1. Vitreomacular traction (VMT) occurs when the vitreous cortex abnormally remains attached to the macula, pulling on it and distorting its structure. 2. Optical coherence tomography (OCT) allows for accurate diagnosis of VMT by visualizing the vitreoretinal interface with high resolution. 3. Treatment options for VMT include observation, vitrectomy surgery, and pharmacological vitreolysis using ocriplasmin injections, with the goal of releasing traction on the macula.

1. Vitreomacular
traction
Moderator:
Dr Rajiv Raman
Presented by:
Abhishek Dixit

2. Vitreoretinal interface anatomy
The vitreous cortex is defined as the peripheral 'shell' of
the vitreous that courses forwards and inwards from the
vitreous base.
The internal limiting membrane (ILM), also termed as
internal limiting lamina, is an acellular structure which
shows a smooth vitreal side adjacent to the vitreous cortex
and an undulated retinal side adjacent to retinal muller cell
endfeet.

4.  Vitreoretinal adhesion posterior to the vitreous base is mediated by
some form of “extracellular matrix glue” that connects cortical
vitreous collagen fibrils with the ILM surface.
 This extracellular matrix glue contains especially fibronectin and
laminin which are the target molecules in pharmacological
vitreolysis
1. Sebag J. Molecular biology of pharmacologic vitreolysis. Trans Am Ophthalmol Soc. 2005;103:473–494.
2. Terranova VP, Rohrbach DH, Martin GR. Role of laminin in the attachment of PAM 212 (epithelial) cells to
basement membrane collagen. Cell. 1980;22(3):719–726.
3. Engvall E, Ruoslahti E, Miller EJ. Affinity of fibronectin to collagens of different genetic types and to fibrinogen.
J Exp Med. 1978; 147(6):1584–1595.

5. The internal limiting lamina (ILL) of the retina formed mainly by the basal lamina
of Müller cells, collagen types I and IV & proteoglycans

6. Firm vitreoretinal attachments are observed at the
vitreous base, optic disc, fovea, and over the major
retinal blood vessels where ILM is thin
Matsumoto B, Blanks JC, Ryan SJ: Topographicm variations in the rabbit and primate internal limiting membrane. Invest
Ophthalmol Vis Sci 1984; 25: 71–82

7. Vitreoretinal interface dynamics
Pysiological changes (Aging):
In vitreous: 1) Rheological changes
progressive synchysis and syneresis
2) Biochemaical changes
reduction in hyaluron and aggregation of
collagen fibers
Vitreoretinal interface changes
Age-related thickening of the basal lamina of retinal Müller cells, perhaps
as a result of traction induced on the inner retina over a period of many
years by the attached posterior vitreous cortex.

8. All the physiological changes in vitreous and at vitreoretinal
interface lead to PVD which is characterized by a separation
between the posterior vitreous cortex and the internal limiting
membrane (ILM) of the retina as a result of a normal
physiologic process that occurs invariably with age.

10. Anomalous PVD
Sebag coined the term “anomalous PVD,” to describe the
condition in which the extent of gel liquefaction and collapse
exceed the attenuation of vitreorentinal adhesion.
Sebag J. Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease.
Graefes Arch Clin Exp Ophthalmol. 2004;242(8):690–698.

12. VMT definition
• VMT is defined as persistent attachment of posterior
vitreous cortex to macula with distortion of foveal
surface, intraretinal structural changes, and/or elevation
of fovea above RPE but no full thickness interruption of
all retinal layers.

13. • Initially Yamada and Kishi classified VMT configuration on
OCT basis into two patterns;
V-shaped pattern
J-shaped configuration.
• The former group fared better postoperatively, with restoration
of retinal architecture or improved vision as compared to the
latter group.
Yamada N, Kishi S. Tomographic features and surgical outcomes of vitreomacular traction
syndrome. Am J Ophthalmol 2005;139:112-117.

14. • In focal VMT, CME is the predominant macular change ,
followed by impending and full-thickness MHs and subfoveal
detachments .
On the contrary, in broad VMT cases, diffuse retinal
thickening prevailed, largely associated with ERM
while only few case shows MH .

