1. 1. PVD is the separation of the posterior vitreous from the retinal ILM1 This is a normal, physiologic process that occurs with aging Processes involved:2 Synchysis: Pockets of liquefaction form within the vitreous and increase in number/size Syneresis: As liquefaction occurs, the collagen fibrillar component collapses Weakening of the vitreoretinal adhesion is also required2,3 The posterior vitreous separates completely from the ILM when these processes have occurred to a sufficient extent2 PVD can be asymptomatic, although some patients report floaters (perception of small gray or dark spots in the visual field) or flashes of light4 ILM, internal limiting membrane; PVD, posterior vitreous detachment 1. Johnson MW. Am J Ophthalmol 2010;149:371; 2. Schneider EW, Johnson MW. Clin Ophthalmol 2011;5:1151; 3. Sebag J. Graefes Arch Clin Exp Ophthalmol 2004;242:690; 4. Hollands H et al. JAMA 2009;302:2243 Early liquefaction Extensive liquefaction Separation
2. 2. There should be sufficient weakening at the vitreoretinal interface when the critical level of liquefaction has been achieved1 If not, incomplete PVD can arise VMA: Areas of adhesion between the posterior hyaloid cortex and the fovea, due to incomplete PVD2 May cause a range of sequelae, e.g.1 VMT MH Retinal tear VMA at the optic nerve and macula resulting in VMT MH, macular hole; PVD, posterior vitreous detachment; VMA, vitreomacular adhesion; VMT, vitreomacular traction 1. Sebag J. Graefes Arch Clin Exp Ophthalmol 2004;242:690; 2. Dugel P. Retina Today April 2012;50;
3. 3. Vitreomacular Traction Tractional forces associated with VMA1 Static anterior traction1 Traction exerted anteriorly, towards the plane of detachment The inner portion of the fovea is often pulled above the plane of the surrounding macula Dynamic traction1 Ocular rotations lead to localization of dynamic tractional forces at the foveola Vitreomacular traction Static anterior traction Dynamic traction 1. Johnson MW. Am J Ophthalmol 2010;149:371
4. 4. Stalmans P et al. Retina 2013;33:2003; Sebag J. Graefes Arch Clin Exp Ophthalmol 2004;242:690; Sebag J. Br J Ophthalmol 2009;93:989 19 Full-thickness macular hole Vitreopapillary traction Macula Optic disc Vitreous base Epiretinal membrane Focal vitreomacular adhesion Foveal retinoschisis Macular pucker Diabetic macular edema AMD Lamellar hole Vitreous hemorrhage Peripheral retinal tear Retinal detachment Complete PVD with fibrosis Incomplete PVD with foveal adhesion Retinal layer separation Concomitant disease Incomplete PVD with optic disc adhesion Increased peripheral traction Vitreomacular traction Isolated Concomitant Vitreoretinal attachment
5. 5. IVTS Definition and Classification of VMT Duker JS et al. Ophthalmology 2013;doi:10.1016/j.ophtha.2013.07.042 Focal VMT The white arrows mark the sites of vitreous attachment The area of attachment is 1500 m and is associated with distortion of the foveal surface Focal VMT with intrafoveal pseudocyst Broad VMT The white arrowheads mark an ERM and macular pucker The area of attachment is >1500 m and is associated with distortion of the foveal surface and elevation of the foveal floor
6. 6. Il segmento posteriore del sistema oculare
7. 7. Corpo Vitreo Transmette la luce verso il segmento posteriore. Sostiene posteriormente il cristallino. Contribuisce a mantenere in sede la retina. Influisce sulla pressione intraoculare (PIO).
8. 8. Corpo Vitreo VOLUME di 4 ml (70-80% delvolume del globo). 99% ACQUA - H20 ACIDO IALURONICO: polisaccaride, fa da ponte FIBRE COLLAGENE : tipo II (IX) di supporto disposte a banda perodica. Maggior densit fibre a livello cortex posteriore cortex anteriore e base vitreale. Minor densit a livello vitreo centrale.
9. 9. 1. CORTEX- Corteccia vitreale Struttura pi densa e fibrillare Adiacente a retina cristallino e nervo ottico Include la base vitreale Condensata in una doppia membrana ialoidea Ialoide posteriore aderisce in fibrille alla limitante interna retinica (c.IV). Spazio clivabile (es.DPV)
10. 10. 1. CORTEX- Corteccia vitreale 1. Adesione lamina basale retinica Muller (limitante) 2. Anello di adesione parafoveale (foro maculare) 3. Adeso ai vasi calibro maggiore (rotture con emoraggie) 4. Adeso vene periferiche (genesi proliferazione Hb) 5. Saldamente adeso in regioni anomale (degenerazione palizzata, ciuffi cistici, cicatrici corioretiniche anche da argon laser), N.O. (Weiss)
11. 11. Pi gelatinoso, meno fibrillare Contiene canale Cloquet fossa patellare Forma legamento ialoideo-capsulare che lateralmente si collega allinserzione fibre zonulari. Ialoide anterioree regiona dellora con FORTE ADESIONE a livello PARS CILISRIS base vitreale.
