Optical Coherence Tomography Imaging of Surgical Resolution of Bilateral Vitreomacular Traction Syndrome Related to Incomplete Posterior Vitreoschisis: A Case Report

Recurrent Vitreomacular Traction in a Patient Treated with Ocriplasmin: A Case Report

INTRODUCTION

To describe a case of recurrent vitreomacular traction and macular edema that appeared both before and after the intravitreal injection of ocriplasmin.

CASE REPORT

An 82-year-old monocular man presented with metamorphopsia and reduced vision of 1-week duration. The patient's general medical history was unremarkable. His ophthalmic history was significant for severe ocular trauma in the right eye in childhood that caused phthisis. The left eye had undergone uncomplicated phacoemulsification 3 months earlier and the 1-month postoperative best corrected visual acuity (BCVA) was logarithmic mean angle of resolution (logMAR) 0.0. There was no history of other ocular conditions. At presentation, BCVA was logMAR 0.2 and optical coherence tomography (OCT) revealed the presence of cystoid macular edema caused by vitreomacular traction (VMT). The patient was scheduled for intravitreal ocriplasmin injection. Prior to treatment, the vision improved spontaneously to logMAR 0.1, and no VMT could be detected with spectral domain (SD)-OCT. The ocriplasmin injection was deferred but 3 weeks later the patient presented again with metamorphopsia, while VMT was again evident on SD-OCT. Ocriplasmin was injected and 1 month later the BCVA reached logMAR 0.1 without VMT. However, at 2 months post injection the VMT reappeared and a conservative approach with observation and topical nepafenac administration was decided. At the 3-month post-injection visit there was no VMT. More than 3 years after the ocriplasmin injection there is still no evidence of VMT, the patient is free of metamorphopsia, and his BCVA is logMAR 0.0.

CONCLUSION

Separation of consecutive layers of the vitreous cortex (vitreoschisis) may account for recurrent VMT.

Optical Coherence Tomography Findings of Incomplete Posterior Vitreoschisis with Vitreomacular Traction Syndrome and Impending Macular Hole: A Case Report

Purpose

Vitreomacular traction syndrome is a clinical entity characterized by partial posterior vitreous detachment in combination with persistent macular adherence. Recently, optical coherence tomography (OCT) allowed visualization of incomplete posterior vitreoschisis leading to vitreomacular traction.

Methods

The authors report on a 57-year-old woman with blurred vision in her left eye.

Results

OCT scan showed incomplete posterior vitreoschisis with vitreomacular traction syndrome and impending macular hole in her left eye.

Conclusions

The intraoperative findings together with the evidence that the internal limiting membrane (ILM) thickness is thinner than the axial resolution of the Stratus OCT (8 μm) and a spontaneous ILM detachment has never been demonstrated are likely to support the hypothesis that posterior vitreoschisis exists and can be associated with vitreomacular traction syndrome.

Vitreoschisis in macular diseases

OBJECTIVES

Vitreoschisis is a possible pathogenic mechanism in macular diseases. Thus, the vitreoretinal interface was evaluated in monkey eyes and patients with various macular diseases in search of vitreoschisis. It is hypothesised that vitreoschisis is present in macular holes (MH) and macular pucker (MP), but not in other maculopathies.

METHODS

Histopathology was studied in 14 monkey eyes and a vitrectomy specimen of a patient with macular pucker. Optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO) was performed in 239 eyes: 45 MH, 45 MP, 51 dry age-related macular degeneration (AMD), 53 non-proliferative diabetic retinopathy (NPDR) and 45 controls.

RESULTS

Immunohistochemistry demonstrated lamellae in the posterior vitreous cortex of 12/14 (86%) monkey eyes. With OCT/SLO, vitreoschisis was detected in 24/45 (53%) MH and 19/45 (42%) MP eyes, but in only 7/53 (13%) NPDR, 3/51 (6%) AMD and 3/45 (7%) control eyes (p<0.001 for all comparisons). Rejoining of the inner and outer walls of the split posterior vitreous cortex was visible in 16/45 (36%) MH eyes and 15/45 (33%) MP eyes. Histopathology of the MP specimen confirmed a split with rejoining in the posterior vitreous cortex.

CONCLUSIONS

Vitreoschisis was detected in half of eyes with MH and MP, but much less frequently in controls, AMD and NPDR patients. These findings suggest that anomalous PVD with vitreoschisis may be pathogenic in MH and MP.

The role of diagnostic imaging techniques in the management of retinal detachment due to macular hole in high myopia

After preoperative assessment revealed anomalous posterior vitreous detachment, a 75-year-old woman affected with retinal detachment due to macular hole was scheduled to undergo the posterior episcleral buckling procedure. Preoperative microperimetry showed unstable eccentric fixation with a dense scotoma within the central 8 degrees. One month postoperatively, best-corrected visual acuity increased from 1.70 to 0.88 logarithm of the minimum angle of resolution. Ultrasonography and optical coherence tomography revealed the indentation of the posterior scleral profile due to the buckle. The retina appeared fully attached and a macular hole with flattened edges was still detectable. Microperimetry showed stable central fixation with recovery of retinal sensitivity within the central 2 degrees. Diagnostic imaging techniques guided the decision to use the posterior episcleral buckling procedure. Microperimetry was useful to explain vision improvement despite residual macular hole.