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Vitreomacular Adhesion/Vitreomacular Traction/Macular Hole

ROUTINE — Retina

Symptoms

  • blurred vision: central vision "fuzziness" or a significant drop in acuity (typically ~20/200 for a full hole)
  • metamorphopsia: straight lines appearing wavy or distorted (e.g., door frames, Amsler grid)
  • central scotoma: a gray or black "blind spot" right in the center of the vision
  • micropsia: objects appearing smaller in the affected eye

Clinical Findings

The disease spectrum

  • VMA (Adhesion): vitreous is "stuck" to the fovea, but the retinal shape is still normal; usually no symptoms
  • VMT (Traction): the vitreous pulls on the fovea, "tenting" it up and causing vision loss or distortion
  • Full-Thickness Macular Hole (FTMH): a literal round hole in the center of the macula

Clinical signs

  • red spot: a round, well-demarcated red defect at the fovea (the "hole")
  • gray cuff: a ring of fluid surrounding the hole
  • klein tags: tiny yellow deposits sometimes visible at the base of the hole
  • watzke-allen sign: a thin beam of light projected on the fovea appears "broken" to the patient

Etiology

Primary mechanism

  • anomalous pvd: as we age, the vitreous gel shrinks. If it stays "glued" to the fovea while pulling away elsewhere, it creates a tugging force (traction)
  • risk factors: more common in women (3:1 ratio), high myopia (nearsightedness), and history of trauma

Red Flags

  • acute onset: holes present for less than 6 months have a much higher surgical success rate
  • large diameter: holes >400 μm are harder to close and may require stricter postoperative positioning
  • fellow eye risk: if a hole is present in one eye, there is a ~10-30% risk of the other eye developing one if the vitreous hasn't detached yet

Investigations

OCT (the gold standard)

  • essential for staging the condition and measuring the hole size
  • differentiates a "true" hole from a "pseudohole" (which is just a wrinkle in the surface)

Slit lamp biomicroscopy

  • using a high-power lens (90D) to visualize the foveal contour and any overlying "operculum" (a floating piece of retinal tissue)

Treatment

Surgical (gold standard)

  • pars plana vitrectomy (ppv): removing the vitreous gel to relieve traction
  • ilm peeling: stripping the thin inner "skin" of the retina to help the hole close
  • gas tamponade: a gas bubble is placed in the eye to act as a "bandage" to seal the hole

Postoperative care

  • face-down positioning: historically required for 1-7 days; still recommended for larger holes to keep the bubble against the macula

Clinical Pearl

Face-down positioning: Cochrane review shows NO significant difference in closure rates vs non-face-down for most holes — burden of strict positioning less justified. Large holes (>400μm): 94% face-down vs 84% non-face-down success.

Differential Diagnosis

  • • macular pucker (epiretinal membrane; causes a "pseudohole" appearance)
  • • solar retinopathy (burn from staring at the sun; can look like a tiny hole)
  • • cystoid macular edema (fluid bubbles in the retina that can mimic a hole on exam)

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