Zdrav Vestn Supl | Results of vitrectomy for vitreomacular traction syndrome I-89
IZVIRnI članek/ORIgInal aRtIcle
Results of vitrectomy for vitreomacular 
traction syndrome
Rezultati vitrektomije pri bolnikih z 
vitreomakularnim trakcijskim sindromom
Xhevat lumi,1 Helena Skačej Friedrich,2 Irena Irman grčar1
Izvleček
Izhodišča: Prikazati anatomske in funkcijske 
spremembe po vitrektomiji pri bolnikih z vitreo-
makularnim trakcijskim sindromom.
Metode: Predstavljena je retrospektivna študija 
23 oči 23 bolnikov z vitreomakularnim trakcij-
skim sindromom, starih od 58 do 86 let. Dia-
gnoza vitreomakularni trakcijski sindrom je bila 
postavljena, kadar je bila prisotna očitna trakcija 
steklovine, ki je povzročala povečano debelino 
mrežnice v področju rumene pege, in ki je bila 
jasno vidna na izvidu optične koherenčne to-
mografije. Pri vseh bolnikih je bila opravljena 
vitrektomija za sprostitev trakcije v rumeni pegi. 
Spremembe v področju rumene pege so bile 
opredeljene z optično koherenčno tomografijo 
pred vitrektomijo in po njej. Podatki so bili stati-
stično obdelani s parnim Studentovim t-testom.
Rezultati: Pri 20 (87 %) od 23 preiskovancev se 
je po operacijskem posegu statistično pomemb-
no izboljšala vidna ostrina od 0,28 pred operaci-
jo na 0,56 po operaciji s povprečnim dvigom za 
tri vrstice na Snellenovih tabelah (p < 0,001). Pri 
3 bolnikih po operaciji ni prišlo do izboljšanja 
vidne ostrine. Pri vseh preiskovancih je bila po 
operaciji prisotna zmanjšana debelina mrežnice 
v področju rumene pege. Povprečna debelina 
mrežnice v centralnem delu rumene pege je bila 
614,00 μm pred operacijo in 332,87 μm po ope-
raciji (p < 0,001). V preiskovani skupini bolnikov 
med samim operacijskim posegom in v poope-
racijskem obdobju ni bilo zapletov.
Zaključki: Vitrektomija, ki sprosti trakcijo v po-
dročju rumene pege, omogoča izboljšanje vidne 
ostrine pri večini bolnikov z vitreomakularnim 
trakcijskim sindromom. Optična koherenčna to-
mografija je pomembno diagnostično orodje za 
ocenjevanje stanja pred operacijo in po njej.
Abstract
Background: To review the anatomical and 
functional results of vitrectomy for the vitreo-
macular traction syndrome.
Methods: A retrospective analysis of 23 eyes of 
23 patients (aged from 58 to 86 years) with vit-
reomacular traction syndrome is presented. The 
diagnosis of the vitreomacular traction syn-
drome was made when apparent traction of the 
vitreous face causing increased thickness of the 
macula had been detected by optical coherence 
tomography. All the patients underwent vitrec-
tomy to relieve the macular traction. History, eye 
examination before and after vitrectomy and the 
follow up period were reviewed. Changes in the 
macular area were evaluated by optical coher-
ence tomography before and after surgery. Sta-
tistical analysis using the Student’s paired t-test 
was performed.
Results: In 20 (87 %) out of 23 patients the mean 
best-corrected visual acuity significantly im-
proved from 0.28 preoperatively to 0.56 post-
operatively with a mean increase by 3 lines on 
the Snellen chart (p < 0.001). In the remaining 
3 (13 %) patients visual acuity did not improve 
postoperatively. All patients showed a reduction 
in the macular thickness postoperatively. The 
mean thickness in the central macular area was 
614.00 μm preoperatively and 332.87 μm postop-
eratively (p < 0.001). Neither intraoperative nor 
postoperative complications were observed in 
this series of patients during the follow-up pe-
riod.
Conclusions: Vitrectomy surgery performed to 
release the macular traction improves the visual 
acuity in most patients with vitreomacular trac-
tion syndrome. Optical coherence tomography 
is a valuable tool for the assessment of the pre-
operative status and postoperative anatomical 
changes.
