Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment

Abstract

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. However, this may be complicated by persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction; VMT). VMT itself may be associated with epiretinal membrane formation and the development of idiopathic macular holes (IMH). Such pathologies may cause visual disturbances, including metamorphopsia, photopsia, blurred vision, and decreased visual acuity, which impact an individual's quality of life. Technologies such as optical coherence tomography allow an increasingly more accurate visualisation of the macular anatomy, including quantification of macular hole characteristics, and this facilitates treatment decision-making. Pars plana vitrectomy remains the primary treatment option for many patients with VMT or IMH; for the latter, peeling of the inner limiting membrane (ILM) of the retina has shown improved outcomes when compared with no ILM peeling. The development of narrow-gauge transconjunctival vitrectomy systems has improved the rate of visual recovery following surgery. Ocriplasmin, by degrading laminin and fibronectin at the vitreoretinal interface, may allow induction of PVD in a non-invasive manner. Indeed, clinical studies have supported its use as an alternative to surgery in certain patient populations. However, further research is still needed with respect to greater understanding of the pathophysiology underlying the development of VMT and IMH.

Figure 1

The orientation of collagen fibrils within the vitreous gel (adapted from Le Goff and Bishop). Redrawn with permission from P Bishop, The University of Manchester.

Figure 2

Stages of posterior vitreous detachment (PVD) during healthy aging (adapted from Johnson; Uchino et al). Stage 1, perifoveal vitreous detachment with residual vitreofoveal adhesion; Stage 2, perifoveal vitreous detachment with persistent attachment to the optic disc but without vitreofoveal adhesion; Stage 3, near-complete PVD with only vitreopapillary adhesion remaining; Stage 4, complete PVD.

Figure 3

Central foveal vitreomacular adhesion without traction. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 4

Vitreomacular traction with retinal cavitation. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 5

Vitreomacular traction with epiretinal membrane. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 6

Fibrous epiretinal membrane visualised using transmission electron microscopy. Collagen fibrils (between the arrowheads) situated between the inner limiting membrane of the retina and a layer of fibrocytes (shown by the arrow). The layer of collagen fibrils is ∼10 nm in thickness. Reproduced with permission from R Spaide, Vitreous-Retina-Macula Consultants of New York, New York, USA.

Figure 7

Complex epiretinal membrane formation (adapted from Chang et al). VRI, vitreoretinal interface. Reproduced with permission from R Spaide, Vitreous-Retina-Macula Consultants of New York, New York, USA.

Figure 8

Vitreomacular traction with pseudocyst. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 9

Vitreomacular traction with inner retinal cystic change and outer retinal detachment. Reproduced with permission from DH Steel.

Figure 10

Idiopathic macular hole with operculum. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 11

Small idiopathic macular hole with vitreomacular attachment. Left, fundus photography; right, optical coherence tomography (OCT); Green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 12

Macular hole with elevated cuff. H, height; MLD, minimum linear diameter; BD, base diameter. Macular hole index (MHI)=height (H)/base diameter (BD). Reproduced with permission from DH Steel.

Figure 13

Lamellar macular hole and macular pseudohole. (a) Lamellar macular hole. (b) Macular pseudohole with epiretinal membrane. (c) Macular pseudohole with lamellar hole formation. Left, fundus photography; right, optical coherence tomography (OCT); green line corresponds with level of OCT image. Reproduced with permission from DH Steel.

Figure 14

Pars plana vitrectomy.