15. s

16. VMT

17. VMA vs VMT

20. Diagnosis
Slitlamp bimicroscopy
OCT

21. Slit lamp bimicroscopy with contact lens or 78D/90D lens is
dependent on subjective interpretation and, therefore, a lack of
reproducibility and limitations imposed by corneal opacities,
lenticular opacities, or both.
PVD is defined by the presence of the Weiss ring in slit lamp
bimicroscopy but weiss ring may be destroyed or fragmented
during the process of vitreous separation.

22. • OCT provides high-resolution, cross-sectional images of the
posterior hyaloid , vitreoretinal interface and the retina .
• OCT uses an incident wavelight of 800 nm and has increased
axial resolution to 5 to 7 μm.

23. Advantages of OCT
OCT is sensitive in detecting ERM, VMT, and
associated macular edema.
OCT is also useful to look for spontaneous resolution of PVD
In VMT OCT is also useful for qualitative and quantitative
assessment , visual prognosis and help in decision making.
.

24. For post operative follow up.
The limitations of OCT include the inability to obtain high
quality images through dense opaque media.

25. Analysis of VR interface
A= The ILM (basement membrane component)
B= Posterior hyaloid face (detached and
extending over nerve)
C=Stretched Muller cells heading up to A
D=Collagen fibrils in the vitreous

31. Patterns of VMT in DR
Tractional
macular
detachment
AP traction
Long axial
length
Tractional
retinal
detachment
Macular
edema
Columnar
bridges
Tangential
traction
Saw tooth
apperaence

32. Tractional retinal detachment Focal attachement
Columnar bridges Saw tooth apperaencec

33. Management options
Observation
Surgical options
Vitrectomy
Vitrectomy + ERM removal
Vitrectomy + ERM removal + ILM peeling
Pharmacological vitreolysis

34. Observation
• Many cases of VMT syndrome maintain good VA and mild
metamorphopsia , and do not require treatment. Some
complete PVD cases can resolve spontaneously (around 11%) ,
generally with favorable anatomic and functional outcomes
comparable to surgical treatment

35. • Relative indication for surgery
1 ) Persistent VMT causing moderate to profound
vision loss and intolerable metamorphopsia or micropsia
2) VMT associated with ERM and FTMH
3) Non resolving Diabetic CME associated with VMT
4) Failure in induction of PVD after intravitreal injection of
ocriplasmin

36. • Surgical aim includes release of both anteroposterior and
tangential traction.
When VMT is associated with ERM, chromovitrectomy can
facilitate its removal.
• Trypan Blue exhibits a strong affinity for ERM because
of presence of many dead glial cells within the membrane.
• It is postulated that ILM removal can minimize the recurrence
of ERMs and completely relieve tractional forces on the
macular area

37. Recent studies have shown that specific preoperative OCT
patterns in VMT may predict postoperative visual improvement.
Baseline VA
Shorter duration of symptoms
Preoperative macular thickness and
VMT configuration
.
• Sonmez K, Capone A Jr, Trese MT, Williams GA. Vitreomacular traction syndrome: impact of anatomical
configuration on anatomical and visual outcomes. Retina 2008;28:1207-1214.
• Yamada N, Kishi S. Tomographic features and surgical outcomes of vitreomacular traction syndrome. Am J
Ophthalmol 2005;139:112-117

38. Pharmacological vitreolysis
• Clinical applications of pharmacologic vitreolysis can be
broadly grouped into two categories :
Pharmacology- assisted vitrectomy and
Pharmacologic PVD induction

39. • In the former , a pharmacologic agent administered
preoperatively acts to either induce vitreous liquefaction,
allowing for more rapid vitreous removal, or weaken the
vitreorentinal adhesion, allowing for greater ease of
mechanical PVD induction with a cleaner vitreoretinal
separation.
Trese MT. Enzymatic-assisted vitrectomy. Eye (Lond). 2002;16(4): 365–368.
Trese MT. Enzymatic vitreous surgery. Semin Ophthalmol. 2000;15(2): 116–121.
Gandorfer A. Pharmacologic vitreolysis. Dev Ophthalmol. 2007;39: 149–156.
Gandorfer A. Enzymatic vitreous disruption. Eye (Lond). 2008;22(10): 1273–1277.