1 University Medical 
Centre, Eye Clinic, 
Grablovičeva 46,  
1000 Ljubljana, Slovenia
2 University Clinical 
Centre Maribor, 
Department of 
Ophthalmology, 
Ljubljanska 5,  
2000 Maribor, Slovenia
Korespondenca/
Correspondence:
Xhevat lumi, MD, 
University Medical 
centre, eye clinic, 
grablovičeva 46,  
1000 ljubljana, Slovenia
tel.: +386 1 5221900
Fax.: +386 1 5221960
e-mail: xhlumi@hotmail.
com
Ključne besede:
vitreomakularni trakcijski 
sindrom, vitrektomija, 
debelina mrežnice v 
rumeni pegi, optična 
koherenčna tomografija, 
vidna ostrina
Key words:
vitreomacular traction 
syndrome, vitrectomy, 
macular thickness, 
optical coherence 
tomography, visual acuity
Citirajte kot/Cite as:
Zdrav Vestn 2012;  
81: I-89–96
Prispelo: 3. jan. 2012, 
Sprejeto: 15. jun. 2012
I-90 Zdrav Vestn Supl | junij 2012 | letnik 81
IZVIRnI članek/ORIgInal aRtIcle
Figure 1: typical optical 
coherence tomography 
image of a vitreomacular 
traction syndrome with a 
3D reconstruction (right). 
as the vitreous remains 
attached to the macula, 
anterior traction to the 
fovea is exerted leading 
to the cystoid macular 
oedema. this increased 
macular thickness can 
be measured by optical 
coherence tomography 
(an optical coherence 
tomography image of one 
of our patients is shown).
associates, vitrectomy should not be postpo-
ned in patients who complain of disturbing 
visual symptoms such as reduced VA, meta-
morphopsia and difficulties in the binocular 
reading.8
Diagnosing the VMT by bomicroscopy 
may be challenging, particularly when the 
area of the vitreoretinal attachment is bro-
ad.9 Optical coherence tomography (OCT) 
has proved to be an excellent tool to evalu-
ate the morphological features of macular 
changes, incomplete posterior vitreous de-
tachment, and postoperative resolution of 
macular changes in VMT with high degree 
of reproducibility.10
Introduction
Vitreomacular traction syndrome 
(VMT) is a clinical entity in which partial 
posterior vitreous detachment is combined 
with persistent macular adherence, leading 
to macular traction and detachment (Figure 
1).
Macular traction, frequently accompani-
ed by cystoid changes in the neurosensory 
retina of the macula, causes decreased visu-
al acuity (VA), metamorphopsia, photopsia, 
and micropsia.1-3 Vitrectomy to surgically 
detach the vitreous from the macular area is 
usually necessary in order to release the ma-
cular traction.2-7 According to Koerner and 
Figure 2: Visual 
acuity before and 
after vitrectomy. the 
improvement of visual 
acuity was observed in 
20 out of 23 patients 
postoperatively.
VPRE = visual acuity 
before vitrectomy; 
VPOST = visual acuity 
after vitrectomy
Zdrav Vestn Supl | Results of vitrectomy for vitreomacular traction syndrome I-91
IZVIRnI članek/ORIgInal aRtIcle
were pseudophakic. Others had clear lenses, 
which did not affect the visual acuity. All the 
patients were examined and operated on at 
the Eye Hospital, University Medical Centre 
Ljubljana, Slovenia. Each of them underwent 
a complete preoperative and postoperative 
examination including the best-corrected 
VA measured with the Snellen chart, intra-
ocular pressure measurement and the ante-
rior as well as the posterior biomicroscopy.
OCT fundus image assessment (3D OCT 
1000, Topcon, Tokyo, Japan) was performed 
before and after the vitrectomy. Thus, the 
morphological changes were determined 
and the central macular thickness was me-
asured. The most central area of 1mm in the 
diameter with the fovea in the centre was 
used for the calculations. For the statistical 
analysis, the Student’s paired t-test was used.
The aim of this study was to review the 
anatomical and functional results of vitrec-
tomy in our patients with VMT. All the exa-
minees were evaluated by OCT before and 
after surgery.
