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Vitreomacular Traction Syndrome - to Treat Or Not to Treat

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Vitreomacular Traction Syndrome - to Treat Or Not to Treat Vitreomacular Traction Syndrome - To treat or not to treat... That is the question. 82-year old male has decreased acuity OD with current VMT/macular hole stage 1a. Patient history of CME vs. Irvine-Gass/VMT macular hole stage 1a OS resolving spontaneously. Treat or observe the right eye and why? Case History: 82 year old Caucasian male currently presents for decreased visual acuity at a 3 month follow up for VMT/macular hole stage 1a OD. The patient has a history of focal VMT/CME vs. Irvine-Gass syndrome/macular hole stage 1a OS 2 month post- op cataract surgery in early 2014. This VMT/macular hole stage 1 spontaneously released to a lamellar hole with a non-full thickness traction aperture of 219 um. Patient has a history of focal vitreomacular adhesion OD 1 month post-op cataract surgery OD in early 2014. The patient’s OD focal VMA turned to focal VMT and is currently at focal VMT/macular hole 1a with symptomatic visual acuity decrease and minor metamorphopsia. The patient’s OS spontaneously resolved after the posterior hyaloid membrane released in late 2014. Ocular/medical Hx: 1. Disorder of voice 2. Sensorineural hearing loss, bilateral 3. Macular Pucker/Epiretinal Membrane (Erm) 4. Pseudophakia CE OS 1/21/14 CE OD 2/11/14 5. RENAL INSUFFCIENCY 6. Coronary Artery Disease 7. Asthenopia 8. Headache 9. Presbyopia 10. HYPERTENSION NOS 11. LUMBAGO 12. HYPERLIPIDEMIA NEC/NOS 13. Presbylarynges 14. DEPRESSIVE DISORDER NEC Allergies: ZOCOR, ATORVASTATIN, NIASPAN 1000MG ER TABLET, PRAVASTATIN, OMEPRAZOLE RABEPRAZOLE, GEMFIBROZIL, PANTOPRAZOLE, LISINOPRIL, ALFUZOSIN Medications: Aspirin, Hydroxyzine, Lansopranzole, Losartan, Lovastatin, Nitroglycerine, Ranitidine, Tramadole, Diazepam, Polyvinyl alcohol Pertinent Findings: The patient currently has decreased vision OD for the last 6 months, with reports of minor metamorphopsia that has not changed in the last 3 months. The patient has not seen any changes in his home amsler grid in the last 3 months either. Upon dilation a trace reddening of the macula is observed and minor thickening OD. Two different epiretinal membranes are observed in the resolved eye, OS. Upon Macular OCT and 5-line raster on focal vitreomacular traction is observed of approximately 1,296 um at the macular with cystic spaces observed underneath the traction point, an impending macular hole at stage 1a. The patient did not appreciate a Watzke- Allen sing. Differential Diagnosis: Vitreomacular Traction syndrome (IVTS study) Vitreomacular Adhesion Lamellar hole Macular hole stage 0-4 Cystoid macular edema vs. Irvine-Gass syndrome Epiretinal membrane with pseudohole Diagnosis and discussion: Patient is observed to have Vitreomacular traction with possible macular hole stage 1a OD. The patient’s macular hole looks like it will turn to a lamellar hole due to the consistent integrity of the photoreceptor layer on 5-line raster OCT. This may change to a possible stage 2 macular hole during detachment of the posterior hyaloid membrane in the future. Treatment will be recommended at that time. Due to the nature of the patient’s resolving macular stage 1a hole OS, we will wait on any treatment. The previous macular stage 1a hole OS resulted in small cystic space at the macula with preserved outer retinal layers. Vitreomacular traction is a real issue that affects an older population. VMT can be debilitating and lead to devastating vision loss due to macular holes in 3.3/1000 patients. According to different studies we will discuss size/shape/depth and measuring options to diagnose as efficiently and completely as possible. The latest results on Jetrea (pharmacological vitreolysis option) are not the most effective compared to the latest surgical intervention options in either macular hole or vitreomacular traction resolution. There have been many studies to show the different efficacies of different gas tamponode options and positioning of the patient post-treatment. Treatment and Management: Observation Pars plana vitrectomy with gas tampanode - Inner limiting membrane peel vs. epiretinal membrane peel - Different gas tampanode options - Seated position vs. face down options - Aperature size and treatment efficacy, adverse events Pharmacological Vitrolysis - Jetrea efficacy and adverse events Conclusion: Due to the nature of the resolved previous VMT/macula hole stage 1a OS, we decided to wait on treatment after outlying the possible future alternatives that we may offer to this patient for his OD. We will observe the patient in 3 months with a visual acuity check, DFE, and macular OCT/5-line raster. Patient educated to return to clinic immediately if any changes occur on home amsler grid, decreased visual acuity per patient, or increased symptoms per patient. Biblibiography: Alexander, LJ. Primary Care of the Posterior Segment – 3rd edition. McGraw Publishing Companies, Inc. 2002. Ezra E, and Gregor ZJ. (2004): Surgery for Idiopathic Full-Thickness Macular Hole: Two- Year Results of a Randomized Clinical Trial Comparing Natural History, Vitrectomy, and Vitrectomy Plus Autologous Serum: Moorfields Macular Hole Study Group Report #1. Archives of Ophthalmology. 122: 224-236. Guillaubey A, Malvitte L, Lafontaine PO, Jay N, Hubert I, Bron A, Berrod JP, and Creuzot- Garcher C. (2008): Comparison of Face-Down Postion and Seated Position After Idiopathic Macular Hole Surgery: A Randomized Clinical Trial. American Journal of Ophthalmology. 146(1): 128-134. Friedman NJ, Kaiser PK, II RP. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Elsevier Health Sciences; 2009. Schurmans A, Calster JV, and Stalmans P. (2009): Macular Hole Surgery with Inner Limiting Membrane Peeling, Endodrainage, and Heavy Silicone Oil Tamponade. American Journal of Ophthalmology. 147: 495-500. De Smet, Marc D. Gandorfer Arnd, et al. “Miroplasmin Intravitreal Administration in Patients with Vitreomacular Traction Scheduled for Vitrectomy: The MIVI 1 Trial”. Ophthalmol 2009;116:1349-1355. Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual, Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams & Wilkins; 2012. Stalmans P, Benz MS, Gandorfer A, et al. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012;367(7):606-15. 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. Dugel PU, Tolentino M, Feiner L, Kozma P, Leroy A. Results of the 2-Year Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) Randomized Trial. Ophthalmology. 2016. .
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