What is Vitreomacular Traction?
- As people get older, the vitreous humour (jelly-like material inside the eye that helps it maintain a round shape) detaches naturally from the retina (the light-sensitive layer of tissue located at the back of the eyeball)2
normal vitreous separation
The eye showing complete separation of the vitreous humour from the retina, a process which occurs naturally with ageing
However, every now and then, the vitreous humour remains attached to some areas of the retina, particularly at the macula (the area of the retina responsible for central vision needed for everyday tasks such as driving, reading and recognizing faces). This is known as vitreomacular adhesion2
Abnormal vitreous separation that may lead to vitreomacular traction (VMT)
These areas of vitreomacular adhesion can exert a ‘pulling force’ on the macula, a condition known as vitreomacular traction, or VMT.
The consequences of this pulling or ‘traction’ depend on where and how firmly the vitreous remains attached. VMT may eventually lead to the formation of a hole in the macula.
How Can Vitreomacular Traction Affect Your Vision?
VMT may cause symptoms such as:
— Distorted vision
— Decreased visual acuity (sharpness of vision)
In some individuals, VMT leads to macular hole, the symptoms of which may include the appearance of a blind spot in the centre of the field of vision
Normal Vitreomacular traction Macular hole
How Are Cases of Vitreomacular Traction and Macular Hole Diagnosed?
VMT can be diagnosed using a technique known as optical coherence tomography (OCT). OCT is a non-invasive scan that produces detailed images of the inside of the eye4. OCT allows the doctor/ophthalmologist to look closely for signs of VMT and macular hole
Sometimes vitreomacular traction causes only mild or no symptoms and does not need treatment. In many cases, the vitreomacular traction may resolve spontaneously, without any treatment, so I usually advise monitoring before treatment.
If you have some cataract also blurring your vision, I advise considering cataract surgery first, as this can help release vitreomacular traction as well.
If you need treatment, then the options we discuss are vitrectomy surgery or intravitreal injection with Ocriplasmin (JETREA®).
Ocriplasmin (JETREA®) treatment for VITREOMACULAR TRACTION and Macular Holes – more details can be downloaded as a pdf Jetrea Patient Booklet
What is JETREA®?
JETREA ® is a synthetic form of the human enzyme plasmin, which is produced using DNA technology In addition to the active substance ocriplasmin, JETREA ® contains mannitol, citric acid, sodium hydroxide and water. JETREA ® is also mixed with sodium chloride solution prior to injection1
JETREA ® works by separating the vitreous from the macula, releasing VMT and helping to close the macular hole (if present)
Possible Side-Effects Associated with JETREA® Treatment
- Like all medicines, JETREA ® can cause side-effects, although not everybody will experience these1
- Most side-effects that occur with JETREA ® appear within 1 week after injection, are not serious and resolve within 2–3 weeks1
- Talk to your doctor/ophthalmologist if you develop any side-effects after receiving JETREA ® , including any not listed in this leaflet
- With JETREA®, patients have experienced the following side-effects in clinical trials:1
— Very common side-effects (may affect more than 1 in 10 patients):
- Dark floating spots in the field of vision (floaters)
- Eye pain
- Bleeding on the surface of the eye
Common side-effects (may affect up to 1 in 10 patients):1
- Decreased vision
- Visual disturbances
- Blurred vision
- Bleeding inside the eye
- Separation or tear of the retina
- Increase in the pressure inside the eye
- Blind spot or blind area in the field of vision
- Distorted vision
- Swelling of the surface of the eye
- Swelling of the eyelid
- Inflammation of the eye
- Flashes of light in the eye
- Eye redness
- Irritation on the surface of the eye
- Dry eye
- A feeling of having something in the eye
- Itching of the eye
- Eye discomfort
- Increased sensitivity to light
- Colour vision changes
Uncommon side-effects (may affect up to 1 in 100 patients):1
- Decreased vision in parts of the field of view
- Displacement or wobbling of the lens inside the eye
- Double vision
- Accumulation of blood in the front part of the eye
- Abnormal constriction of the pupil (black part in the centre of the eye)
- Different sized pupils
- A scratch or scrape of the cornea (transparent layer that covers the front of the eye)
You may experience some reduced vision for a short time immediately after your injection1
— The immediate vision loss is caused by a temporary increase in the pressure of the fluid within the eye (known as an increase in intraocular pressure)
— It is normal to experience such symptoms with an injection of this type, and symptoms usually resolve within a few minutes1
- The white area of the eye, where the injection was given, will likely become red
— This redness is normal and it will go away after a few days
— Contact your doctor/ophthalmologist if it does not go away within 1 week after the injection or becomes worse
When to Seek Urgent Attention from Your Healthcare Provider
- It is important that you monitor for changes in the condition of your eye in the week after the injection. You must contact your doctor/ophthalmologist immediately if you develop any of the following symptoms after an injection of JETREA ®:1
— A severe decrease in vision within 1 week of JETREA ® treatment. This is generally reversible and will usually disappear within 2 weeks
- If you do experience reduced vision after injection, it is important that you do not drive, or use any tools or machines, until your vision improves
— Eye pain, worsening eye redness, severely blurred or decreased vision, increased sensitivity to light or increased number of dark floating spots in the field of vision (floaters). These symptoms may be the signs of an infection, bleeding, separation or tear of the retina, or an increase in the pressure inside the treated eye
— Symptoms such as fluctuation of vision, double vision, headache, halos around light, nausea and vomiting may be the signs of a displacement or wobbling of the lens of the eye from its normal position
Questions I usually ask
· Are you having difficulty seeing the TV screen clearly or reading subtitles?
