Vitreomacular Traction and Macular Hole

Aetiology

Posterior Vitreous Detachment (PVD) is regarded as part of the normal human ageing process. It may be complicated by persistent adhesion between the
vitreous cortex and the macula. This is the pathological basis of what is known as ‘Idiopathic Macular Hole’.

Vitreomacular Traction (VMT)

  • where there is Vitreomacular Adhesion, which is not in itself a pathological entity, antero-posterior and/or tangential traction forces (VMT) can cause a macular hole to develop
  • a number of different stages of macular hole evolution, traditionally based on ophthalmoscopic appearances, have been described. These have more recently been replaced by an OCT-based classification system

Macular Hole

  • an anatomical discontinuation of the neurosensory retina at the centre of the macula
    • Lamellar Macular Defects: these have been categorized into three subtypes according to their OCT morphology:
      • Lamellar Macular Hole (LMH)
      • Macular Pseudohole (MPH) (appearance of a macular hole but no loss of foveal tissue)
      • Foveal Pseudocyst (FP)
    • Full Thickness Macular Hole (FTMH): interruption of all retinal layers from the internal limiting membrane to the retinal pigment epithelium
  • affects 7.8 per 100,000 of the general population per year
  • predominantly in those >65 years
  • two thirds are women
  • unilateral in 80% of cases
  • spontaneous resolution in 4-6%

Predisposing factors

Macular Hole

  • ‘idiopathic’ (most common)
  • risk factors: older age, female gender, myopia ≥-6.0D
  • 10-15% risk of a patient with full-thickness macular hole (FTMH) developing a FTMH in the fellow eye within five years, unless the fellow eye already has a PVD in which case the risk falls to 1%

Other non-idiopathic factors

  • diabetic eye disease
  • retinal detachment
  • involutional macular thinning
  • cystoid macular oedema
  • following posterior segment surgery such as scleral buckling
  • following ocular trauma

Symptoms of macular hole

Macular hole

  • decreased visual acuity, which may be profound
  • metamorphopsia
  • micropsia
  • photopsia
  • there may be no symptoms

Signs of vitreomacular traction and macular hole

VMT
The clinical signs and OCT appearances of VMT are tabulated below

Macular hole

  • Amsler grid test (shows central distortion rather than scotoma)
  • Watzke-Allen test (narrow slit-beam projected over the macular hole appears to the patient to be thinned or broken up)
  • The International Vitreomacular Traction Study Group has published an OCT-based classification of vitreomacular adhesion, traction and macular hole which can be tabulated along with clinical signs and symptoms (see below)
StageClinical appearance /
symptoms
OCT appearance
1-A
  • Loss of foveal depression and yellowish foveal spot 100-200μm diam
  • Decreased VA (6/7.5 to 6/24)

VMT

  • Localised detachment of perifoveal vitreous cortex with persistent adherence to foveola
  • Vitreofoveolar traction splits retina at fovea (pseudocyst) which corresponds to yellow spot
  • Epiretinal membranes uncommon
1-B
  • Yellow ring 200-350μm diam
  • Decreased VA (6/7.5 to 6/24)

VMT

  • Posterior extension of pseudocyst with disruption of outer retinal layer
  • Retinal ‘roof’ intact with persistent adherence of vitreous cortex
  • Epiretinal membranes uncommon
2
  • Small full thickness macular hole, often eccentric
  • Symptoms include metamorphopsia and decreased VA (6/7.5 to 6/24)

Small or medium FTMH with VMT

  • Epiretinal membranes uncommon
3
  • Full thickness macular hole
  • Operculum clinically visible
  • Drusen-like deposits may be seen at base of macular hole
  • Severely decreased VA (6/30 to 6/120); central scotoma may be present

Medium or large FTMH with VMT

  • Posterior vitreous detached from macula but may remain attached to optic disc and more peripherally
  • Operculum visible on posterior vitreous face over macular hole
  • Cuff of subretinal fluid may be present; also intraretinal oedema and cysts
  • Rim of hyper- or hypo-pigmented RPE between detached and non-detached retina in long-standing cases
  • Epiretinal membranes may be present
4
  • Large full-thickness macular hole
  • Complete vitreous detachment with Weiss ring
  • Drusen-like deposits may be seen at base of macular hole
  • Severely decreased VA (6/30 to 6/120); central scotoma may be present

Small, medium or large FTMH without VMT

  • Cuff of subretinal fluid, intraretinal oedema and cysts
  • Epiretinal membranes more likely to be present

VMT = vitreomacular traction; FTMH = full thickness macular hole; ILM = inner limiting membrane. Macular hole size (at narrowest point): small (<250μm); medium (>250μm
 and ≤400μm); large (>400μm)

Differential diagnosis

Macular pseudohole
Cystoid macular oedema
Diabetic macular oedema
Central serous retinopathy
Solar maculopathy
Sub-foveolar drusen

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological 

OCT examination (if not available, consider referring to a colleague who has the equipment). OCT imaging provides information on the size of a macular hole
and the presence of vitreoretinal traction and/or epiretinal membrane formation. OCT images are also helpful in patient education

Careful examination of the fellow eye to identify presence of ‘at risk’ features e.g. vitreous traction at or near the centre of the macula (VMT)
(GRADE*: Level of evidence=low; Strength of recommendation=strong)

Patient education on early warning signs e.g. metamorphopsia and/or change in central vision. Supply Amsler Grid and emphasise importance of using it (a)
monocularly and (b) regularly. Alternatively, ask the patient to regularly read with each eye independently to check for changes in vision (blur or metamorphopsia)

