CaseWise 19

Vitrectomy in Vitreo Macular Traction- A Case Report

Dr. Chennamsetty Alekhya, Dr. Sarang Lambat, Dr. Vinay Nangia
Suraj Eye Institute, Nagpur, India

INTRODUCTION

Vitreo macular traction syndrome (VMTS) is characterized by incomplete separation of the posterior vitreous with persistent macular attachment.1 The residual persistent cortical attachment at the macula may lead to tractional retinal distortion and macular edema with resultant vision loss, metamorphopsia, micropsia and photopsia. Pars plana vitrectomy is effective in releasing the VMT with visual improvement in some cases.3,4

CASE REPORT 1

A female, 65 years of age, reported to us with the chief complaints of floaters in left eye since 1 year. She had undergone cataract extraction with intraocular lens implant in right eye 6 years back and in left eye 7 years back. She was a known diabetic and was on antidiabetic medications.  She had a visual acuity of 6/9 in right eye and 6/36 in left eye. Anterior segment examination showed pseudophakia in both eyes. Intraocular pressure was 18mmHg in both eyes. Fundus examination of both eyes showed mild diabetic retinopathy changes and vitreomacular traction in left eye. Spectral domain Optical Coherence Tomography (SDOCT) showed focal vitreo macular adhesion causing tractional foveal detachment with schitic changes in left eye (Fig .1). She underwent pars plana vitrectomy with internal limiting membrane peeling in left eye. Post surgery the SDOCT showed release of VMT and falling back of retina and gradual resolution of the schitic changes with development of macular hole (Fig .2c) in left eye. The visual acuity improved to 6/12, 4 months after the surgery and was maintained at 5 years post surgery.

Fig. 1: Left eye OCT showing focal vitreo macular traction causing foveal detachment with schitic changes
Fig. 1: Left eye OCT showing focal vitreo macular traction causing foveal detachment with schitic changes
Fig .2a: OCT of left eye showing released traction, 3 days following vitrectomy with ILM peel.
Fig .2b: OCT of left eye, 2 months following surgery showing better foveal architecture and improvement of VA to 6/18.
Fig .2c: OCT of left eye showing gradual resolution of schitic changes, with return of foveal contour 4 months after surgery with visual acuity of 6/12. Outer nuclear layer still shows minimal schitic changes. Fig. 2d: Appearance 5 years later showing almost near normal foveal architecture.

DISCUSSION

The configuration of vitreomacular traction affects final visual outcome after surgery.  It is difficult to diagnose subtle vitreo macular traction (VMT) by biomicroscopy, particularly when the area of vitreoretinal attachment is broad. SDOCT better defines the vitreoretinal relationships in eyes with VMT and also documents concomitant epimacular membrane and macular edema.2 Spontaneous vitreoretinal separation may occur when it is not associated with epi retinal membrane. VMT tends to progress over time, when it is not completely separated. The indications for vitrectomy are decreased visual acuity and metamorphopsia persisting for >3 months, as in our case. Visual outcome after vitrectomy for VMT is correlated with preoperative vitreomacular structure, duration of symptoms, and preoperative CMT (Central Macular Thickness).2 Pars plana vitrectomy is effective in releasing the VMT with visual improvement in some cases.3,4 In our case there was significant improvement in the morphology of retinal layers post vitrectomy and hence we got an improved anatomical and functional outcome in our case.

REFERENCES

1. Odrobina et al. Evaluation of Vitreo Macular Traction disorder in Spectral Domain Optical Coherence Tomography, The journal of Retinal and Vitreous diseases 2011   volume 31. doi: 10.1097/IAE.0b013e3181eef08c

2. Sonmez et al. Vitreomacular traction syndromeand Visual Outcomes, The journal of retinal and vitreous diseases 2008   volume 28. doi:10.1097/IAE.0b013e31817b6b0f

3. Smiddy et al. Vitrectomy for macular traction caused by incomplete vitreous separation. Arch Ophthalmol  1988; 106:624–628. doi:10.1001/archopht.1988.01060130678025

4. Larsson J. Vitrectomy in vitreomacular traction syndrome evaluated by ocular coherence tomography (OCT) retinal mapping. Acta Ophthalmol 2004; 82:691–694. doi:10.1111/j.1600-0420.2004.00344.x

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