The role of abnormal vitreomacular adhesion in age-related macular degeneration: spectral optical coherence tomography and surgical results

Abstract

Purpose: To assess the incidence of vitreomacular adhesion and traction in age-related macular degeneration (AMD), and to evaluate surgical treatment in a subset of patients with choroidal neovascularization (CNV) nonresponsive to anti-neovascular growth factor (anti-VEGF) treatment.

Design: Retrospective observational case-control and interventional case series.

Methods: Spectral optical coherence tomography, combined with simultaneous scanning laser ophthalmoscope (Spectral OCT/SLO), was performed in 170 eyes of 94 elderly patients, 61 with exudative AMD, 59 with nonexudative AMD, and 50 control eyes. The presence of hyaloid adhesion to the posterior pole, and vitreomacular traction (VMT) were determined. Five patients with VMT underwent surgical hyaloid removal. Best-corrected visual acuity (BCVA) and retinal thickness were evaluated as outcomes.

Results: Hyaloid adhesion was present in 17 eyes with exudative AMD (27.8%), 15 eyes with nonexudative AMD (25.4%), and eight control eyes (16%). Significant difference was found among the groups (P = .002). Among the eyes with hyaloid adhesion, VMT was shown in 10 eyes (59%) with exudative AMD, two eyes (13%) with nonexudative AMD, and one control eye (12%). VMT was associated with the severity of AMD (P = .0082). The area of hyaloid adhesion was significantly smaller than and concentric to the area of CNV complex in eyes with exudative AMD. Eyes with VMT that underwent surgery experienced a modest improvement of BCVA and decrease of retinal thickness.

Conclusions: Hyaloid adhesion to the macula is associated with AMD, and frequently causes VMT in eyes with CNV. Tractional forces may antagonize the effect of anti-VEGF treatment, and cause pharmacological resistance in a subpopulation of patients. Future studies are needed to define the role of vitreoretinal surgery in such cases. Spectral OCT/SLO allows careful diagnosis and follow-up.

FIGURE 1

Classification scheme of hyaloid adhesion and vitreomacular traction (VMT) seen with Spectral optical coherence tomography (OCT). (Top) A normal eye of an elder patient: the hyaloid membrane is visible and completely detached from the fovea, though there is a persistent adhesion to the optic nerve (right frame). (Middle) Eye with nonexudative age-related macular degeneration (AMD) and drusen: the hyaloid is attached over the entire macula, including the fovea. We considered this as a “no traction” configuration, since no distortion is visible on the retinal surface and the angle of insertion of the hyaloid onto the retina is not steep. The lucency between the center of the macula and the vitreous collagen is likely the posterior precortical vitreous pocket. (Bottom) Eye with choroidal neovascularization (CNV). The persistence of hyaloid adhesion causes VMT over the CNV complex: a focal distortion of the retinal profile is visible at the site of hyaloid attachment.

FIGURE 2

Anatomic configuration of hyaloid adhesion and CNV complex. (Top) Cross-sectional view of Spectral OCT B-scan and corresponding scanning laser ophthalmoscope (SLO) image. The simultaneous images allow for precise topographic correlation of the OCT findings. (Bottom) Three-dimensional reconstruction of the same eye in two different perspectives. On the left, the surface of the retina and the continuous adhesion of the hyaloid are clearly seen. On the right, a slice through the fovea is showing the exudative complex and its relationship to the hyaloidal adhesion.

FIGURE 3

Drusenoid retinal pigment epithelial (RPE) detachment with VMT, surgical outcome (Patient 1). This patient experienced a recent decrease in vision to 20/80. (Top left) Horizontal Spectral OCT scan through the fovea shows hyaloid attachment to the apex of the pigment epithelial detachment (PED) causing macular traction. Postoperatively (Top right), a scan in the same anatomic location shows collapse of the large PED, some residual RPE changes, and a focal photoreceptor defect. Vitreous is absent. Vision improved to 20/40. The corresponding vertical scans done preoperatively (Bottom left) and postoperatively (Bottom right) confirm the release of VMT and the PED collapse.

FIGURE 4

Exudative AMD with VMT, surgical outcome (Patient 4). Vertical Spectral OCT scans through the center of the macula are shown. (Top) Baseline scan shows vitreous adherent to the apex of large cavities within edematous retina, and an underlying CNV complex; this fluid persisted despite eight previous monthly injections of intravitreal Bevacizumab. (Middle) Image shows center of macula one month after vitrectomy with removal of the attached hyaloid membrane. Fluid is reabsorbing (note: the scale is adjusted to facilitate direct comparison with the other scans). (Bottom) (same magnification as top) six months follow-up: complete reabsorption of intra- and sub-retinal fluid. Monthly Bevacizumab treatment was continued after surgery. Vision improved by one line, from 20/400 to 20/320.

FIGURE 5

Spontaneous resolution of VMT in exudative AMD. Four scans through the fovea of the same eye. (Top left) Large amount of intraretinal fluid with cystic formation that persisted after three monthly intravitreal injections of Bevacizumab. (Top right) Same view after five months. A spontaneous release of the central VMT is detected by Spectral OCT. (Bottom left) Vertical scan through the fovea at the same time as the top left panel. (Bottom right) Vertical view after the spontaneous release of traction. There was no improvement in vision despite ongoing treatment.