Treatment options for VMT

Pneumatic vitreolysis seems to be a safe and highly effective technique for treating symptomatic vitreomacular traction (VMT), once careful patient selection is respected, according to Marc Veckeneer MD. “We have experienced excellent results with pneumatic vitreolysis in cases of focal vitreomacular traction with severe symptoms. For those patients with epiretinal membrane (ERM) or larger macular holes, vitrectomy will probably be required,” he told delegates attending the 19th EURETINA Congress in Paris, France. Management options for VMT typically include observation, vitrectomy, intravitreal injection of ocriplasmin or pneumatic vitreolysis, noted Dr Veckeneer, Middelheim Hospital, Antwerp, Belgium. The clinical trial results of ocriplasmin were disappointing, said Dr Veckeneer, with VMT resolution in about 26.5% of patients. “This outcome improved in some recent ‘real-world’ studies to around 50%, but there are still some concerns with adverse events and we are not using it in our clinic at the moment.” In the meantime, evidence on the efficacy of pneumatic traction release is accumulating. In a recent case series of 22 eyes of 19 patients treated with an injection of 0.2 cc C2F6 gas for focal vitreomacular traction with severe symptoms, Dr Veckeneer and co-authors achieved VMT release in 18 eyes (82%) within three months. Other recent studies in the scientific literature on gas injection for VMT confirm our positive results, said Dr Veckeneer. “These are not randomised trials, but if we look at the published data for pneumatic release and combine the patient numbers, the chances of having a VMT release by just injecting gas are very high – about 89% in 131 patients overall,” he said. In addition, with regards to safety, the longstanding experience with the injection of a gas bubble in the vitreous cavity is vast and reassuring. The optimal timing for intervention is not obvious, said Dr Veckeneer, noting that one-third of VMT patients will get worse, one-third will have spontaneous VMT release and one-third will remain stable throughout follow-up. Observation is probably the best strategy for those patients with good visual acuity and no or minimal symptoms, while intervention is justified in cases of severe symptoms and visual loss. For patients with concomitant disease such as macular degeneration or diabetic macular oedema, Dr Veckeneer said that the impact of successful traction release on the underlying disease progression remains highly uncertain. Chances of a successful outcome seem higher in cases where the outer retinal and retinal pigment epithelium (RPE) degenerative changes, as seen on OCT, are still limited and in close correspondence to the area of vitreous adhesion. “If the retinal changes are more extensive and do not correspond well with the traction, I would be very careful indeed in proceeding with surgery in these patients,” he said. Marc Veckeneer: veckeneer.icare@gmail.com