Spark ImageWise 30 – Retina

10 years follow up of a case of vitreomacular traction 

Dr. Shashank Somani, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A female, 70 years of age, presented to us in 2011 for a routine evaluation. She was a diagnosed case of primary open angle glaucoma in both eyes (BE) and was using Latanoprost and Timolol Maleate eye drops for the same. She was a known case of diabetes mellitus, hypertension and hyperthyroidism and was on treatment for the same. On examination the visual acuity was 6/9, N6 in right eye (RE) and 6/12,N6 in left eye (LE). Anterior segment showed the presence of immature cataract in BE. Intraocular pressure (IOP) measured with Goldmann applanation tonometer was 16 mmHg in RE and 20 mmHg in LE. Gonioscopy in BE showed angles opening upto scleral spur in all quadrant. Her axial length was 24.11mm in RE and 24.09mm in LE.

Figure 1: Right eye colour fundus photo suggestive of peripapillary atrophy around the disc (blue arrow), vertical CD ratio of 0.7:1. Multiple drusen can be seen around the macula (yellow arrow) suggestive of early age related macular degeneration (AMD)
Figure 2: Left eye colour fundus photo suggestive of peripapillary atrophy around the disc (blue arrow), vertical CD ratio of 0.8:1. Multiple drusen can be seen around macula (yellow arrow) suggestive of early AMD
Figure 3: RE OCT line scan passing through macula shows distortion of normal foveal contour and a thin hyper-reflective membrane in the vitreous phase attached to the fovea, showing a point of attachment along the slope of the foveal pit suggestive of vitreomacular Traction (VMT) (yellow arrow). posterior hyaloid face was not very well visible in this scan. Multiple drusen can be seen in the infrared image (blue arrow) as well as in OCT scan (red arrow) suggestive of early age related macular degeneration.
Figure 4: LE OCT line scan passing through macula shows distortion of normal foveal contour and a thin hyper-reflective membrane indicative of the posterior hyaloid attached to the fovea (yellow arrow) with formation of retinal cyst at the fovea (blue arrow) suggestive of grade 2 vitreomacular Traction (VMT). Multiple drusen can be seen in the infrared image (white arrow) as well as in OCT scan (red arrow) suggestive of early age  related macular degeneration.

The patient underwent phacoemulsification with trabeculectomy in RE in 2017. She underwent left eye phacoemulsification in 2012 followed by trabeculectomy in 2014. 

Figure 5: Sequential line scan of macula of RE over the past 9 years showing progression of VMT from grade 1 to grade 2 and subsequent improvement to grade 1. We can see the formation of retinal cyst (yellow arrow in Fig 5c)
Figure 6: Sequential line scan of macula of RE over the 9 years show gradual reduction of VMT with formation of ERM after resolution of traction. The ERM also shows some separation nasally due to the traction effect of the hyaloid. (Fig 6e, 6f and 6g)

Discussion

This is a typical case of AMD who required multiple injections of anti-VEGF. The patient used to respond to the monthly injections but the edema used to recur again at the end of a month. The management of such a situation includes switching to a treat and extend regime or plan for a long acting anti-VEGF injection. We discussed the options with the patient and he was willing to go for the long acting anti-VEGF – Brolucizumab. The patient was informed about the possible side effects that may  on occasion be associated with the use of Intravitreal Brolucizumab. The response to Brolucizumab was quite satisfactory as the edema got completely resolved and patient did not require an injection even at the end of 2 months at the last follow up. 

Repeated follow ups in cases of AMD  and non availability of an escort apart from the pain and difficulties  associated with monthly injections has been a significant  challenge in  treatment of the elderly population.  This is known to cause treatment drop outs and delay in treatment which could have  a significant impact on vision. Long acting anti-VEGFs are a plausible options in such a scenario and with the availability of these newer molecules take us closer to the goal of  greater efficacy and duration of action.

ReadWise

  1. Bottós J, Elizalde J, Arevalo JF, Rodrigues EB, Maia M. Vitreomacular traction syndrome. J Ophthalmic Vis Res. 2012 Apr;7(2):148-61.PMID: 23275824; PMCID: PMC3520473.
  1. Theodossiadis GP, Grigoropoulos VG, Theodoropoulou S, Datseris I, Theodossiadis PG. Spontaneous resolution of vitreomacular traction demonstrated by spectral-domain optical coherence tomography. American journal of ophthalmology. 2014 Apr 1;157(4):842-51. DOI: 10.1016/j.ajo.2014.01.011

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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