Pharmacological 

None

Management category

B1 (modified): for VMT, Stages 1-A and 1-B, monitoring with OCT
A3: for Stages 2, 3 and 4 macular hole: urgent referral to an ophthalmologist (within one week, or in accordance with local protocols)

Possible management by ophthalmologist

30 years ago macular hole was considered incurable; nowadays surgical management results in hole closure in close to 90% of cases and visual
improvement in over 70%

Surgery or intravitreal injection of Ocriplasmin following OCT confirmation of presence and type of macular hole. Surgery is most likely when the diagnosis
is full-thickness macular hole, but lamellar macular defects may require surgery where there is significantly impaired visual acuity and/or visual distortion

FTMH (Stages 2 and 3)
Pars plana vitrectomy with internal limiting membrane (ILM) peeling and intravitreal gas, usually performed within one month of diagnosis
The ILM is usually peeled to a radius of one disc diameter around the hole. It can be visualised with the aid of dyes such as trypan blue. If the macular hole
is larger than 400μm horizontal width, the patient may need to be positioned face down, or face forward, for a week. The presence of intravitreal gas will
preclude air travel for several weeks

Cataract develops within a year following this procedure in 50-65% of patients, when it can be dealt with by conventional surgery. Some surgeons recommend
vitrectomy and peeling with cataract surgery as a single combined procedure

OCRIPLASMIN (Stage 2)
Intravitreal injection of Ocriplasmin, which induces enzymatic vitreolysis, may be recommended instead of surgery.
This technique, has been approved by NICE for patients with VMT with no epiretinal membrane and a macular hole of ≤400μm horizontal width and/or severe visual symptoms. It has a lower success rate, in terms of hole closure, than surgery (around 34%) but can produce a significant improvement in vision.
NICE concluded that it is cost-effective for this group of patients

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation. (see https://www.gradeworkinggroup.org/)

Sources of evidence

Chen JC, Lee LR. Clinical spectrum of lamellar macular defects including pseudoholes and pseudocysts defined by optical coherence tomography. Br J Ophthalmol. 2008;92(10):1342-1346

Duker JS, Kaiser PK, Binder S, de Smet MD, Gaudric A, Reichel E, Sadda SR, Sebag J, Spaide RF, Stalmans P. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120(12):2611-2619

Flaxel CJ, Adelman RA, Bailey ST, Fawzi A, Lim JI, Vemulakonda GA, Ying GS. Idiopathic Macular Hole Preferred Practice Pattern®. Ophthalmology. 2020;127(2):184-222

National Institute for Health and Care Excellence (NICE). Ocriplasmin for treating vitreomacular traction Technology appraisal guidance. Published: 23 October 2013

Neffendorf JE, Kirthi V, Pringle E, Jackson TL. Ocriplasmin for symptomatic vitreomacular adhesion. Cochrane Database Syst Rev. 2017;10(10):CD011874.

Parravano M, Giansanti F, Eandi CM, Yap YC, Rizzo S, Virgili G. Vitrectomy for idiopathic macular hole. Cochrane Database Syst Rev. 2015;2015(5):CD009080

Steel DH, Lotery AJ. Eye (Lond). Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment. Eye (Lond). 2013;27 Suppl 1(Suppl 1):S1-21

Steel DH, Donachie PHJ, Aylward GW, Laidlaw DA, Williamson TH, Yorston D; BEAVRS Macular hole outcome group. Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort. Eye (Lond). 2020 Mar 30. doi: 10.1038/s41433-020-0844-x. Online ahead of print

Tanner V, Williamson TH. Watzke-Allen slit beam test in macular holes confirmed by optical coherence tomography. Arch Ophthalmol. 2000 Aug;118(8):1059-63. doi: 10.1001/archopht.118.8.1059. PMID: 10922198

Plain language summary

The back of the eye is filled with a gel-like fluid called the vitreous which helps the eye to keep its shape. As people age the vitreous becomes more watery and starts to shrink. It normally pulls harmlessly away from the retina (this is known as posterior vitreous detachment) but sometimes the retina can tear in the process. If this happens at the macula, the centre of the retina, where the vision is sharpest and colour vision is best, a hole can develop. This causes a sudden drop in vision in the affected eye. There are also other, rarer causes of macular hole. Macular hole is not related to age-related macular degeneration.

A special examination known as optical coherence tomography (OCT) has been available since 1990. This works like an ultrasound, but using light rather than sound. It is painless and quick. There is no contact with the eye and no radiation. OCT shows the structures inside the eye, including the retina and macula, in great detail.

If an optometrist finds a macular hole, he or she will refer the patient to an ophthalmologist (eye doctor) who will probably recommend an operation, as there are no eye drops, medicines or diets that can help. The most usual operation for macular hole is called a vitrectomy, in which the vitreous pulling on the retina is removed. A bubble of gas is then placed inside the eye to help the retina to settle back into place and the macular hole to seal. In most cases this results in better vision.

An eye that has had a vitrectomy is likely to develop cataract, but this can be dealt with later by a routine operation. Surgeons sometimes perform the two operations at the same time. Some patients will be offered another kind of treatment which involves injecting a substance into the eye. This is Ocriplasmin, an enzyme that liquefies the vitreous, releasing tension on the retina.

Vitreomacular Traction and Macular Hole
Version 1
Date of search 03.11.20
Date of revision 25.06.21
Date of publication 07.09.21
Date for review 02.11.22
© College of Optometrists