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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. 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. 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
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. Il segmento posteriore del sistema oculare
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. 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. 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. 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. 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. 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. Corpo Vitreo
14. Fotocoagulazione ed atrofie
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. 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. 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. 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. 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. 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. MIVI 6/7 Enzymatic Vitreolysis with Ocriplasmin for
Vitreomacular Traction and Macular Holes
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. 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