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Current Management of Vitreomacular Interface Disorders

By: Carl Regillo, MD and Peter K. Kaiser, MD

This course has expired. You can still review the content but course credit is no longer available.

Supplement Credits: 1

This certified CME activity will be designed for retina specialists and general ophthalmologists involved in the management of patients with retinal disease.

Expiration Date: Monday, January 12, 2015
Release Date: January 1, 2014

Learning Objectives

Upon completion of this activity, the participant should be able to:

  • Explain the process by which VMA occurs
  • Identify the disease states with which VMA is associated
  • Identify the clinical implications of anomalous PVD
  • Explain the mechanism of action of pharmacologic vitreolysis
  • Discuss the available data on the safety and efficacy of vitreolysis agents for PVD induction
  • Understand the importance of patient selection for pharmacologic PVD

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Dulaney Foundation and Retina Today. The Dulaney Foundation is accredited by the ACCME to provide continuing edu- cation for physicians. The Dulaney Foundation designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Statement of Need

Symptomatic vitreomacular adhesion (VMA) is a condition when the vitreous gel adheres in an abnormally strong manner to the retina. VMA can lead to vitreomacular traction (VMT) and subsequent loss or distortion of visual acuity. Anomalous posterior vitreous detachment (PVD) is linked to several retinal disorders including macular pucker, macular hole, age-related macular generation (AMD), macular edema, and retinal tears and detachment. The incidence of VMA has been reported to be as high as 84% in cases of macular hole; 74% in VMT syndrome; and 56% in idiopathic epimacular membrane.1 The incidence of VMA in macular edema appears to depend on the severity of the underlying condition.2,3 In AMD, the rates vary3-12 but have been reported to be as high as 59% in exudative AMD.12 Currently, pars plana vitrectomy (PPV) is used to surgically induce PVD and release the traction on the retina for selected cases. A vitrectomy procedure, however, is not without risk. Complications with standard PPV12-15 and more recently with small-gauge PPV16-20 have been reported and include retinal detachment, retinal tears, endophthalmitis, and postoperative cataract formation. Additionally, PPV may result in incomplete separation and it may potentially leave a nidus for vasoactive and vasoproliferative substances or it may induce development of fibrovascular membranes. Further, as is with any invasive surgical procedure, PPV introduces more trauma to the vitreous and surrounding tissues.21,22 There are data showing that nonsurgical induction of PVD using ocriplasmin, a vitreolysis agent, can offer the benefits of successful PVD while eliminating the risks associated with a surgical procedure. Pharmacologic vitreolysis has the following advantages over PPV: It induces complete separation, creates a more physiologic state of the vitreomacular interface, prevents the development of fibrovascular membranes, is less traumatic to the vitreous, and is potentially prophylactic.21,22 Additionally, vitreolysis obviates the costs associated with surgery and allows for earlier intervention, whereas surgery is reserved for more advanced cases. In 2 phase 3 studies, a single injection of ocriplasmin was shown to be safe and effective for PVD induction,23 providing further evidence that pharmacologic vitreolysis with ocriplasmin may provide a safe and effective alternative to PPV for inducing PVD. To address these gaps, retina specialists and other ophthalmologists must master insights on the pathogenesis of VMA, the role that VMA plays in various retinal pathologies, and the benefits of induced PVD vs anomalous PVD. Mastery includes knowledge of the clinical implications of VMA and the results of recent clinical trials on both surgical and pharmacologic PVD induction, an understanding of vitreolysis agents and their differences, and the ability to identify patients who may benefit from PVD induction. 1. Koerner F, Garweg J. [Diseases of the vitreo-macular interface]. Klin Monbl Augenheilkd. 1999;214(5):305-310. 2. Takahashi MK, Hikichi T, Akiba J, Yoshida A, Trempe CL. Role of the vitreous and macular edema in branch retinal vein occlusion. Ophthalmic Surg Lasers. 1997;28(4):294-299. 3. Kado M, Jalkh AE, Yoshida A, et al. Vitreous changes and macular edema in central retinal vein occlusion. Ophthalmic Surg. 1990;21(8):544-549. 4. Lambert HM, Capone A, Jr., Aaberg TM, et al. Surgical excision of subfoveal neovascular membranes in agerelated macular degeneration. Am J Ophthalmol. 1992;113(3):257-262 5. Weber-Krause B, Eckardt U. [Incidence of posterior vitreous detachment in eyes with and without age-related macular degeneration. An ultrasonic study]. i 1996;93(6):660-665. 6. Ondes F, Yilmaz G, Acar MA, et al. Role of the vitreous in age-related macular degeneration. Jpn J Ophthalmol. 2000;44(1):91-93. 7. Krebs I, Brannath W, Glittenberg C, et al. Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration? Am J Ophthalmol. 2007;144(5):741-746. 8. Lee SJ, Lee CS, Koh HJ. Posterior vitreomacular adhesion and risk of exudative age-related macular degeneration: paired eye study. Am J Ophthalmol. 2009;147(4):621-626 e1. 9. Robison CD, Krebs I, Binder S, et al. Vitreomacular adhesion in active and end-stage age-related macular degeneration. Am J Ophthalmol .2009;148(1):79-82. 10. Wheatley HM. Posterior vitreomacular adhesion and exudative age-related macular degeneration. Am J Ophthalmol. 2008;145(4):765; author reply -6. 11. Schmidt JC, Mennel S, Meyer CH, Kroll P. Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration. Am J Ophthalmol. 2008;145(6):1107; author reply -8. 12. Mojana F, Cheng L, Bartsch DU, et al. The role of abnormal vitreomacular adhesion in age-related macular degeneration: spectral optical coherence tomography and surgical results. Am J Ophthalmol. 2008;146(2):218-227. 13. Doft BH, Wisniewski SR, Kelsey SF, Groer-Fitzgerald S; Endophthalmitis Vitrectomy Study Group. Diabetes and postcataract extraction endophthalmitis. Curr Opin Ophthalmol. 2002;13(3):147-151. 14. Doft BM, Kelsey SF, Wisniewski SR. Retinal detachment in the endophthalmitis vitrectomy study. Arch Ophthalmol. 2000;118(12):1661-1665. 15. Wisniewski SR, Capone A, Kelsey SF, et al. Characteristics after cataract extraction or secondary lens implantation among patients screened for the Endophthalmitis Vitrectomy Study. Ophthalmology. 2000;107(7):1274-1282. 16. Gupta OP, Weichel ED, Regillo CD, et al. Postoperative complications associated with 25-gauge pars plana vitrectomy. Ophthalmic Surg Lasers Imaging. 2007;38(4):270–275. 17. Liu DT, Chan CK, Fan DS, Lam SW, Lam DS, Chan WM. Choroidal folds after 25 gauge transconjunctival sutureless vitrectomy. Eye. 2005;19(7):825–827. 18. Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after 25-gauge and 20-gauge pars plana vitrectomy: incidence and outcomes. Retina. 2008;28(1):138–142. 19. Kunimoto DY, Kaiser RS; Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology. 2007;114(12):2133–2137. 20. Kaiser RS. Complications of sutureless vitrectomy and the findings of the Micro-Surgical Safety Task Force. Paper presented at: Retina Subspecialty Day, Annual Meeting of the American Academy of Ophthalmology; November 7-8, 2008; Atlanta, GA. 21. de Smet MD, Gandorfer A, Stalmans P, et al. Microplasmin intravitreal administration in patients with vitreomacular traction scheduled for vitrectomy: the MIVI I trial. Ophthalmology. 2009;116(7):1349-1355. 22. Goldenberg DT, Trese MT. Pharmacologic vitreodynamics and molecular flux. Dev Ophthalmol. 2009;44:31-36. 23. Stalmans P, Benz MS, Gandorfer A, et al; MIVI-TRUST Study Group. Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes. N Engl J Med. 2012;367(7):606-615.

