Diabetic vitreopapillary traction and macular oedema

Approach to patient with unilateral optic disc edema and normal visual function

In patients with swollen optic nerve head and normal visual function, optic disc drusen (ODD) is the most common diagnosis. The best tests for detecting ODD are funds autofluorescence and enhanced-depth imaging ocular coherence tomography (EDIOCT). After ODD has been ruled out, asymmetric papilledema should be assumed to be the cause and MRI of the brain and orbits with contrast and venography should be performed in all patients. It allows one to look for indirect signs of increased inctracranial pressure (ICP), optic perineuritis, and other inflammatory or compressive processes affecting optic nerve or its sheath such as optic nerve sheath meningioma. If imaging signs of raised ICP are present, lumbar puncture should be performed with measurement of opening pressure and analysis of cerebrospinal fluid (CSF) contents in all patients with fever, meningismus or neurologic deficits as well as patients who are not in the typical demographic group for idiopathic intracranial hypertension (IIH). Optic nerve sheath enhancement on MRI should prompt work-up for causes of optic perineuritis. When the appropriate neuroimaging is normal, the differential diagnosis is limited and ophthalmological consultation is necessary to determine whether other subtle ocular abnormalities are present on biomicroscopic and dilated fundus examination.

The vitreopapillary interface in healthy and glaucoma: posterior vitreous detachment in the vitreopapillary interface study

PURPOSE

To investigate the vitreopapillary interface (VPI) in health and glaucoma according to the different stages of posterior vitreous detachment (PVD) formation.

METHODS

Prospective single centre study including healthy subjects and glaucoma patients. PVD staging was performed with spectral domain optical coherence tomography. Gender, age, lens status and refractive error were assessed in both groups. Glaucoma patients additionally had a comprehensive ophthalmological investigation including intraocular pressure measurement, visual field testing and confocal imaging of the optic nerve head.

RESULTS

Data on 523 subjects (993 eyes) were included from the VPI study (clinicaltrials.gov NCT02290795) database (493 eyes of 258 healthy subjects and 500 eyes of 265 glaucoma patients). Healthy subjects were significantly younger than primary open angle glaucoma patients (59.7 ± 14.81 versus 70.0 ± 10.78 years, p < 0.001), but were otherwise matched for refractive error and gender. Significantly more glaucomatous eyes were pseudophakic (26.6% versus 5.1%). Including only phakic nonoperated eyes from subjects between 50 and 80 years old decreased the age difference between healthy and open angle glaucoma (64.1 ± 8.0 versus 65.9 ± 6.7 years, p = 0.051). Comparing these subgroups rendered similar average ages for PVD stages 0 and 4, in contrast to the significant older age for the glaucoma subgroup in stage 1 (64.1 ± 6.01 versus 61.4 ± 8.38 years, p < 0.001) and a trend towards significance in stage 3 (70.8 ± 69.8 versus 67.5 ± 5.92 years, p = 0.051).

CONCLUSION

The VPI study is a large clinical trial investigating the VPI in health and glaucoma. A subset of glaucoma patients seems to experience stages 1-3 of PVD formation at older age compared to healthy subjects.

Vitrectomy for vitreopapillary traction in a nondiabetic 16-year-old girl

Vitreopapillary traction (VPT) is an unusual clinical entity and its management and prognosis have been sparsely studied. It has been described in adults with various vitreomacular pathologies and the possible effects on visual functions. However, the role of surgical intervention in altering the course of the disease is not well understood. Hereby, we describe a case of idiopathic VPT in a 16-year-old girl who presented with decreased vision and visual field changes corresponding to the area of retinal traction. This case was managed with pars plana vitrectomy and epiretinal membrane removal that resulted in improved visual field sensitivity; thus, emphasizing the role of surgical intervention in such eyes.

Spectral-domain optical coherence tomography findings of tractional retinal elevation in patients with diabetic retinopathy

PURPOSE

To evaluate the clinical and morphological characteristics as well as the surgical outcomes of tractional retinal elevation (TRE) in patients with proliferative diabetic retinopathy (PDR) by analyzing spectral-domain optical coherence tomography (SD-OCT).

METHODS

SD-OCT images of 26 eyes (24 patients) who visited our clinic because of TRE and PDR from August 2011 to August 2014 were reviewed. According to the presence or absence of tractional retinal detachment (TRD), patients were classified into group 1 (without TRD) or group 2 (with TRD), and the clinical characteristics and surgical outcomes of the two groups were compared. Furthermore, we categorized the SD-OCT morphological components into sponge, cystoid, saw tooth, bridging columnar, and TRD and compared the characteristics among patients who had different components.

