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Paper text:
vitreomacular traction ( vmt ) or vmt syndrome is an increasingly recognized disorder that has attracted recent attention as a target for both surgical and pharmacologic treatments . despite recent advances , however ,
furthermore , the nomenclature used to describe disorders of this interface may be confusing and subject to imprecise characterization .
vmt may be found with increased incidence in disorders that involve disordered vitreoretinal adhesion such as diabetic retinopathy or foreshortening of the vitreous as partial vitreous detachment .
isolated vmt with decreased vision loss  termed vmt syndrome  occurs in isolation without associated macular disease ; however , it is recognized that symptomatic vitreomacular adhesion ( svma ) may be associated with other conditions such as macular hole ( mh ) , epiretinal membrane ( erm ) , age - related macular degeneration ( amd ) , diabetic macular edema ( dme ) , or retinal vein occlusion ( rvo ) [ 3 , 4 , 5 ] .
both vmt and its pathologic cousin svma require evidence of vitreomacular attachment and vitreous tension ; moreover , in the case of svma , vision loss typically manifested as blurring , reduced acuity , or metamorphopsia is present .
vmt may be confirmed only when the vitreous tensional force is sufficient to result in characteristic retinal or vitreous structural changes , which is best identified on optical coherence tomography ( oct ) .
such changes include widespread to point - like macular retinal thickening ( including an increase in intraretinal fluid ) , tenting of the inner limiting membrane and/or other inner retinal tissues , and/or focal tractional macular detachment(s ) [ 3 , 6 ] . symptoms of retinal distortion in the absence of vmt are usually due to other disorders , most commonly erms or subretinal or intraretinal fluid .
recent attempts to define photographic standards relating to the oct abnormalities associated with vma that may result in vmt has been proposed by simpson et al . .
we have found that for purposes of defining inclusion criteria for studies and general thresholds of disease definition , these standards may be useful , although they represent a starting point in our quantification of image - disorder correlation .
intravitreal ocriplasmin ( jetrea ) was approved in the usa in october 2012 to relieve vma causing vmt and mh , and just recently , in august 2013 , has been approved in canada based on several clinical trials [ 7 , 8 , 9 , 10 ] .
ocriplasmin is primarily used for the treatment of stage 2 mhs less than 400 m .
nonetheless , it is not clear what the role of pharmacological enzymatic vitreolysis will play in cases of vma associated with macular disease like dme . in this report , we describe the spontaneous resolution of vmt in two eyes of 2 patients with dme . as both surgical and pharmacologic intervention
have been suggested to treat dme in the setting of vmt , we feel that a clarification of the nomenclature and reporting of these cases of natural history may be useful in more fully understanding the complex decision - making involved when determining whether to treat this subset of patients .
this study was conducted in full adherence to the declaration of helsinki and all federal and state laws .
case 1 is a 63-year - old white male , previously treated for proliferative diabetic retinopathy with panretinal photocoagulation . additionally , the patient had persistent dme ou with stable vision after focal laser photocoagulation and anti - vascular endothelial growth factor .
his visual acuity in os was 6/9 , and he had macular thickening diagnosed as mild diffuse dme [ central macular thickness ( cmt ) 344 m ] .
1 ) . because his edema and visual acuity were stable , observation was recommended .
six months later , the patient returned and had developed spontaneous resolution of vmt and an improved visual acuity of 6/6 os with no interval interventions . of note ,
1 ) os . case 2 is a 68-year - old white male with non - proliferative diabetic retinopathy ou and dme od . in od
, he had a visual acuity of 6/12 , mild dme ( cmt 314 m ) , and oct evidence of vmt ( fig .
2 ) . similar to case 1 , the acuity and retinal thickness were stable and observation was recommended .
six months later , vmt had spontaneously resolved with no interval treatments during the follow - up period .
the visual acuity improved to 6/7.5 in od , but the mild cystic dme was unchanged ( cmt 314 m ) on oct .
studies indicate that prolonged vmt may lead to progressive vision loss ; however , while treatment decision - making for mh and erm associated with vmt is more straightforward based on current evidence , in cases of vmt in the context of dme , amd , and rvo , natural history is poorly understood and significant gaps in the literature exist .
we demonstrate 2 cases with a history of dme and vmt who had spontaneous resolution of vmt with concomitant improvement in their visual acuity with no associated intervention over the course of 6 months .
it necessitates emphasizing that in both cases , visual acuity and vmt were inversely correlated ; however , cystic retinal changes in dme may be consistent with 6/6 vision . upon resolution of vmt , both visual acuity and symptomatology improved despite abnormalities in macular morphology .
improvement in visual acuity can thus be postulated to be partly derived from the release of vmt .
vma may contribute to the pathogenesis of several macular diseases and it has been recently estimated that the total number of eye diseases that are caused by , or associated with , vma ranges from 0.35 to 1.5% of the population .
this range , even at the lower end , is an astoundingly immense number , which may be difficult to triage , treat , and track over time .
accordingly , before one rushes to an intervention , all treatment considerations need to be ascertained and discussed with the patient and the natural history considered .
the latter is especially true in cases of vmt associated with dme , amd , and rvo where the natural history is unclear and the preferred treatment modality unknown . in this report
, we presented 2 cases of spontaneous resolution of vmt in patients with dme . indeed , spontaneous resolution is likely to occur in a significant number of these cases given an abnormal vitreal - retinal interface , and we recommend that observation be considered when vmt is associated with relatively good visual acuity and stable dme .
additionally , we postulate that treatments like intravitreal anti - vascular endothelial growth factor may help with resolution of vmt in a fashion similar to sham injections of intravitreal saline in the ocriplasmin clinical trials , and consequently , would support a period of observation as a reasonable course of action .
we look forward to studies in similar patients of vmt associated with macular disease as treatment paradigms continue to evolve .
the nature of the vitreoretinal interface in conditions like diabetic macular edema ( dme ) remains incompletely understood . 
 furthermore , it is not clear what the role of pharmacological enzymatic vitreolysis will play in cases of vitreomacular traction ( vmt ) associated with macular disease like dme . 
 we describe the spontaneous resolution of vmt in 2 patients with dme . as both surgical and pharmacologic interventions 
 have been suggested to treat dme in the setting of vmt , we feel that a clarification of the nomenclature and reporting of these cases of natural history may be useful in more fully understanding the complex decision - making involved when determining whether to treat this subset of patients .