Safe to Just Observe Mild Vitreomacular Adhesion?

Saranya C. Balasubramaniam, MD; Sophie J. Bakri, MD


October 16, 2014

Clinical Course of Vitreomacular Adhesion Managed by Initial Observation

John VJ, Flynn HW, Smiddy WE, et al
Retina. 2014;34:442-446

Study Summary

Vitreomacular adhesion (VMA) can lead to reduced visual acuity, metamorphopsia, photopsia, and micropsia. These symptoms are explained by vitreomacular traction (VMT) at the vitreomacular junction. Spectral domain optical coherence tomography (SD-OCT) allows for a better understanding of the extent of VMA and provides a mechanism for longitudinal follow-up. At present, VMA can be treated surgically with pars plana vitrectomy, expansile gas, or intravitreal injection of microplasmin.

John and colleagues studied 106 eyes with clinical symptoms and SD-OCT findings consistent with VMA. The study was designed as a noncomparative case series of patients for whom observational management was recommended initially by vitreoretinal surgeons at three centers.

Using SD-OCT, eyes were graded using the following classification:

Grade 1 (43 eyes) had incomplete cortical vitreous separation and attachment at the fovea;

Grade 2 (56 eyes) had grade 1 with intraretinal cysts; and

Grade 3 (7 eyes) had grade 2 with subretinal fluid.

The median follow-up time was 18 months.

For grade 1 eyes, 30% improved with release of VMA, 53% were stable, and 16% progressed to grade 2 or 3. For grade 2 eyes, 30% improved, 55% remained stable, and 14% progressed to a higher grade or to macular hole or surgery. With grade 3 eyes, four improved, one remained stable, and two worsened to macular hole or surgery.

The mean best corrected visual acuity was noted to be stable on follow-up. Although the sample size of this study was small, it does provide evidence that observational management is a reasonable initial option in patients with milder grades of VMA. It also provides a classification for grading VMA and following for progression.


The clinical course of patients with VMA is not well established. Although surgical management has been shown to have favorable outcomes in patients with severe VMA, this study shows that observation can be favorable in patients with relatively mild symptoms. In addition, SD-OCT provides a mechanism to safely observe VMA patients with milder disease.



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