Idiopathic Macular Hole Classification Revisited
Update on Vitreomacular Traction and Macular Holes Kyle D Klute, OD, FAAO Heartland Eye Consultants Omaha, NE @heartland_eye Heartland Eye Consultants Goals What am I looking at? How did it get there? Definitions Pathophysiology What do I do with it? Management Heartland Eye Consultants Vitreomacular Traction Epiretinal Membrane Pseudohole Vitreoretinal Interface Disorders Lamellar Hole Idiopathic Macular Hole Heartland Eye Consultants What am I looking at? Heartland Eye Consultants What is it? What do I do with it? FTMH Heartland Eye Consultants What is it? What do I do with it? Heartland Eye Consultants What is it? What do I do with it? VMA Heartland Eye Consultants What is it? What do I do with it? Heartland Eye Consultants What is it? What do I do with it? Heartland Eye Consultants What is it? What do I do with it? Heartland Eye Consultants Vitreomacular Adhesion Definition The normal anatomic state, often used clinically to describe the adhesion of the posterior vitreous face to the macula with surrounding separation of the hyaloid face from the neurosensory retina Perifoveal vitreous detached (stage 1 PVD) No evidence of foveal distortion Heartland Eye Consultants Vitreomacular Traction Definition VMA that exerts focal traction and distorts the macula Pathologic, VMA is not pathologic Heartland Eye Consultants Vitreomacular Traction Syndrome VMT that is symptomatic CASE Hx + Heartland Eye Consultants Vitreomacular Traction and Macular holes Patient Characteristics: Slight female predilection (65%) Visual complaints new onset blur, metamorphopsia Can occur at any age 50% are aged 65-74 Beaver Dam Eye Study: FTMH prevalence of 0.29% Heartland Eye Consultants OCT interpretation Heartland Eye Consultants Pathogenesis of PVD Vitreous Liquefaction Weakening of Vitreoretinal adhesions Heartland Eye Consultants Vitreoretinal Adhesion At vitreous base Collagen fibrils run perpendicular and pass through ILM to form strong adhesion Posterior pole Fibrils run parallel, do not pass into ILM “Extracellular matrix glue” Laminin Fibronectin Collagen Heartland Eye Consultants Vitreous Liquefaction (syneresis) Begins in front of macula and central vitreous cavity Liquid vitreous: 20% mid-late teens, 50% at 70 Premacular liquified pocket enlargens Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc 2005;103:537–567.) Heartland Eye Consultants Stages of PVD Stage 1 Perifoveal PVD Vitreofoveal adhesion Stage 2 Macular PVD No vitreofoveal adhesion Stage 3 Near-complete PVD Vitreopapillary adhesion Stage 4 Complete PVD Wiess Ring Months to years process Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc 2005;103:537–567.) Heartland Eye Consultants Pathogenesis of PVD Vitreous Liquefaction Vitreous Liquefaction Weakening of Vitreoretinal Weakening of adhesions Vitreoretinal adhesions Johnson, MW. Posterior Vitreous Detachment: Evolution and Complications of its Early Stages. Am J Ophthalmol 2010;149:371–382 Heartland Eye Consultants Pathogenesis of PVD Vitreous Liquefaction >> Weakening of Vitreoretinal adhesions =Anomalous PVD Johnson, MW. Posterior Vitreous Detachment: Evolution and Complications of its Early Stages. Am J Ophthalmol 2010;149:371–382 Heartland Eye Consultants Complications of PVD Causes of accelerated liquefaction Stickler and Marfan syndromes (Type II collagen) Retinal vascular disease Trauma Aphakia Inflammation Vitreous hemorrhage Reduced estrogen = reduced hyaluronic acid synth Heartland Eye Consultants Complications of PVD Early-stage PVD (Stage 1-3) Epiretinal membrane Macular microhole Idiopathic macular hole Pseudo-operculum Inner lamellar macular hole Vitreofoveolar traction (CME) Vitreomacular traction syndrome Traction diabetic macular edema Myopic traction maculopathy Neovascular age-related macular degeneration Vitreopapillary traction syndrome Complete PVD (Stage 4) Retinal or Optic disc hemorrhage – NTG or PVD? Vitreous hemorrhage Retinal tear ~10% of acute symptomatic PVD’s Rhegmatogenous retinal detachment International Vitreomacular Traction Study Group Classification