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Case Reports and Small Case Series
October 1998

Optical Coherence Tomography in Successful Surgery of Vitreomacular Traction Syndrome

Arch Ophthalmol. 1998;116(10):1388-1389. doi:

Vitreomacular traction syndrome (VTS) is a disorder caused by incomplete posterior vitreous detachment with persistent traction on the macula that produces in most eyes cystoid changes and decreased visual acuity.1 We report the use of optical coherence tomography (OCT) in a patient in whom clinical findings were characteristic of VTS, and the anatomical outcome of successful surgery.

Report of a Case

A 67-year-old woman was referred to our institution for assessment of visual loss. She complained of a 2-month history of blurred vision in the right eye. Visual acuity was 20/80 OD and 20/25 OS. Fundus examination by biomicroscopy revealed macular cysts with posterior hyaloid attachment at the posterior pole and no epiretinal membrane in the right eye. Fluorescein angiography confirmed macular cystoid edema. B-scan ultrasonography revealed vitreous adhesion to the optic nerve and macula with clear vitreoretinal separation peripheral to the vitreofoveal junction in the right eye. The left eye was normal.

Ocular coherence tomography (Humphrey Instruments, San Leandro, Calif) showed a thickened retina with localized nonreflective cystoid spaces in the outer retina of the right eye and a large central cyst that extended near the internal limiting membrane (Figure 1). Central macular thickness measured by OCT was 604 µm. The scan also showed the presence of a thin, moderately reflective membrane from the surface of the retina at the fovea, which followed the configuration of the posterior vitreous and was identified as the posterior hyaloid.

Figure 1.
A, Preoperative clinical picture showing loss of foveal reflex. Macular cystoid changes are present. Arrow shows optical coherence tomographic scan orientation. B, Preoperative linear optical coherence tomogram acquired through the macula shows cystoid changes and the posterior hyaloid, which appears as 2 reflective bands anterior to the retina that exhibit traction on the fovea (arrow).

A, Preoperative clinical picture showing loss of foveal reflex. Macular cystoid changes are present. Arrow shows optical coherence tomographic scan orientation. B, Preoperative linear optical coherence tomogram acquired through the macula shows cystoid changes and the posterior hyaloid, which appears as 2 reflective bands anterior to the retina that exhibit traction on the fovea (arrow).

The diagnosis of VTS was made and a 3-port pars plana vitrectomy performed. After the excision of the posterior two thirds of the vitreous gel, the posterior vitreous surface was cut, thereby relieving anteroposterior traction. The posterior hyaloid membrane was easily separated from the macula by gentle suction with the vitrectomy probe, and later it was clearly separated from the papilla. No gas or air tamponade was used.

Four weeks after surgery, visual acuity improved to 20/25 OD. Fundus examination revealed a reddish, round (600 µm in diameter), sharply circumscribed lesion, corresponding to the location of the preoperative central macular cyst, that had the clinical appearance of a lamellar macular hole. An OCT scan showed partial restoration of normal appearance with less retinal thickening, much less prominent cystic spaces, and no hyaloid adherence on the inner surface of retina, but a marked central depression similar to the appearance of a lamellar macular hole (Figure 2). Maximum retinal thickness at the margin of the hole after surgery was 422 µm at 2 weeks, 386 µm at 4 weeks, and 349 µm at 8 weeks. Retinal thickness at the base of the hole after surgery was 233 µm at 2 weeks, 225 µm at 4 weeks, and 204 µm at 8 weeks. Fundus examination results remained unchanged at all postoperative times.

Figure 2.
Postoperative linear optical coherence tomograms through the macula. A, 2 weeks after vitrectomy reflexes from posterior hyaloid have disappeared. The picture resembles a lamellar macular hole. A steepened edge of the foveal pit is detected, while the outer retinal layers are preserved. Cystic changes are resolving, and some intraretinal fluid remains accumulated at the base of the hole (arrow). B, 4 weeks after surgery, optical coherence tomography shows a faint decrease in retinal thickness and less intraretinal fluid at the base of the hole. C, 8 weeks after surgery retinal thickness is already normal. Intraretinal fluid, seen as low backscattering cavities, is markedly reduced.

Postoperative linear optical coherence tomograms through the macula. A, 2 weeks after vitrectomy reflexes from posterior hyaloid have disappeared. The picture resembles a lamellar macular hole. A steepened edge of the foveal pit is detected, while the outer retinal layers are preserved. Cystic changes are resolving, and some intraretinal fluid remains accumulated at the base of the hole (arrow). B, 4 weeks after surgery, optical coherence tomography shows a faint decrease in retinal thickness and less intraretinal fluid at the base of the hole. C, 8 weeks after surgery retinal thickness is already normal. Intraretinal fluid, seen as low backscattering cavities, is markedly reduced.

Comment

High-resolution cross-sectional in vivo OCT imaging of the retina, with a longitudinal resolution of 10 µm, is a useful tool for identifying and monitoring macular diseases.2 In this case of type B VTS (as classified by Smiddy et al3), OCT provided images of localized vitreous adhesion caused by VTS and also showed secondary cystoid changes in the macula. Features of VTS discovered with OCT have been previously reported, mainly associated with epiretinal membrane4; however, in this case no epiretinal membrane could be detected either by ophthalmoscopy or OCT. Our findings are similar to those of stage 1 impending macular hole in that there is an absent foveal pit and minimal reflective spaces within the fovea without full-thickness loss of retinal tissue or vitreous separation. The main differences are the greatly increased macular thickness, the persistence of retinal tissue at the base of the fovea, and the hyaloid attachment limited to the fovea.

When patients have progressive visual impairment due to VTS, vitrectomy may provide functional and anatomical improvement.3 In our patient, postoperative OCT scans revealed that posterior hyaloid reflexes were absent and also that macular edema and cyst spaces were resolving, which was correlated with a substantial increase in visual acuity.

We conclude that macular examination with OCT allows confirmation of the diagnosis of VTS, helps to explain the pathogenesis of the disease, and can objectively assess the anatomical improvement of secondary macular changes.

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Article Information

Corresponding author: Juan M. Munuera, MD, Departmento de Oftalmología, Clínica Universitaria de Navarra, 31080 Pamplona, Spain (e-mail: jmmunuera@unav.es).

References
1.
Hikichi  TYoshida  ATrempe  CL Course of vitreomacular traction syndrome. Am J Ophthalmol. 1995;11955- 61
2.
Puliafito  CAHee  MRLin  ChP  et al.  Imaging of macular diseases with optical coherence tomography. Ophthalmology. 1995;102217- 229Article
3.
Smiddy  WEMichels  RGGlaser  BMdeBustros  S Vitrectomy for macular traction caused by incomplete vitreous separation. Arch Ophthalmol. 1988;106624- 628Article
4.
Puliafito  CAHee  MRSchuman  JC  et al.  Optical Coherence Tomography of Ocular Diseases.  Thorofare, NJ Slack Inc1996;
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