RESULTS

Group 1 had 18 eyes and group 2 had eight eyes. No differences in age, best corrected visual acuity (BCVA), or spherical equivalent were observed between the two groups, but group 2 had longer axial length than that of group 1 (p = 0.02). A large variety of combined OCT findings was found in group 1 compared to that in group 2. TRD was the least combined form with the other morphological components. Although 92 % of eyes with the bridging columnar component had the cystoid component, TRD and tractional retinoschisis (TRS, bridging columnar morphology) were combined in only one eye.

CONCLUSION

Diabetic TRE may progress to TRD or TRS, which are mutually exclusive. They may progress to TRD in eyes with a long axial length, and cystoid macular edema seems to develop into TRS.

Retinal Changes Induced by Epiretinal Tangential Forces

Two kinds of forces are active in vitreoretinal traction diseases: tangential and anterior-posterior forces. However, tangential forces are less characterized and classified in literature compared to the anterior-posterior ones. Tangential epiretinal forces are mainly due to anomalous posterior vitreous detachment (PVD), vitreoschisis, vitreopapillary adhesion (VPA), and epiretinal membranes (ERMs). Anomalous PVD plays a key role in the formation of the tangential vectorial forces on the retinal surface as consequence of gel liquefaction (synchysis) without sufficient and fast vitreous dehiscence at the vitreoretinal interface. The anomalous and persistent adherence of the posterior hyaloid to the retina can lead to vitreomacular/vitreopapillary adhesion or to a formation of avascular fibrocellular tissue (ERM) resulting from the proliferation and transdifferentiation of hyalocytes resident in the cortical vitreous remnants after vitreoschisis. The right interpretation of the forces involved in the epiretinal tangential tractions helps in a better definition of diagnosis, progression, prognosis, and surgical outcomes of vitreomacular interfaces.

Vitreopapillary traction in eyes with idiopathic epiretinal membrane: a spectral-domain optical coherence tomography study

PURPOSE

To investigate the prevalence of vitreopapillary traction (VPT) and its effect on peripapillary structure and visual function in eyes with idiopathic epiretinal membrane (ERM).

DESIGN

Observational, comparative study.

PARTICIPANTS

Patients with idiopathic ERM (n = 116 eyes) and controls with similar age (n = 62 eyes).

METHODS

Spectral domain optical coherence tomography (SD-OCT) axial optic disc scans were evaluated to identify VPT in eyes with idiopathic ERM. Based on VPT presence/absence, eyes were categorized as ERM with VPT (ERM+VPT, n = 52 eyes) or ERM without VPT (ERM-VPT, n = 64 eyes). Optic nerve head (ONH) parameters, average and sectoral retinal nerve fiber layer (RNFL) thickness, and central macular thickness (CMT) were compared between groups. Best-corrected visual acuity (BCVA) and visual field (VF) (automated Humphrey central 30-2 perimetry) mean deviation (MD) and pattern standard deviation (PSD) were compared between groups.

MAIN OUTCOME MEASURES

The ONH parameters, peripapillary RNFL thickness, BCVA, VF MD, and PSD.

RESULTS

Fifty-two of 116 eyes (44.8%) with idiopathic ERM had VPT. The ERM+VPT group had larger rim area, smaller average and vertical cup-to-disc ratios, and smaller cup volume than ERM-VPT and normal groups (all P < 0.001). Eyes with VPT had greater CMT than eyes without VPT (421.87±97.31 μm vs. 377.08±75.1 μm; P = 0.006). Average and temporal RNFL thickness was higher in ERM+VPT (98.64±9.33 μm and 93.90±23.42 μm) than in normal eyes (94.02±8.45 μm and 66.42±12.71 μm). No significant difference in BCVA was found between ERM-VPT and ERM+VPT eyes, but MD was lower in ERM+VPT than in ERM-VPT (-3.91±3.68 dB vs. -2.18±2.42 dB; P = 0.005). Additionally, PSD was greater in ERM+VPT. Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.190; P = 0.014) and increased CMT (OR, 1.013; P = 0.005) were associated with vision loss, whereas VPT presence was associated with VF defects (OR, 6.290; P = 0.024).

CONCLUSIONS

Vitreopapillary traction was observed in >40% of eyes with idiopathic ERM, as confirmed by SD-OCT imaging. Vitreopapillary traction with idiopathic ERM was associated with altered optic disc architecture, increased average and temporal RNFL thickness, and VF defects.

Importance of 3-D image reconstruction of spectral-domain OCT on outcome of grid laser photocoagulation for diffuse diabetic macular edema

AIM

To present the outcome of modified grid laser photocoagulation (GLP) in diffuse diabetic macular edema (DDME) in eyes without extrafoveal and/or vitreofoveal traction.

