Vitreomacular traction: symptoms, diagnosis and treatment options

The vitreous is a transparent gel-like structure that sits behind the iris and lens and in front of the retina, the light-sensing tissue at the back of the eye. The macula is the central part of the retina and gives the sharp central vision used for reading, recognising faces and driving. Kingston and Richmond NHS Foundation Trust explains that as we get older the vitreous gel shrinks and naturally separates from the retina.

Sometimes the gel does not separate cleanly and instead remains attached to certain areas of the retina, usually at the macula. This is called vitreomacular adhesion. When the adhesion exerts a pulling force on the macula, the condition is called vitreomacular traction. University Hospitals Plymouth NHS Trust describes it as an unusually strong attachment between the vitreous gel and the very centre of the retina, so that the central retina is lifted slightly and does not function properly.

The Kingston and Richmond leaflet says VMT may cause reduced vision or distortion of vision, where straight lines look bent. In some people it causes a macular hole, which can lead to further reduced vision or a central blind spot. The Plymouth leaflet describes reduced and distorted central vision. Because the macula handles fine detail, tasks such as reading small print or recognising faces are usually affected first, while side vision is preserved.

Any new distortion or blurred patch in central vision should be assessed promptly by an optometrist or eye clinic, and a sudden change in vision should be treated as urgent, with same-day contact with an eye casualty or NHS 111.

The Kingston and Richmond leaflet says the diagnosis involves using eye drops to dilate the pupils and an optical coherence tomography (OCT) scan, described as non-invasive and using light energy to produce detailed images of the back of the eye. This allows VMT to be diagnosed and also shows whether a macular hole has formed.

In the UK, an optometrist may notice distortion or changes on OCT in the community and refer you to a hospital eye service. A hospital ophthalmologist then confirms the diagnosis and discusses whether monitoring or treatment is more appropriate.

The Plymouth leaflet lists four main options. No treatment is one of them, and it says that if untreated you would expect one of three scenarios: spontaneous resolution, which may occur in around 10% of cases within a few months, persistence in the majority, with vision staying the same or getting worse, or progression to a macular hole with further reduction in vision. Kingston and Richmond similarly says VMT may improve, stay the same or worsen if not treated, and that some people choose not to be treated if symptoms do not bother them.

After an ocriplasmin injection, Kingston and Richmond lists common temporary side effects such as a sore, gritty eye, raised eye pressure, floaters, flashing lights, yellowing of vision and reduced vision, with rarer serious effects including permanent reduction of vision, macular hole, retinal detachment and a serious infection called endophthalmitis, which it says affects 1 in 1500 patients. Plymouth describes antibiotic drops for around a week afterwards.

After vitrectomy, Plymouth says there is a 20% chance a gas bubble will be left in the eye, in which case posturing, keeping the head in a certain position for most of the time for up to 2 weeks, may be needed. The leaflet also says that all patients who have not had cataract surgery will develop a cataract more rapidly. Any worsening pain, loss of vision or redness after eye surgery or injection needs same-day contact with the eye unit.

Plymouth gives an overall expectation for ocriplasmin patients: after 6 months a 25% chance of gaining at least 10 letters and a 7% chance of losing at least 10 letters. Its leaflet review date has passed, so ask your own eye unit for its current figures.

If you are being observed rather than treated, ask your eye team how often you will be reviewed and how to check your own vision at home, and report any change in distortion or blurring promptly.

On the NHS, diagnosis and treatment decisions are made in a hospital eye service, usually after referral from an optometrist or GP. Some people see a private ophthalmologist for faster OCT imaging or surgery, and the treatment options are the same ones described above. Because the ocriplasmin injection is no longer marketed, the remaining options in the leaflets are vitrectomy and, where offered, gas injection.