Methods
Medical records of the patients diagno-
sed with VMT who underwent the pars 
plana vitrectomy between September 2007 
and November 2011 were reviewed. The di-
agnosis of VMT was made when apparent 
traction from the vitreous causing increased 
thickness of the macula had been observed 
and had been clearly seen by OCT. Epireti-
nal membranes were not present in any of 
the examinees. 23 eyes of 23 patients were 
included in the study. The examinees’ age 
ranged from 58 to 86 years. Nine (9) eyes 
Figure 3: Mean central 
macular thickness before 
and after vitrectomy. 
Decrease of the central 
macular thickness was 
observed in all the 
patients postoperatively.
OCTPRE = mean central 
macular thickness 
before vitrectomy; 
OCTPOST = mean central 
macular thickness after 
vitrectomy
I-92 Zdrav Vestn Supl | junij 2012 | letnik 81
IZVIRnI članek/ORIgInal aRtIcle
Figure 4: Oct image 
of the macular area of 
patient number 12, whose 
visual acuity did not 
improve postoperatively. 
the image shows the 
photoreceptor layer 
atrophy.
6–30 months). Characteristics of patients 
are summarised in Table 1.
All the patients were operated on using 
either 23 or 25 gauge vitrectomy. There were 
no intraoperative complications.
The improvement of the best-correc-
ted VA was observed in 20 (87 %) out of 
23 patients. The VA improved from 0.28 to 
0.56 with a mean increase by 3 lines on the 
Snellen chart (Figure 2). This difference was 
statistically significant (paired samples T-
-test, p< 0.001). However, in the remaining 
3 (13 %) examinees the visual acuity did not 
change postoperatively.
All the patients showed a reduction in 
macular thickness after vitrectomy.
The mean preoperative central macular 
thickness was 614.00 μm and significantly 
decreased to 332.87 μm postoperatively (pai-
red samples T-test, p< 0.001) (Figure 3).
None of the patients had any signs of 
persistent vitreomacular traction after sur-
Patients underwent pars plana vitrecto-
my with the hyaloid membrane removal by 
a single surgeon using the transconjunctival 
sutureless vitrectomy system (XL). The core 
vitrectomy was followed by the circumfe-
rential cutting of the posterior hyaloid using 
a high speed cutter. After the retinal traction 
had been released, the remnant of the poste-
rior hyaloid membrane was peeled off with a 
microforceps. Simultaneous cataract surge-
ry was not performed in any of the patients 
from this group.
Results
Out of the 23 patients under investigati-
on, 13 were male and 10 female. The average 
age of the examinees was 72.3 years. All the 
patients had reduced VA and metamorphop-
sia preoperatively. Duration of symptoms 
ranged from 3 to 72 months. Mean posto-
perative follow up was 15.4 months (range 
Zdrav Vestn Supl | Results of vitrectomy for vitreomacular traction syndrome I-93
IZVIRnI članek/ORIgInal aRtIcle
period of 60 months only 6 (11 %) of 53 pati-
ents with VMT developed a complete spon-
taneous posterior vitreous detachment.1
In the present series, visual and anatomi-
cal recovery after the surgical release of vi-
treomacular traction was very good. Twenty 
out of 23 operated patients showed visual im-
provement, while in the remaining 3 patents 
VA did not change postoperatively. Two of 
these cases showed atrophic retinal changes 
on the OCT images at the first presentation. 
Even though the history was not always cle-
ar enough, in our opinion there was a chro-
nic macular traction, which resulted in the 
degeneration of the photoreceptors (Figure 
4).15 The third patient presented with a good 
visual acuity (0.7 in Snellen charts) at the 
beginning and this visual acuity remained 
gery. Moreover, no postoperative complica-
tions during the period under observation 
were noted.
Discussion
Vitrectomy surgery to release the macu-
lar traction has been proven to be an effecti-
ve and successful treatment for the patients 
wih VMT.1-4,8,9,11 According to these studi-
es, visual improvement can be expected in 
44 %,3 63 %,2 73 %,8 75 %,4 87.5 %9 or even in 
100 %11 of cases. Spontaneous detachment 
of the vitreous from the macula in VMT 
with the resolution of macular oedema and 
improvement in the VA is usually limited 
only to a few case reports.12-14 Hikichi and 
associates reported that during a follow up 
Figure 5: Oct image 
of the macular area 
of patient number 22 
before (right) and three 
months after vitrectomy 
(left). normal macular 
structure with the foveal 
umbo can be observed 
(left).