· Are you struggling to recognize bus numbers or people’s faces until they are really close?
· Is it difficult reading small print unless the lighting is really bright?
· Do you feel that your glasses aren’t giving you clear vision, and your optician has said that
they can’t improve with a new prescription?
· Do you have hazy vision?
· Is it difficult to see clearly when you are driving?
· Do you have glare with night driving or in bright lights (such as supermarket lighting)?
· Are you having difficulty reading music?
· Is your vision affecting your work?
· Do have a particular hobby or interest that your vision is affecting?
What is a vitrectomy?
A vitrectomy operation is an operation inside the eye, which is done through three small keyhole incisions made on the white of the eye. The vitreous gel in the back half of the eye is removed as part of the surgical treatment of a range of conditions such as retinal detachment, macular holes, epiretinal membranes, vitreous haemorrhages and advanced complications of diabetic eye disease. Your eye does not need the vitreous gel, and does not replace or regrow it. At the end of the operation, it will be replaced with a balanced salt solution, a gas bubble or an oil bubble. The role of the gas or oil bubble is to ‘tamponade’, or hold the layers of the retina in place to secure the retina in the post-operative period. Balanced salt solution and gas bubbles will be gradually replaced with an aqueous fluid produced naturally by the inside of the eye. Usually this fills just the front part of the eye, the anterior chamber, but after vitrectomy it fills the whole eye. I will explain each of these next.
Balanced Salt Solution
If you do not need a gas bubble, you will have a balanced salt solution in the eye to replace the vitreous gel. This will be gradually replaced with an aqueous fluid produced by the inside of the eye, and you should follow the advice in the general advice section. You will have no particular requirements for posturing and there are no restrictions on air travel or travelling to high altitudes.
BUBBLES (TAMPONADE AGENTS) THAT I MAY PUT IN YOUR EYE AND POST-OPERATIVE POSTURING.
When the vitreous gel is removed it is replaced with saline fluid, gas or oil, and the next section tells you about these and about posturing that you may be required to adopt for a few days after surgery. Not all patients need to posture after vitrectomy surgery and you will be given information on posturing before you are discharged from the hospital.
Some vitrectomy operations require a gas bubble in the eye at the end of surgery. Some conditions, such as macular holes and retinal detachments routinely need a gas bubble, but a vitrectomy for any condition may require a gas bubble, and the decision is made during the operation if there is a tear in the retina during surgery.
The role of the gas bubble is to hold two layers of the retina together whilst the necessary sealing takes place. The principle is similar to when you want to stick 2 sheets of paper together, and you put them between two books to hold the wet sides together till the glue dries. The gas bubble floats upwards and holds the two layers of torn retina together until the sealing treatment takes effect – this usually takes about 5 to 7 days. Because the gas always floats upwards, the tear will be supported in the upright position if it is at the top of the eye, but if the tear is on the side, you will be asked to adopt a posture on one side or the other to bring the tear into a the right position for the gas bubble to hold the retina together.
There are three types of gas bubble I generally use, a shorter acting gas, sulphur hexafluoride (SF6), which lasts from 2 to 4 weeks, C2F6, and a longer acting gas, perfluoropropane (C3F8), which lasts between 4 to 8 weeks. A gas bubble will gradually dissolve over the next few weeks and disappear – you will have poor vision in the eye whilst it is full of gas, and over the following days and weeks you will recover the vision as the gas bubble gets smaller, starting with the top of your vision.
You must not travel by air or to high altitude for as long as there is a gas bubble in your eye.
This may be anything from 2 weeks to 8 weeks, and therefore I generally advise not to plan any air travel in the weeks after vitrectomy surgery as a precaution. If air travel is absolutely necessary we can use silicone oil instead – see below.
If you later need a general anaesthetic whilst you have gas in the eye you must inform the anaesthetist as the gases used for general anaesthesia may need to be changed.
Anaesthesia for Vitrectomy Surgery
Most vitrectomy surgery can be done with just local anaesthetic, using an injection to numb the eye (you will be awake during surgery).
Some patients are not good candidates for local anaesthesia – either they are unable to lie still for the required time, or they are very nervous or simply have a fear of being awake whilst they have an eye operation. In such situations I can arrange for you to have general anaesthesia as long as your general health can tolerate it – the decision is one that we make with the anaesthetist looking after you to make sure you are safe at all times. I also have the option of offering light sedation instead of full general anaesthesia.
How long do I have to stay in hospital for vitrectomy surgery?
Vitrectomy surgery is usually done as a daycase procedure under local anaesthesia. This means that you will be in hospital for a few hours, and can go home the same day. Often, patients can also go home the same day after general anaesthesia, but this depends on how well you recover.