|Year : 2015 | Volume
| Issue : 3 | Page : 153-155
Surgical technique to avoid deroofing in advanced vitreomacular traction
Prabhushanker Mahalingam1, Kumar Sambhav2, Geetha Ganesan1
1 Department of Vitreo-Retina, Sankara Eye Care Institutions, Coimbatore, Tamil Nadu, India
2 Department of Vitreo-Retina, Brar Eye Hospital, Kot Kapura, Punjab, India
|Date of Web Publication||20-Aug-2015|
Sankara Eye Centre, Sathy Road, Sivanandapuram, Coimbatore - 641 035, Tamil Nadu
Source of Support: None, Conflict of Interest: None
We report a novel management technique in case of advanced vitreomacular traction which avoids deroofing of macula and prevent the formation of iatrogenic macular hole. The primary treatment modality in the management of such cases is pars plana vitrectomy with posterior vitreous detachment (PVD) induction and with or without membrane peeling. We performed pars plana vitrectomy with minimal induction of PVD and release of traction all around the macula. No membrane peeling was done due to risk of deroofing of the macula and formation of iatrogenic macular hole. Postoperative course was stable with improvement in visual acuity (VA) and flattening of macula. This technique marked an alternative surgical approach in treatment of advanced vitreomacular traction.
Keywords: Iatrogenic macular hole, pars plana vitrectomy, posterior vitreous detachment, vitreomacular traction
|How to cite this article:|
Mahalingam P, Sambhav K, Ganesan G. Surgical technique to avoid deroofing in advanced vitreomacular traction. J Clin Ophthalmol Res 2015;3:153-5
|How to cite this URL:|
Mahalingam P, Sambhav K, Ganesan G. Surgical technique to avoid deroofing in advanced vitreomacular traction. J Clin Ophthalmol Res [serial online] 2015 [cited 2021 Apr 14];3:153-5. Available from: https://www.jcor.in/text.asp?2015/3/3/153/163299
Vitreomacular traction is an anomaly in the common age related process of posterior vitreous detachment (PVD). It can progress to spontaneous complete vitreous detachment or presents with development of epiretinal membrane or idiopathic macular holes. Vitreomacular traction is the presence of persistent adhesions at macula which exerts tractional forces leading to symptoms of visual disturbances such as diminution of vision, metamorphopsia, and photopsia. With the advent of newer machines like optical coherence tomography (OCT), there are increasingly more accurate visualizations of the macular disorders including vitreomacular traction. The improved diagnostic technique facilitates proper planning of the management strategy. 
The primary treatment modality is pars plan a vitrectomy and induction of PVD with or without peeling of the inner limiting membrane.  The development of intravitreal agents like ocriplasmin facilitates induction of PVD.  During surgery, it has been noted that in few cases, induction of PVD and the release of vitreomacular traction is associated with complete deroofing of the area leading to the formation of iatrogenic macular hole. This article presents a modification of standard surgical procedure to improve the anatomic and functional outcome.
| Case Report|| |
A 73-year-old male patient presented to us with complaints of diminution of vision in both eyes for 6 months. The patient was a known diabetic. His best corrected visual acuity (VA) in right eye was counting fingers at 2 m and in left eye was 5/60. His intraocular pressure was 9 and 13 mmHg in right and left eye, respectively. Anterior segment examination showed pseudophakia in both eyes with bullous keratopathy in right eye. The fund us view of the right eye was hazy due to corneal disease, but the left eye fundus examination showed absent foveal reflex with early epiretinal membrane. OCT was done, which showed the presence of vitreomacular traction with a central macular thickness of 479 μm [Figure 1]. After taking informed consent, patient was taken up for surgery. Twenty-three gauge pars plana vitrectomy was done and minimal PVD was induced around the disc and the traction all around the macula was released using the vitreous cutter. No membrane peeling was done due to risk of deroofing of the macula and formation of iatrogenic macular hole. Fluid air exchange was done at the end of surgery. Postoperatively, patient was started on topical steroids. Patient was reviewed after 1 week. OCT showed that the vitreomacular traction is relieved and macula has started flattening with tuft of vitreous stained with triamcinolone attached to the fovea [Figure 2]. After 1 month, OCT showed further flattening of macula with a central macular thickness of 271 μm with presence of subretinal fluid [Figure 3]. At the end of 3 months, patient had a best corrected VA of 6/36 [Figure 4]. At the end of 6 months, best corrected VA further improved to 6/18. The OCT showed complete flattening of macula with a central macular thickness of 250 μm with epiretinal membrane and lamellar hole [Figure 5]. Patient was reviewed at 1 year with a stable vision of 6/18 [Figure 6].
| Discussion|| |
Normal aging process is associated with a number of physiological changes in the eye ball including vitreous gel. The vitreous gel itself is most firmly attached to the retina at the vitreous base, optic disc, and fovea, and along the major retinal blood vessels. As the age advances, there is collapse of the collagen fibrils in vitreous gel leading to its detachment from the retina. This process is sometimes complicated by persistent vitreomacular adhesions between the vitreous cortex and the macular area. This macular disorder was first described in 1970 by Reese et al.  OCT is the most accurate method for visualizing and identifying vitreomacular adhesions.
According to a study by Johnson, PVD with a small vitreofoveolar adhesion (500 μm or less) may cause localized cystoid foveal thickening or one of several macular hole conditions, while traction associated with larger adhesion zones may cause or exacerbate a separate group of macular disorders. 
Many patients with vitreomacular traction maintain good VA with minimal symptoms, and do not require any intervention. They resolve spontaneously in most cases with favorable anatomic and functional outcomes comparable to surgical treatment.  But a few patients present with poor VA and progressive macular traction, necessitating surgical intervention.
The standard surgical management is pars plana vitrectomy with release of posterior hyaloid membrane and peeling of epiretinal membrane/internal limiting membrane (ILM). In some cases, the posterior hyaloid is tightly anchored to the foveal center, and its separation is extremely difficult. Sometimes, these strong adhesions lead to iatrogenic macular holes leading to subnormal visual gain. Odrobina et al.,  presented a case of a macular hole formation and its spontaneous closure after vitrectomy for vitreomacular traction. They documented that the release of the mechanical traction may be the main reason for the eventual closure of the macular hole. The ILM peeling induces glial cell proliferation across the hole and this mechanism helped the spontaneous closure of macular hole.
We have modified the technique by releasing the vitreomacular adhesions all around the foveal attachment, and thus avoiding deroofing of macula. In this procedure we did not peel the ILM, and hence patient developed epiretinal membrane with lamellar hole post-surgery. The visual gain after the surgery was comparable to standard technique. However, more surgeries with similar technique are to be done before incorporating this technique into the standard operating procedures in patients with advanced vitreomacular traction.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]