I-94 Zdrav Vestn Supl | junij 2012 | letnik 81
IZVIRnI članek/ORIgInal aRtIcle
Ta
bl
e 
1:
 P
at
ie
nt
s’
 c
ha
ra
ct
er
is
tic
s.
Pa
ti
en
t N
o.
Ag
e 
(y
ea
rs
)
Se
x
D
ur
at
io
n 
of
 
sy
m
pt
om
s 
(m
on
th
s)
Fo
ll
ow
 u
p 
(m
on
th
s)
Ty
pe
 o
f 
su
rg
er
y
(G
)
Pr
eo
p 
VA
Po
st
op
 V
A
Pr
eo
p 
m
ea
n 
ce
nt
ra
l 
m
ac
ul
ar
 
th
ic
kn
es
s 
(μ
m
)
Po
st
op
 m
ea
n 
ce
nt
ra
l 
m
ac
ul
ar
 
th
ic
kn
es
s 
(μ
m
)
1.
80
F
6
16
23
0.
20
0.
60
56
4
35
5
2.
69
M
72
10
23
0.
20
0.
40
60
9
39
7
3.
72
F
3
20
25
0.
50
1.
00
53
2
39
7
4.
81
M
9
30
23
0.
40
0.
70
64
7
17
9
5.
59
M
48
29
25
0.
20
0.
70
74
3
29
3
6.
62
F
6
25
25
0.
20
0.
90
62
2
25
4
7.
73
M
72
20
23
0.
02
0.
05
90
9
41
2
8.
58
M
3
19
23
0.
50
1.
00
40
3
27
8
9.
76
M
5
16
25
0.
20
0.
70
58
5
33
9
10
.
82
M
24
13
25
0.
50
0.
70
55
2
43
0
11
.
81
M
12
13
25
0.
15
0.
20
73
4
40
9
12
.
74
F
6
6
23
0.
01
0.
01
60
3
20
0
13
.
78
M
8
16
23
0.
15
0.
40
47
5
27
5
14
.
75
M
6
13
25
0.
20
1.
00
86
5
41
2
15
.
60
F
12
15
23
0.
01
0.
02
65
9
23
6
16
.
72
F
6
11
23
0.
90
1.
00
35
6
23
0
17
.
64
M
60
18
23
0.
40
0.
50
55
9
38
2
18
.
84
F
24
6
23
0.
15
0.
60
72
5
26
5
19
.
62
F
26
23
23
0.
15
0.
15
69
5
41
5
20
.
86
M
12
10
23
0.
20
0.
60
58
6
40
5
21
.
72
M
12
8
23
0.
70
0.
70
44
0
33
4
22
.
70
F
13
8
23
0.
02
0.
20
64
0
44
9
23
.
72
F
12
9
23
0.
60
0.
90
61
9
31
0
N
o 
= 
nu
m
be
r; 
F 
= 
fe
m
al
e;
 M
 =
 m
al
e;
 G
 =
 g
au
ge
; V
A 
= 
vi
su
al
 a
cu
ity
; P
re
op
 =
 p
re
op
er
at
iv
e;
 P
os
to
p 
= 
po
st
op
er
at
iv
e
Zdrav Vestn Supl | Results of vitrectomy for vitreomacular traction syndrome I-95
IZVIRnI članek/ORIgInal aRtIcle
Conclusion
In conclusion, decrease in the central 
macular thickness without any remaining 
VMT at the follow up was observed in all 
eyes under investigation (Figure 5). OCT is a 
very important diagnostic tool for the VMT 
as a more precise understanding of the vi-
treoretinal attachment can be obtained and 
analysed. This enables the surgeon to make a 
more certain diagnosis and to select a safer 
access point into the subhyaloid space.6,7,10 
According to the studies mentioned above, 
vitrectomy should not be postponed in pa-
tients suffering from vitreomacular traction 
syndrome.
throughout the follow-up period. Similar 
surgical outcomes had been reported previ-
ously.11,16,17 The type of VMT was not defi-
ned in these case series.18
I-96 Zdrav Vestn Supl | junij 2012 | letnik 81
IZVIRnI članek/ORIgInal aRtIcle
11. Johnson MW. Tractional cystoid macular ede-
ma: a subtle variant of the vitreomacular traction 
syndrome. American Journal of Ophthalmology 
2005; 140: 184–92.