Faculty and Disclosures

Carl D. Regillo, MD, is the Director of the Retina Service of Wills Eye Institute and a Professor of Ophthalmology at Thomas Jefferson University in Philadelphia. He is a member of the Retina Today Editorial Board. He may be reached at cregillo@aol.com.

Peter K. Kaiser, MD, is a Professor of Ophthalmology at the Cleveland Clinic Lerner College of Medicine and a staff surgeon in the Vitreoretinal Department at the Cole Eye Institute, Cleveland Clinic. He is a Retina Today Editorial Board member. Dr. Kaiser may be reached at pkkaiser@aol.com.

Faculty/Staff Disclosure Declarations Dr. Regillo states that he receives grant research support from Alimera, Allergan, Genentech, Glaxo Smith Kline, Ophthotech, Regeneron, ThromboGenics, Advanced Cell Technology, Johnson and Johnson, QLT, and Alcon Laboratories, Inc. He is a consultant and speaker for Alimera, Alcon, Genentech, GlaxoSmithKline, and Regeneron. Dr. Kaiser states that he has received research funding from Acucela, Alimera, Allergan, National Institutes of Health, Novartis, LPath, Research to Prevent Blindness, National Eye Institute, Genentech, Pfizer, Potentia, and Regeneron. He is a consultant to Alcon, Alimera, Allegro Ophthalmics, Arctic Dx, Bausch + Lomb, Bayer, Carl Zeiss Meditec, Genentech, GlaxoSmithKline, InSitu Therapeutics, Kanghong Biotech, LPath, Novartis, Ophthotec, Oraya, and Regeneron. All of those involved in the planning, editing, and peer review of this educational activity report no financial relationships.

Disclaimer

In accordance with the disclosure policies of the Dulaney Foundation and to conform with ACCME and US Food and Drug Administration guidelines, anyone in a position to affect the content of a CME activity is required to disclose to the activity participants (1) the existence of any financial interest or other relationships with the manufacturers of any commercial products/ devices or providers of commercial services and (2) identification of a commercial product/device that is unlabeled for use or an investigational use of a product/ device not yet approved.

DISCLAIMER The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of The Dulaney Foundation, Retina Today, or ThromboGenics. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

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