40. • When pharmacologic vitreolysis is used as stand-alone
therapy, vitreolytic agents can be employed either as a
definitive treatment in active VMA-related disease or as a
prophylactic measure in conditions in which PVD is
associated with an improved prognosis such as DME,
proliferative diabetic retinopathy (PDR), RVO and ARMD.

41. Vitreolytic agents
• The biochemical properties requisite in any potential
vitreolytic agent include the ability to induce vitreous
liquefaction (liquefactants), weakening of the vitreorentinal
adhesion (interfactants), or both.

43. • Ocriplasmin (Jetrea , Thrombogenics) FDA-approved on Oct
12 for symptomatic VMA
Ocriplasmin, sometimes referred to as microplasmin, is a
recombinant truncated form of human plasmin obtained by
recombinant DNA technology

44. Analyses from the Phase III MIVI-TRUST
Program
• To evaluate the efficacy of a single intravitreal
injection of ocriplasmin as compared to placebo in
the treatment of patients with vitreomacular traction
and macular hole.

45. • A single injection of 125 μg of ocriplasmin provides effective
resolution of VMA in approximately 30% of patients with
VMT and FTMH closure in approximately 40% of patients.
Resolution of these conditions resulted in clinically significant
and durable VA benefits. Ocriplasmin has a favorable safety
profile and allows for a minimally invasive pharmacologic
treatment for patients with VMT and FTMH.

48. • Non-MIVI Trials.
The effect of bevacizumab (an anti-VEGF agent) in
combination with ocriplasmin facilitated the penetration of
bevacizumab into the retina in the treatment of Wet AMD .
Microplasmin in Children (MIC) Trial is also recruiting
patients to assess the safety and efficacy of intravitreal
ocriplasmin as an adjunct to conventional vitrectomy for the
treatment of pediatric patients under 16 years of age.

49. Success depends on appropriate patient selection-
Focal VMA(<1500 micron)
Small early stage macular hole(<250-
400micron)
No ERM
Most patients experience worsening symptoms, i.e., flashes,
floaters and/or reduced vision, in first few days before they
improve

50. If ocriplasmin does not induce the release of the vitreomacular
adhesion with in a month after injection, it likley will not
Pharmacologic vitreolysis offers complete PVD without
mechanical manipulation at the vitreoretinal interface, reducing
the complication related to vitrectomy

51. Cleaving the cortical hyaloid completely from the retina changes
the molecular flux across the vitreoretinal interface and
improves oxygen supply to the retina, reducing retinal hypoxia
and overexpression of vasoactive substances such as vascular
endothelial growth factor.
.
Gandorfer A (ed): Pharmacology and Vitreoretinal Surgery. Dev Ophthalmol.
Basel, Karger, 2009, vol 44, pp 1–6 (DOI: 10.1159/000223938
Also ,prior to use, ocriplasmin must be stored in a freezer at or
below -4deg F( - 20 deg C) in its original package. At room
temperature, it thaws within a few minutes.

52. Pneumatic vitreolysis
Intravitreal Injection of Expansile Perfluoropropane
(C3F8) for the Treatment of Vitreomacular Traction
AAO Volume 155, Issue 2, February 2013, Pages 270–276.e2
Fifteen eyes of 14 consecutive patients with symptomatic and
persistent vitreomacular traction (>3 months’ duration), single
intravitreal injection of 0.3 mL 100% perfluoropropane (C3F8) as
an alternative to pars plana vitrectomy (PPV)

53. One month following treatment, vitreomacular traction was
released in 6 eyes (40%). Three further eyes (20%) had
resolution of vitreomacular traction within 6 months, 4 (27%)
underwent PPV, and 2 (13%) subsequently declined surgery.
Eyes with
maximal horizontal vitreomacular adhesion less than
750 μm,
maximum foveal thickness less than 500 μm, and
low vitreous face reflectivity

54. Take home message
• In symptomatic VMA patients condition resolves in around
13% by 6 months and only 1/3rd of unresolve cases may
continue to progress in an unpredictable manner.
• Patient undergoing surgery for VMT , risk to benefit ratio
should be assessed.
• Though Ocriplasmin could be useful in few selected patients
but its cost effectiveness, safety profile is still unclear.