Vitreomacular Adhesion Vitreomacular Traction Macular Hole Lamellar Hole Pseudohole Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants Heartland Eye Consultants Full Thickness Macular Holes Pathophysiology debated Tangential traction? Anterior-posterior traction? Classification originally by Gass in 1988 Revised due to OCT Primary (Idiopathic) due to anomalous PVD Secondary (other pathologic features, no VMT): trauma, high myopia, macular schisis, wet ARMD, surgical trauma, etc. Heartland Eye Consultants Gass, J.D. 1988, then reappraised in 1995 Classification based upon biomicroscopic findings Tangential traction Gass JD. Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 1988;106:629-39. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752-9 Heartland Eye Consultants Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995;119:752-9 Heartland Eye Consultants Gaudric et al. 1999 Archives of Ophthalomology Staging of I-III based upon OCT findings Anterior-posterior traction Gaudric A, Haouchine B, Massin P, et al. Macular hole formation: new data provided by optical coherence tomography. Arch Ophthalmol 1999;117:744-51 Heartland Eye Consultants Gaudric et al. 2001 Ophthalmology Haouchine B, Massin P, Gaudric A. Foveal pseudocyst as the first step in macular hole formation: a prospective study by optical coherence tomography. Ophthalmology 2001;108:15-22. Heartland Eye Consultants Altaweel and Ip, 2003 Stage 1a Foveal splitting (not detachment as proposed by Gass), a pseudocyst visible on OCT prior to the clinically recognized yellow spot Altaweel M, Ip M: Macular hole: improved understanding of pathogenesis, staging, and management based on optical coherence tomography. Semin Ophthalmology 18:58-66,2003 Heartland Eye Consultants Altaweel and Ip, 2003 Stage 1b Pseudocyst enlargement and extension to the outer retina, roof intact Altaweel M, Ip M: Macular hole: improved understanding of pathogenesis, staging, and management based on optical coherence tomography. Semin Ophthalmology 18:58-66,2003 Heartland Eye Consultants Full Thickness Macular Holes Tangential: Anterior-posterior: International Vitreomacular Traction Study Group Classification Vitreomacular Adhesion Vitreomacular Traction Macular Hole Lamellar Hole Pseudohole Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants Heartland Eye Consultants Vitreomacular Adhesion Classification Focal VMA Broad VMA <1500 µm >1500 µm Isolated or Concurrent Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants Vitreomacular Adhesion Isolated, Focal VMA Heartland Eye Consultants Vitreomacular Adhesion Heartland Eye Consultants Vitreomacular Traction Classification Focal VMT Broad VMT <1500 µm >1500 µm Isolated or Concurrent Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants Vitreomacular Traction Isolated, Focal VMT Heartland Eye Consultants Vitreomacular Traction Heartland Eye Consultants Vitreomacular Traction Vitreomacular Traction Heartland Eye Consultants Haochine MD, et al. Foveal pseudocyst as the first step in macular hole formation. Ophthalmology 2001;108:15-22. Vitreomacular Traction Heartland Eye Consultants Haochine MD, et al. Foveal pseudocyst as the first step in macular hole formation. Ophthalmology 2001;108:15-22. VMA VMT FTMH Heartland Eye Consultants Bottos J, et al. Vitreomacular Traction Syndrome. J Ophth Vis Res 2012;7(2):148-161. Heartland Eye Consultants Full Thickness Macular Hole Definition Full thickness foveal interruption of all macular layers from ILM to RPE Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 IVTSG Full Thickness Macular Hole Heartland Eye Consultants Classification Small (≤250 µm) Medium (>250 µm and ≤400 µm) Large (>400 µm) Presence or absence of VMT Cause Primary Secondary Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants IVTSG Small Full Thickness Macular Hole ≤250 µm No concurrent VMT Gass Stage 2 or 3 Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Small Macular Hole Small (≤250 µm) Concurrent VMT Heartland Eye Consultants IVTSG Medium Full Thickness Macular Hole >250 µm and ≤400 µm No concurrent VMT Gass staging? Heartland