*reviewed and approved by the conflict of interest ... · vitreomacular traction syndrome (vmts)...

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PETER K. KAISER, MD

C h a n e y F a m i l y E n d o w e d C h a i r i n O p h t h a l m o l o g y R e s e a r c h , P r o f e s s o r O f O p h t h a l m o l o g y

C l e v e l a n d C l i n i c L e r n e r C o l l e g e o f M e d i c i n e , C l e v e l a n d , O H

OCT of Vitreomacular Interface Disorders

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Financial Disclosure*Reviewed and approved by the Conflict of Interest Committee of the Cleveland Clinic

Alcon (C)

Alimera (C, R)

Allegro (C, S)

Bayer (C)

Genentech (C, R)

InSitu Therapeutics (C, S)

Kanghong Biotech (C)

National Eye Institute (R)

National Institute of Health (R)

Novartis (C)

Ophthotech (C, S)

Oraya (C, S)

Regeneron (C, R)

Research to Prevent Blindness (R)

SKS Ocular (S)

Thrombogenics (C)

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Loss of interfibrillar hyaluronan

Degenerative breakdown of the collagen network

Liquefied lacunae increase with age in number, size, and coalescence

Age-related changes of vitreous gel

Sebag, J. The Vitreous. Springer-Verlag New York, NY,1989

76 year old vitreous

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Vitreoretinal Adhesion

There is progressive age-related weakening of the adhesion between the posterior vitreous cortex (posterior hyaloid) and the internal limiting membrane (ILM)

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Posterior Vitreous Detachment

Natural with aging (common over 50 years of age)1

Characterized by2

– Synchisis: vitreous gel liquefaction

– Syneresis: separation of the vitreous at the vitreoretinal interface Natural Aging

1. Hikichi T, et al. Ophthalmic Surg. 1995;26(1):39‐43.

2. Sebag J, Wang MY. In: Holz FG, Spaide RF, eds. Medical Retina: Focus on Retinal Imaging. Berlin, Germany: Springer‐Verlag; 2009:157‐168.3. Faulborn J, et al. Ophthalmologica. 1998;212(6):369‐376. 4. Gandorfer A, et al. Eye (Lond). 2002;16(1):95‐97. 6

Normal Vitreous Aging

Stage 1 – Vitreomacular adhesion (VMA)

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Stage 2 – Separation from macula

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Stage 3 – Separation for entire posterior retina except optic nerve

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9

Complete PVD is rare

Faulborn Oph 1998. Gandorfer Eye 2002 1010

Liquefaction without vitreoretinal dehiscence

Macular

Pucker

Macular

Pucker

VMT

Syndrome

VMT

Syndrome

Vitreopapillary

Traction

Vitreopapillary

Traction

Retinal

Tear

Retinal

Tear

Anomalous

PVD

Anomalous

PVD

Peripheral Separation

Posterior Traction

Centripetal (inward)

Contraction

Premacular

Membrane

Premacular

Membrane

J. Sebag, Retina 2009;29(7):871-874.

Centrifugal (outward)

Contraction

Full Thickness,

but partial PVD

Peripheral Separation

Peripheral Traction

Macular

Hole

Macular

Hole

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International VMI Consensus Working Group

Jay Duker, MDNew England Eye CenterBoston, MassachusettsUSA

Peter K Kaiser, MDCole Eye InstituteCleveland, OhioUSA

Susanne Binder, MDRudolf Foundation ClinicVienna, Austria

Marc de Smet, MD, PhDMontchoisi ClinicLe Mont‐sur‐Lausanne, Switzerland

Alain Gaudric, MDLariboisière HospitalParis Diderot UniversityParis, France

Elias Reichel, MDNew England Eye CenterBoston, MassachusettsUSA

SriniVas Sadda, MDDoheny Eye InstituteLos Angeles, CaliforniaUSA

Jerry Sebag, MDVMR InstituteHuntington Beach, CAUSA

Richard Spaide, MDVitreous‐Retina‐Macula ConsultantsNew York, New YorkUSA

Peter Stalmans, MDUZ LeuvenLeuven, Belgium

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Goals of the Classification Scheme

Simple, easy to use, easy to remember

Objective – no symptoms, no clinical findings

Based on OCT alone

Applicable to clinical practice

Helpful in predicting surgical outcomes

Useful for clinical trials

Allow retina community to speak a “common language”

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1313

Vitreomacular adhesion (VMA)

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Vitreomacular Adhesion (VMA) –International Classification

Exclusively an OCT “finding”– No symptoms

– No clinical findings

Due to age-related changes of the vitreous

Rarely pathologic

Common

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Swept Source

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Focal versus Broad

Why 1500 microns?– Known site of strong VM adhesion by histology– Pre-existing cut-off employed by reading centers

< 1500 = focal

= 1500 microns

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1818

Isolated versus Concurrent

Isolated = isolated finding on OCT in absence of posterior segment disease

Concurrent = associated with a posterior segment diseaseoVMA may or may not be directly attributable to concurrent disease

oVisual affects, if present, may be due to VMA or the secondary disease or both

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Isolated Focal VMA

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Otherwise normal macula = Isolated focal VMA

