but exist. Therefore, every indication of ocriplasmin should be considered carefully.