Eye Consultants Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Medium Macular Hole >250 µm and ≤400 µm Concurrent VMT Gass staging? Heartland Eye Consultants Heartland Eye Consultants IVTSG Large Full Thickness Macular Hole >400 µm Concurrent VMA Primary Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Large Macular Hole 716 µm width Gass Stage 3 FTMH Heartland Eye Consultants International Vitreomacular Traction Study Group Classification Vitreomacular Adhesion Vitreomacular Traction Macular Hole Lamellar Hole Pseudohole Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants Heartland Eye Consultants Lamellar Hole Pathway Aborted Stage 1 macular hole Description Irregular foveal contour Defect in inner fovea Intraretinal splitting Intact photoreceptor layer Funduscopy? Duker et al. International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Holes. Ophthalmology 2013;120:2611-2619 Heartland Eye Consultants VMA VMT Lamellar Hole Haochine MD, et al. Foveal pseudocyst as the first step in macular hole formation. Ophthalmology 2001;108:15-22. Heartland Eye Consultants Lamellar Macular Hole Heartland Eye Consultants Lamellar Macular Hole Heartland Eye Consultants Macular Pseudohole • Definition • Heaped foveal edges • Concommitant ERM • Steep macular contour with near normal foveal thickness • No loss of retinal tissue • Appears as FTMH on fundoscopy • VA difference • Watske Allen? Heartland Eye Consultants Heartland Eye Consultants Epiretinal Membrane Majority of eyes have partial or complete PVD Two mechanisms: 1. Traction causes breaks in ILM – glial cell poliferation, fibrous astrocytes, fibrocytes, myofibroblasts, and RPE cells 2. Vitreous cortical remnants left on the retinal surface, allowing proliferation and transdifferentiation of hyalocytes Heartland Eye Consultants Epiretinal Membrane Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc 2005;103:537–567.) ERM with Pseudohole Heartland Eye Consultants Heartland Eye Consultants PSH vs LMH vs VMT Chen JC. Clinical spectrum of lamellar macular defects including pseudholes and pseudocysts defined by OCT. Br J Ophthalmol 2008;92:1342-1346 Heartland Eye Consultants Differential Dx Summary Visual acuity: ~ 20/60 or worse = FTMH ~20/50 or better = Pseudohole/Lameller/VMT Fundus appearance OCT appearance Full thickness? Loss of tissue? Associated ERM? Heartland Eye Consultants Treatment/Management Observation PPV/ILM/C3F8 Ocriplasmin (Jetrea®) Heartland Eye Consultants VMT Treatment: Observation Theodossiadis et al. followed 192 eyes with idopathic, isolated VMA and found majority of patients do not progress to VMT. Patients followed for 4 years with OCT every 3 months: 35.9% worsened to VMT 33.9% remained stable 30.2% exhibited spontaneous release of VMA with complete PVD Authors could not predict which patients would progress to VMT Heartland Eye Consultants VMT Treatment: Observation John et al. retrospectively reviewed 106 eyes with VMT Mean acuity: 20/37 F/U 23 months spontaneous release in 32% worsening of VMT in 16% 4.7% 5 eyes underwent PPV for either FTMH or worsening vision mean snellen 20/35 at f/u Dimopoulos et al. 46 patients who presented with VMT measuring less than 1500um managed with observation. Mean acuity: 20/36 43% spontaneous release of VMT at a median of 374 days (91008 days) following VMT diagnosis 15% ultimately underwent PPV Heartland Eye Consultants VMT Treatment: Observation Factors predictive of spontaneous release (~1/3 of VMT): Adhesion diameter < 400 um wide angle b/t vitreous surface and nasal and temporal macula (V pattern adhesion) Isolated inner retinal distortion Concurrent treatment of retinal diseases with intravitreal injections Heartland Eye Consultants VMA VMT Spontaneous resolution Johnson MW. Posterior Viteous Detachment: Evolution and Complications of its Early Stages. Am J Ophthalmol 2010;149:371-382 Heartland Eye Consultants VMT Treatment: Observation OD OS Initial Exam 20/20 20/20-2 3 months later 20/20-2 9 months later 20/20-1 20/20-1 VMT Treatment: PPV Heartland Eye Consultants Visual acuity indication (VMT/LH/ERM): ~ 20/40 – 20/50 ? Recent systematic review of PPV for VMT (19 studies, 392 eyes): VA post PPV: 9.2% of eyes worsened, 11.7% were unchanged, and 64.3% (217 eyes) improved 32.9% had an improvement of 2 or more Snellen lines. VMT Treatment: PPV Most frequent complications: Intraoperative: Retinal hemorrhages (5.6%) Peripheral retinal breaks (1.6%) Postoperative: Cataracts ERM (34.7%) (5.7%) Retinal detachment (1.4%) Heartland Eye Consultants Heartland Eye Consultants Vitreomacular Traction Focal VMT Isolated BVA 20/60+ Heartland Eye Consultants Vitreomacular Traction 6 weeks post PPV BVA 20/30- FTMH Treatment: Observation? Heartland Eye Consultants 3-11% spontaneously resolve 75% of stage 2 (Gass) progress to stage 3 or 4 15-20% risk of fellow eye FTMH Treatment: PPV Introduced in 1991 Indicated for treatment of holes of all sizes/stages Small/Medium/Large or Gass stage 2,3,4 Success: Anatomic (closure): 80%-100% VA improvement (20/40 or better): 25%-40% Predictors of success: Duration of symptoms < 6 months Hole size < 400 um Complications: Cataracts: 75% in 3 years Retinal tears: 3-17% RD: 1-5% Heartland Eye Consultants FTMH Treatment: PPV Heartland Eye Consultants OD OS 20/60+2 20/20+2 20/40+1 20/20+2 Initial Exam Post PPV with membrane peel and C3F8 gas FTMH Treatment: PPV ILM peel? Face down positioning? Patient education: Heartland Eye Consultants 5 year risk of developing FTMH in fellow eye is 15%-20% ~2% if complete PVD present Heartland Eye Consultants Pharmacologic Vitreolysis: Ocriplasmin Cleaves fibronectin, laminin, and possibly type IV collagen, inducing vitreoretinal separation and liquefaction FDA approved in 2012 for treatment of symptomatic VMT MIVI-TRUST (Microplasmin for intravitreal Injection – Traction Release without Surgical Treatment) 652 patients: 125ug ocriplasmin vs. placebo Inclusion criteria: Focal VMA seen on OCT BCVA of 20/25 or worse Exclusion criteria: High myopia Prior vitrectomy, prior macular photocoagulation MH greater than 400 um ERM was not excluded Jetrea® (Ocriplasmin) Heartland Eye Consultants Primary Endpoint: non-surgical VMA resolution at day 28 26.5% vs. 10.1% Stalmans P, et al. Enzymatic Vitreolysis with Ocriplasmin for Vitreomacular Traction and Macular Holes. N Engl J Med 2012;367:606-15 Jetrea® (Ocriplasmin) Heartland Eye Consultants Secondary Endpoint: Total PVD at 6 months Stalmans P, et al. Enzymatic Vitreolysis with Ocriplasmin for Vitreomacular Traction and Macular Holes. N Engl J Med 2012;367:606-15 Jetrea® (Ocriplasmin) Heartland Eye Consultants Presence of ERM? Stalmans P, et al. Enzymatic Vitreolysis with Ocriplasmin for Vitreomacular Traction and Macular Holes. N Engl J Med 2012;367:606-15 Jetrea® (Ocriplasmin) Heartland Eye Consultants Secondary Endpoint: nonsurgical closure of FTMH at 6 months Stalmans P, et al. Enzymatic Vitreolysis with Ocriplasmin for Vitreomacular Traction and Macular Holes. N Engl J Med 2012;367:606-15 Jetrea® (Ocriplasmin) Heartland Eye Consultants Subgroup analysis of FTMH: Small holes <250 um: 58% closure rate (at 6 months) Medium holes 250 to 400 um: 37% closure rate Large holes >400 um: 0% closure rate Predictors of success: Adhesion < 1500um Absence of ERM Phakic status Age < 65 Small FTMH Jetrea® (Ocriplasmin) Heartland Eye Consultants AJO May 2015: Efficacy of ocriplasmin on VMT and FTMH Retrospective, 58 eyes treated with ocriplasmin 50% VMT release rate (vs. 26.5% in MIVI-TRUST) 27% FTMH closure rate (vs. 40.6% in MIVI-TRUST) Jetrea (Ocriplasmin) Safety? Most common: (mostly mild and transient) Vitreous floaters Photopsia Conjunctival hemes Less common but more concerning: Vision loss Dyschromotopsia Darkening of vision Ellipsoid layer changes (IS/OS junction) Reduced ERG amplitudies Heartland Eye Consultants Management summary Heartland Eye Consultants Monitor VMA Asymptomatic VMT LH/ERM/Pseudo stable VA ≥ 20/40 and patient happy WATCH Management summary Heartland Eye Consultants Treatment indicated FTMH Symptomatic VMT with patient consent LH/ERM VA ≤ 20/50 WARNING! Heartland Eye Consultants Questions?
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