2020

Concurrent Focal VMA

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Concurrent focal VMA (associated with CSC)

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Clinical Course of VMA

Asymptomatic

VMA

SpontaneousResolution

VMT

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2222

Vitreomacular Traction (VMT) –International Classification

Definition = VMA with ANY abnormal macular retinal architecture

OCT diagnosis

“symptomatic VMA” = VMT

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VMT

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Isolated Focal VMT

VMT = VMA with retinal architectural changes

2525

Isolated Focal VMT


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2626

Isolated Focal VMT


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Isolated Broad VMT

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Isolated Broad VMT

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Pathology at the vitreoretinal interface

Growth factors at the vitreoretinal interface– Laminin, fibronectin, and others

May contribute to fibrocellular proliferation at the retinal surface in the presence of vitreous remnants

“Vitreoschisis”: collagen and cells left firmly attached to the ILM

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VMT Becomes ERM

52 year old high myope

VA = 20/25

Mild metamorphopsia

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VMT Becomes ERM

2 years later

Worsening symptoms

VA = 20/50

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Epiretinal Membrane

Cellular proliferations ona layer of native vitreous collagen

The ILM and/or vitreous collagen serves as a scaffold for cellular proliferation

Adhesion of vitreous collagen transmits tangential tractionalforces to the retina

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Epiretinal membrane

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C-Scan ERM

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Vitreomacular traction syndrome (VMTS)

Characteristic clinical appearance at macular surface (wrinkling, tightening, thickening)

Typically has double membrane due to hyaloidal splitting or surface profileration

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3737


An ERM is present in the VMT syndrome (VMTS)

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Full Thickness Macular Hole

A full-thickness defect of retinal tissue involving the anatomic fovea

– First described in 1869 following ocular trauma by Knapp

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Pseudohole

Differentiate macular holes, lamellar holes, and pseudoholes

Macular hole Lamellar hole

OCT in vitreoretinal interface disorders

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Pseudohole

Steepened foveal contour, small foveal aperture

Thickening of macular edges (without thinning of foveal center)

Reduced macular diameter

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OCT of Pseudohole

Steep profile consistent with Allen and Gass' hypothesis of centripetal ERM constriction

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ERM with Pseudohole

4343UHR-OCT Courtesy of Jay Duker, MD

ERM with PseudoholeERM with Pseudohole

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Lamellar Hole

Gass definition: aborted macular hole

Complete PVD - pulls off inner retinal tissue leaving outer retina (photoreceptors) intact

Vision usually good - 20/20 to 20/30

Usually stable

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Lamellar Hole

Visual Acuity 20/30Followed 18 months

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Lamellar Hole

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Gass Classification

Stage 1

Stage 2

Stage 3/4

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“Stage 1a Macular Hole” = VMT


“Stage 2 Macular Hole” = FTMH

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5151


5252




5454


14

5555

Swept Source

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Stage 3 Macular Hole

5757


5858


15

5959

OD = 20/50 OS = 20/20

Stage “0” hole = VMA

• Stage 0 macular hole has a 42% risk of going to full thickness macular hole

• If contralateral eye does not have a stage 0 only 3% risk

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OCT for Macular Hole

Diameter of macular hole associated with initial closure rates

– Prognosis better for eyes with small diameter macular holes

– Late re-opening of macular holes with larger diameter more common

Ip MS, et al. Arch Ophthalmol 2002;120:29-35

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Size for FTMH

Size (not stage) most important variable to predict anatomic success (eg Stage 4 holes can be small)

SMALL: < 250 microns near 100% closure

MEDIUM: > 250 < 400 about 95% closure

LARGE: ≥ 400 microns about 75% closure

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FTMH International Classification System

Based on size of full thickness defect

VMT = present or absent

Primary versus secondary

Note:– No stages

– No “idiopathic” . Now referred to as Primary. Due to VMA VMT

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6363

FTMH Subclassification – Small (< 250 microns)

80 microns

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FTMH Medium (251 – 400 microns)

390 microns

6565

FTMH Large (> 401 microns)

516 microns

6666

FTMH – VMT Present or Absent

Small FTMH –VMT released

Small FTMH –VMT present

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6767

FTMH Primary vs Secondary

Primary = due to VMA leading to VMT (formerly “idiopathic” macular hole)

Secondary– Not initiated by VMA or VMT

– Secondary to preexisting or concurrent condition or disease

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Secondary FTMH

Pre-existing or concurrent condition or disease without evidence of VMT

– TraumaoBlunt trauma

oLightning strike

oSurgical procedure

– Myopia

– Macular schisis

– MacTel Type 2

– Choroidal neovascularization (CNV) treated with anti-VEGF

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OCT of the Vitreomacular Interface

OCT is invaluable for evaluation of the vitreomacularinterface

Diagnosis and management will be altered based on OCT findings

OCT can visualize subtle findings that may be impossible to see clinically

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Thank you...

*reviewed and approved by the conflict of interest ... · vitreomacular traction syndrome (vmts)...

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