Classifying Vitreomacular Disease

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


June 30, 2014

Classification System Summary

Vitreomacular Adhesion

VMA has the characteristic finding of perifoveal vitreous detachment on OCT and is defined by elevation of the cortical vitreous above the retina with persistent vitreous attachment within a 3-mm radius of the fovea in the absence of changes in the contour of the retina. Spontaneous, asymptomatic separation of the vitreous can occur with time.

VMA may be subclassified by size -- focal or broad -- and by the presence or absence of concurrent macular abnormalities, including age-related macular degeneration, retinal vein occlusion, or diabetic macular edema.

Vitreomacular Traction

VMT features excessive traction of the vitreous on the macula, resulting in anatomic changes in the contour of the foveal surface, including intraretinal pseudocyst formation and/or elevation of the fovea from the retinal pigment epithelium (RPE) without full-thickness defects in the retinal layers. OCT findings must include detectable anatomic changes with perifoveal posterior vitreous detachment and macular attachment of the vitreous cortex within a 3-mm radius of the fovea.

Similar to VMA, VMT can be subclassified by size and by the presence or absence of concurrent macular abnormalities.

Macular Holes

Full-thickness macular hole (FTMH) is characterized by an anatomic defect in the fovea with interruption of all neural retinal layers, ILM to RPE, with or without vitreous attachments to the edge of the hole.

FTMH can be subclassified by size -- OCT-based measurement of the minimum width of the hole in the midretina and the presence or absence of vitreous attachment to the edges of the hole. Classification of FTMH is imperative for determination of treatment modality as well as for prognosis. Small FTMHs, ≤ 250 μm, have a high rate of closure with vitrectomy and are most responsive to pharmacologic vitreolysis. Medium FTMHs, 200-400 μm, have a high rate of closure with complete removal of residual hyaloid, but they have a lower rate of closure with pharmacologic therapy than small FTMHs. Finally, large FTMHs, > 400 μm, comprise approximately one half of all FTMHs, and they have a lower rate of closure with both vitrectomy with ILM peel and pharmacologic therapy.

Primary FTMHs result from vitreous traction on the fovea, whereas secondary FTMHs result from other pathologic features without pre-existing or concurrent VMT.

Impending macular holes feature an FTMH in one eye with OCT evidence of VMA or VMT in the fellow eye. OCT-based features of a lamellar macular hole include irregular foveal contour, defect in the inner retina with intraretinal splitting (schisis), and an intact photoreceptor layer. Macular pseudohole characteristics on OCT include invaginated or heaped foveal edges, concomitant epiretinal membrane with central opening, and steep macular contour in the central fovea with near-normal central foveal thickness in the absence of loss of retinal tissue.


Anatomic classification of VMI diseases is clinically applicable for the development of treatment strategies and also in the prediction of therapeutic outcomes. With the emergence of pharmacologic therapies for VMI diseases, this classification system will enable standardization in clinical trials and other studies. The IVTS classification system for VMA, VMT, and macular holes provides a standardized, objective means to classify changes at the VMI.



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