Classifying Vitreomacular Disease

Vaidehi S. Dedania, MD; Sophie J. Bakri, MD


June 30, 2014

The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Hole

Duker JS, Kaiser PK, Binder S, et al
Ophthalmology. 2013;120:2611-2619

Vitreomacular Interface Diseases

The composition of vitreous is 98% water and 2% structural macromolecules. Early in embryonic development, the molecular constituents of vitreous form a clear, gel-like structure that is adherent to all contiguous structures of the inner eye.

As the eye ages, the attachment of the posterior vitreous cortex to the internal limiting membrane (ILM) of the retina weakens, resulting in a posterior vitreous detachment and other vitreomacular interface (VMI) diseases that can lead to impaired vision.

VMI imaging with ocular coherence tomography (OCT) has contributed significantly to the diagnosis and management of VMI diseases, including vitreomacular adhesion (VMA), vitreomacular traction (VMT), and macular holes.

Study Summary

The International Vitreomacular Traction Study (IVTS) Group is a panel of vitreoretinal disease experts who were assembled to formulate a classification system for diseases of the VMI based on OCT imaging. The classification system is strictly anatomic, without reference to reported symptoms (Table). The IVTS classification system requires evidence of VMI disease on a single OCT B-scan, although multiple scans may be necessary to capture affected areas.

Table. IVTS Classification System for VMA, VMT, and Macular Hole

Anatomic State Classification Definition Gass Classification
VMA Size of attachment area
   Focal (≤ 1500 μm)
   Broad (> 1500 μm)
Presence of associated macular abnormalities
No detectable change in foveal contour Stage 0
VMT Size of attachment area
   Focal (≤ 1500 μm)
   Focal (≤ 1500 μm)
Presence of associated macular abnormalities
Absence of full-thickness interruption of all retinal layers and vitreous attachment associated with:
  • Distortion of foveal surface

  • Intraretinal structural changes

Elevation of the fovea above the RPE
Stage 1
Full-thickness macular hole Size -- horizontal diameter at narrowest point
   Small (≤ 250 μm)
   Medium (250-400 μm)
   Large (> 400 μm)
Presence or absence of VMT
Full-thickness foveal lesion from the ILM to the RPE Stage 2: small or medium hole with VMT
Stage 3: medium or large hole with VMT
Stage 4: any size hole without VMT
Lamellar macular hole Irregular foveal contour with defect in the inner fovea and an intact photoreceptor layer  
Macular pseudohole Concomitant ERM with central opening and invaginated or heaped foveal edges without loss of retinal tissue  

*Due to associated disease or trauma in the absence of VMT. ERM = epiretinal membrane; ILM = internal limiting membrane; IVTS = International Vitreomacular Traction Study; RPE = retinal pigment epithelium; VMA = vitreomacular adhesion; VMT = vitreomacular traction


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