METHODS

Inclusion criteria for the retrospective study were DDME eyes of patients with type II diabetes mellitus that had ≥4 months of follow-up following GLP. Only one eye per patient was analyzed. Using 3-D spectral-domain optical coherence tomography (3-D SD-OCT), eyes that had either extrafoveal or vitreofoveal traction, or had been previously treated by an intravitreal medication(s) were excluded. Treated DDME eyes were divided into 4 groups: A) "Classic" DDME that involved the central macula; B) edema did not involve the macular center; C) eyes associated with central epiretinal membrane (ERM); D) DDME that was associated with macular capillary dropout ≥2 disc-diameter (DD).

RESULTS

GLP outcome in 35 DDME eyes after 4-24 (mean, 13.1±6.9) months was as follows: Group A) 18 eyes with "classic" DDME. Following one or 2 (mean, 1.2) GLP treatments, best-corrected visual acuity (BCVA) improved by 1-2 Snellen lines in 44.4% (8/18) of eyes, and worsened by 1 line in 11.1% (2/18). Central macular thickness (CMT) improved by 7%-49% (mean, 26.6%) in 77.8% (14/18) of eyes. Causes of CMT worsening (n=4) were commonly explainable, predominantly (n=3) associated with emergence of extrafoveal traction, 5-9 months post-GLP. Group B) GLP(s) in DDME that did not involve the macular center (n=6) resulted in improved BCVA by 1-2 lines in 2 eyes. However, the central macula became involved in the edema process after the GLP in 3 (50%) eyes, associated with an emergence of extrafoveal traction in one of these eyes 4 months following the GLP. Group C) GLP failed in all 5 eyes associated with central ERM. Group D) GLP was of partial benefit in 2 of 6 treated eyes with macular capillary dropout ≥2DD.

CONCLUSION

Eyes with DDME that involved the macular center were found to achieve favourable outcomes after GLP(s) during mid-term follow-up, unless complicated pre-GLP or post-GLP by vitreoretinal interface abnormalities, often extrafoveal traction or ERM, or by capillary dropout ≥2DD. Prospective studies with larger cohorts are required.

Vitreopapillary and vitreomacular traction in proliferative Eales' disease

Vitreoretinal interface alterations leading to vitreopapillary and vitreomacular traction in a 29-year case of proliferative Eales' disease is described for the first time. On fundus examination, an ellipsoid area of vitreomacular traction was noted temporal to the optic disc. A triangular-shaped infolding of the retina was observed superior to the fovea. Epiretinal membrane was seen temporal to the disc involving the macula. Imaging by spectral domain optical coherence tomography in the papillomacular bundle region revealed retinoschisis at the level of the outer nuclear layer and confirmed the presence of retinal infolding and epiretinal membrane in the macular area. Three-dimensional imaging documented vitreoretinal interface alterations exquisitely.

Optical coherence tomographic patterns in diabetic macula edema can predict the effects of intravitreal bevacizumab injection as primary treatment

PURPOSE

To identify optical coherence tomography (OCT) patterns in diabetic macular edema (DME) that were predictive of visual outcomes after intravitreal bevacizumab (IVB) injection.

METHODS

This was a retrospective study. We examined 31 eyes (24 patients) with clinically significant macular edema that received IVB injections along with macular OCT data. The eyes were categorized into 4 groups by using OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), serous retinal detachment (SRD), and vitreomacular interface abnormalities (VMIAs). Changes in retinal thickness, retinal volume, and visual acuity (VA) after IVB injection were compared on the basis of OCT patterns.

RESULTS

After IVB injections, changes in VA logarithm of the minimum angle of resolution were -0.06±0.36, -0.26±0.26, 0.09±0.13, and -0.08±0.15, respectively, for DRT, CME, SRD, and VMIA patterns. Central macular thickness decreased by 70.5±105.5, 110.67±97.28, 181±125.87, and 24.25±77.12 μm for the DRT, CME, SRD, and VMIA patterns, respectively. The CME group was associated with a greater reduction in retinal thickness (P=0.009) and volume (P=0.027) with superior VA improvement (P=0.012) as compared with the DRT, SRD, and VMIA groups.

CONCLUSIONS

Patients with CME gained greater improvement in visual acuity and macular thickness and volume after IVB injection had been administered as the primary treatment for DME, as compared with other patients. The OCT patterns of DME may indicate the appropriate treatment; we consider these patterns to be prognostic of the response to IVB injection for macular edema.

Vitrectomy for exudative age-related macular degeneration with vitreous hemorrhage

PURPOSE

The purpose of this study was to study the effect of pars plana vitrectomy (PPV) for age-related macular degeneration with vitreous hemorrhage on choroidal neo-vascularization (CNV).

METHODS

A retrospective interventional case series in which 92 eyes with age-related macular degeneration with vitreous hemorrhage that received PPV were studied. Among them, 60 eyes without pre- or posttreatment other than PPV were selected. Choroidal neovascularization was expressed as the incidence of bleeding 6 months before and after PPV. The status of CNV after PPV was compared and classified as worsened, remained, regressed, disappeared, or unclassified. The influence of posterior vitreous detachment was examined.