12. Sulkes DJ, Ip MS, Baumal CR, Wu HK, Puliafito 
CA. Spontaneous resolution of vitreomacular 
traction documented by optical coherence to-
mography. Archives of Ophthalmology 2000; 118: 
286–7.
13. Kusaka S, Saito Y, Okada AA, Sasamoto M, Hayashi 
A, Ohji M, Tano Y. Optical coherence tomography 
in spontaneously resolving vitreomacular traction 
syndrome. Ophthalmologica 2001; 215: 139–41.
14. Cheng CL, Hoh ST, Chuan JC, Wong EY, Koh AH. 
Acute vitreomacular traction with early spontane-
ous resolution. Clinical & Experimental Ophthal-
mology 2003; 31: 161–3.
15. Weinand F, Jung A, Becker R, Pavlovic S. Sponta-
neous resolution of vitreomacular traction syn-
drome. Ophthalmologe 2009; 106: 44–6.
16. Falcone PM. Vitreomacular traction syndrome 
confused with pseudophakic cystoid macular ede-
ma. Ophthalmic Surgery & Lasers 1996; 27: 392–4.
17. Munuera JM, Garcia-Layana A, Maldonado MJ, 
Aliseda D, Moreno-Montanes J. Optical coherence 
tomography in successful surgery of vitreomacu-
lar traction syndrome. Archives of Ophthalmolo-
gy 1998; 116: 1388–9.
18. Globocnik-Petrovic M. Vitreoretinalni posegi in 
njegove indikacije v očesni kirurgiji. Zdrav Vestn 
2002; 71: 691–5.
19. Koizumi H, Spaide RF, Fisher YL, Freund KB, 
Klancnik JM Jr, Yannuzzi LA. Three-dimensional 
evaluation of vitreomacular traction and epire-
tinal membrane using spectral-domain optical 
coherence tomography. American Journal of 
Ophthalmology 2008; 145: 509–17.
References
1. Hikichi T, Yoshida A, Trempe CL. Course of vitre-
omacular traction syndrome. American Journal of 
Ophthalmology 1995; 119: 55–61.
2. Smiddy WE, Michels RG, Glaser BM, deBustros S. 
Vitrectomy for macular traction caused by incom-
plete vitreous separation. Archives of Ophthalmo-
logy 1988; 106: 624–8.
3. McDonald HR, Johnson RN, Schatz H. Surgical 
results in the vitreomacular traction syndrome. 
Ophthalmology 1994; 101: 1397–403.
4. Melberg NS, Williams DF, Balles MW, Jaffe GJ, Me-
redith TA, Sneed SR, Westrich DY. Vitrectomy for 
vitreomacular traction syndrome with macular 
detachment. Retina 1995; 15: 192–7.
5. Pournaras CJ, Kapetanios AD, Donati G. Vitrec-
tomy for traction macular oedema. Documenta 
Ophthalmologica 1999; 97: 439–47.
6. Uchino E, Uemura A, Doi N, Ohba N. Postsurgi-
cal evaluation of idiopathic vitreomacular tracti-
on syndrome by optical coherence tomography. 
American Journal of Ophthalmology 2001; 132: 
122–3.
7. Chung EJ, Lew YJ, Lee HJ. OCT-guided hyaloid re-
lease for vitreomacular traction syndrome. Korean 
Journal of Ophthalmology 2008; 22: 169–73.
8. Koerner F, Garweg J. Vitrectomy for macular 
pucker and vitreomacular traction syndrome. Do-
cumenta Ophthalmologica 1999; 97: 449–58.
9. Kenan S, Capone A, Trese MT, Williams GA. Vi-
treomacular traction syndrome: Impact of ana-
tomical configuration on anatomical and visual 
outcomes. Retina 2008; 28: 1207–14.
10. Massin P, Vicaut E, Haouchine B, Erginay A, 
Paques M, Gaudric A. Reproducibility of retinal 
mapping using optical coherence tomography. Ar-
chives of Ophthalmology 2001; 119: 1135–42.