12. 12. Zona di adesione pi importante del vitreo anteriore. 1,5 davanti e 3 mm dietro ORA 5 mm dal limbus Tenacemente adesa PARS PLANA Arretramento posteriore con let: genera trazioni Traumi chirurgici da introduzione VPP 3. Base Vitreale
13. 13. Corpo Vitreo
14. 14. Fotocoagulazione ed atrofie
15. 15. The Prognosis of Vitreomacular Traction and Macular Hole The prognosis for patients with VMT is generally poor, and the development of visual impairment and MH can be rapid15 ~30% of patients have a visual acuity of 20/200 or worse 6 months after diagnosis of VMT2 64% of eyes with VMT experience a loss of 2 lines of vision 5 years after initial presentation2 In patients with MH:6,7 Only ~8% have a visual acuity of 20/50 or better Up to 54% have a visual acuity of 20/200 or worse 7484% of patients with Stage 2 MH progress to Stage 3 or 4 MH within 1 year, which if left untreated, can lead to legal blindness8,9 1. Girach A, Pakola S. Expert Rev Ophthalmol 2012;7:311 2. Hikichi T, Yoshida A. Am J Ophthalmol 1995;119:55 3. Gass JD. Arch Ophthalmol 1988;106:629 4. AAO. Preferred Practice Pattern Guidelines 2008 5. Reese AB et al. Trans Am Ophthalmol Soc 1966;64:134 6. Chew EY et al. Arch Ophthalmol 1999;117:242 7. Casuso LA et al. Ophthalmology 2001;108:1150 8. Kim JW et al. Ophthalmology 1995;102:1818 9. Hikichi T et al. Br J Ophthalmol 1995;79:517
16. 16. Progression of Vitreomacular Traction to Macular Hole OCT, optical coherence tomography Normal OCT VMA causing VMT VMA causing macular hole Normal vision Metamorphopsia Central blindness MH incidence estimated between 8-30 /100 000 3 times more frequent in females Bilateral in 11%> 80% have VMT
17. 17. Current Standard of Care for Treatment of Vitreomacular Adhesion, Vitreomacular Traction, and Macular Hole Observation (watchful waiting) until visual symptoms justify intervention1 I.e. when patients have, or are at risk of, severe visual disturbance and/or central blindness Vitrectomy surgery is used to relieve the adhesion and resulting tractional forces2 A surgical procedure that entails removal of the vitreous gel of the eye, and may include the peeling of retinal membranes 1. Girach A, Pakola S. Expert Rev Ophthalmol 2012;7:311; 2. Carpineto P et al. Eur Ophthalmic Rev 2011;5:69 MH, macular hole; VMA, vitreomacular adhesion; VMT, vitreomacular traction
18. 18. Surgical Outcomes in Vitreomacular Traction 1. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern. Idiopathic Macular Hole, 2008. http://www.aao.org/ppp (accessed 12 December 2012); 2. Sonmez K et al. Retina 2008;28:1207; 3. Engelbert M, Chang S. In: Ophthalmology. 3rd edn. 2009 VMT, vitreomacular traction
19. 19. Pharmacologic Treatments Provide an Alternative Strategy to Watchful Waiting Eyes with VMA-related disorders can experience rapid deterioration of vision and function1 Early intervention may help to limit the deterioration2 Pharmacologic treatment options have progressed in recent years2,3 May be used as an adjunct to surgery Offer the possibility for earlier intervention without surgery 1. Koerner F, Garweg J. Doc Ophthalmol 1997;97:449; 2. Stalmans P. Retinal Physician 2011. http://www.retinalphysician.com/article.aspx?article=105651 (accessed 12 November 2012); 3. Carpineto P et al. Eur Ophthalmic Rev 2011;5:69 MH, macular hole; VMA, vitreomacular adhesion; VMT, vitreomacular traction
20. 20. Ocriplasmin ILM: inner limiting membrane. 1. Gandorfer et al. Invest Ophthalmol Vis Sci. 2004;45:641647. 2. In vitro experiments. ThromboGenics, Data on File. Pre-clinical data shows that ocriplasmin1,2 Targets fibronectin, laminin and collagen Induces vitreous liquefaction and separation of the vitreous at the vitreoretinal interface Cleanly separates vitreous from ILM Collagen Fibronectin Laminin
21. 21. MIVI 6/7 Enzymatic Vitreolysis with Ocriplasmin for Vitreomacular Traction and Macular Holes
22. 22. Inclusion criteria 18 years of age Focal VMA on OCT BCVA 20/25 in the study eye BCVA 20/800 in the non-study eye High myopia (more than -8 diopters) Concurrent ocular conditions that could affect visual function Prior vitrectomy or laser photocoagulation to the macula Treatment with ocular surgery, intravitreal injection, or retinal laser photocoagulation in the past 3 months Proliferative diabetic retinopathy or neovascular AMD OCT, optical coherence tomography Stalmans P et al. N Engl J Med 2012;367:606 Defined as vitreous adhesion to the macula within a 6-mm central retinal field surrounded by elevation of the posterior vitreous cortex
23. 23. Patient Demographics and Baseline Disease Characteristics Stalmans P et al. N Engl J Med 2012;367:606 (supplementary material) The study groups had similar demographic and baseline disease characteristics, with two exceptions: pseudophakia was more common in the ocriplasmin group compared with the placebo group (37.1% vs 28.2%, respectively; p