RESULTS

The incidence of bleeding was reduced dramatically after PPV (1.11 +/- 0.44 in preoperative 6 months vs. 0.03 +/- 0.18 in postoperative 6 months, P < 0.0001). The status of CNV improved in most cases; 40 of 54 classifiable eyes (74.1%) were categorized as "regressed" or "disappeared." Postoperative visual acuity was significantly better than preoperative visual acuity (P < 0.0001). The status of CNV subsided more in those eyes without posterior vitreous detachment than in those with posterior vitreous detachment (odds ratio, 1.02; 95% confidence interval, -0.01-2.08; P = 0.054).

CONCLUSION

The activity of CNV was reduced after PPV in eyes with age-related macular degeneration with vitreous hemorrhage. Visual acuity significantly improved, with only rare severe complications. The involvement of vitreomacular traction in the patho-physiology of CNV in age-related macular degeneration is possible.

Vitreous traction and epiretinal membranes in diabetic macular oedema using spectral-domain optical coherence tomography

PURPOSE

The purpose of this study was to present an association between diabetic macular oedema (DME) and vitreoretinal interface abnormalities using 3D spectral domain optical coherence tomography (SD-OCT).

METHODS

In a retrospective study, charts and SD-OCT of consecutive patients with diffuse or focal DME were reviewed. Only one randomly chosen eye per patient with DME was included, and eyes that had another retinopathy that could affect the study analysis or that underwent vitreoretinal surgery were excluded.

RESULTS

Out of 58 eyes (58 patients) with DME, 11 eyes (19.0%) had vitreofoveal traction (Group A), either unifocally (n=6) or multifocally; that is, associated with additional extrafoveal traction site(s). Group B comprised 20 eyes (34.5%) that had sole extrafoveal vitreous traction, at either retinal and/or papillary sites. In each, the retinal oedema underlying extrafoveal traction was in continuum in at least one site with that at the central macula, as verified by the macular maps, thus presented as diffuse macular oedema. In Group C, 13 eyes (22.4%) had an epiretinal membrane (ERM), 1.5 × 3 mm to ≥6 × 6 mm in size that overlaid diffuse oedematous macula. Group D included 14 eyes (24.1%) that had neither vitreous traction nor ERM; 12 (20.7%) of them had DME secondary to leaking microaneurysms with or without leaking capillary beds, and the remaining two had leakage from non-microaneurysms sources.

CONCLUSIONS

DME was detected by the SD-OCT to be associated with sole extrafoveal vitreous traction in one-third of the patients. Further studies are required to evaluate the clinical consequences of these observations.

Vitreo-papillary adhesion in macular hole and macular pucker

PURPOSE

Vitreo-macular pathology may be influenced by vitreo-papillary adhesion (VPA). Optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO) was used to identify VPA in full-thickness macular hole, lamellar hole, and macular pucker (MP).

METHODS

Ultrasonography and OCT/SLO were performed in 55 subjects: 16 with macular hole, 11 with lamellar hole, and 28 with MP. The main outcome measures were the presence of posterior vitreous detachment by ultrasound, and the findings of VPA and intraretinal cysts by OCT/SLO.

RESULTS

Posterior vitreous detachment was detected by ultrasound in 26/28 (92.9%) eyes with MP, 6/11 (54.5%) eyes with lamellar hole (P < 0.05), and 4/16 (25%) eyes with macular hole (P < 0.00001). Optical coherence tomography/scanning laser ophthalmoscopy detected VPA in 14/16 (87.5%) macular hole eyes, 4/11 (36.4%) lamellar hole eyes (P < 0.05), and 5/28 (17.9%) MP eyes (P < 0.00005). Intraretinal cysts were present in 4/5 (80%) MP eyes with VPA but only 1/23 (4.3%) MP eyes without VPA (P < 0.005).

CONCLUSION

Vitreo-papillary adhesion was significantly more common in full-thickness macular hole than lamellar hole or MP. When present in MP, VPA was frequently associated with intraretinal cysts. Hence, VPA may have an important influence on the vectors of force at the vitreo-retinal interface inducing holes and cysts.

Optical Coherence Tomography Use in Evaluation of the Vitreoretinal Interface: A Review

Optical coherence tomography (OCT) is a valuable tool for assessment of the vitreoretinal interface. This article reviews the normal process of age-related posterior vitreous detachment as viewed by OCT. Abnormalities of the vitreoretinal interface as imaged by OCT are described including vitreomacular traction syndrome, cystoid macular edema/ diabetic macular edema, epiretinal membranes, full thickness macular holes, lamellar holes, pseudoholes, microholes, and schisis from myopia or optic pits/colobomas. This tool has given us new insights into the pathogenesis of these retinal abnormalities.