Vitreomacular Traction in Action

A 59-year-old White male presented complaining of a constant, circular, blurred spot in his central vision OS, described as “small specks” that moved with his vision. He said the symptoms began 1 week prior to this appointment. Additionally, he reported a similar experience 3 to 4 months earlier that resolved spontaneously within 30 minutes.

HISTORY

The patient’s medical history was significant for hyperlipidemia, acid reflux, gallbladder removal, and anxiety. For the latter, the patient reported starting escitalopram approximately 2 weeks prior to this appointment and noted that he was in the process of tapering the medication. 

His ocular history was unremarkable aside from spectacle wear for refractive error, including progressive lenses for myopia and presbyopia.

The patient’s BCVA measured 20/50-1 OS, improving to 20/20 with pinhole acuity, and 20/25+2 OD. His pupils were equal and reactive without afferent pupillary defect. Extraocular motilities were full, and IOPs were 14 mm Hg OD and 15 mm Hg OS.

Anterior segment examination was unremarkable OU. Dilated fundus examination revealed a small, round, yellow area of glistening superior-temporally to the fovea OS (Figure 1). While this finding is more typically associated with epiretinal membranes, it may also indicate localized traction on the macula, as confirmed by OCT. This highlights how subtle fundus findings can correspond to clinically significant vitreomacular interface changes and underscores the value of multimodal imaging in diagnosis. The patient’s optic nerves had a 0.2 cup-to-disc ratio, well-perfused with distinct margins, and exhibited mild myelination. No peripheral retinal pathology was noted.

Family medical history and review of systems were unremarkable.

IMAGING AND DIAGNOSIS

At the initial appointment, spectral-domain (SD)-OCT OS revealed vitreomacular adhesion (VMA) with distortion of the foveal contour, sans a full-thickness macular hole. Also, structural changes within the inner retinal layers were consistent with tractional forces at the macula. Retinal nerve fiber layer OCT imaging was within normal limits OU (Figure 2).

Based on the patient’s visual complaint and SD-OCT findings, vitreomacular traction (VMT) syndrome OS was diagnosed. Central serous chorioretinopathy was considered given the patient’s age and stress history; however, OCT did not reveal subretinal fluid. Early macular hole was also considered, though the absence of a full-thickness foveal disruption made this particular clinical diagnosis less likely.

At the 1-month follow-up, OCT showed resolution of the VMT with normal foveal contour restoration. A small area of focal vitreous attachment remained, but no residual traction or distortion of the macular architecture was seen, consistent with anatomic improvement (Figure 3).

MANAGEMENT

Mild cases of VMA or VMT can often be monitored by an optometrist when patients are asymptomatic, visual acuity remains stable, Amsler grid testing is stable, and OCT shows an intact foveal contour. Referral to a retina specialist is recommended for moderate to severe cases in which patients are symptomatic, experience reduced visual acuity or metamorphopsia, demonstrate changes on Amsler grid testing, or show disruption of the foveal contour on OCT.

In this case, given the patient’s symptomatic presentation, including noticeable central visual changes and a defect on Amsler grid testing, along with OCT-confirmed disruption of the foveal contour, he was referred to a retina specialist for confirmation of the diagnosis of VMT syndrome, assessment of traction severity, and a discussion of potential management options. He was advised to continue routine optometric care, including monitoring visual acuity and symptoms, while following recommendations regarding observation versus intervention. He was also encouraged to self-monitor using an Amsler grid and promptly report any changes in vision if they were to occur.

Due to its more predictable anatomic and visual outcomes, pars plana vitrectomy is typically considered in cases of persistent or progressive VMT associated with reduced visual acuity, metamorphopsia, or significant foveal distortion on OCT, particularly when spontaneous resolution is unlikely or when nonsurgical options are less effective.¹

Recent studies suggest posterior hyaloid stripping during vitrectomy can effectively relieve traction, restore foveal anatomy, and improve visual outcomes while preserving the internal limiting membrane.²

DISCUSSION

VMT syndrome occurs when an incomplete posterior vitreous detachment results in persistent adhesion at the macula, leading to distortion of retinal architecture. While mild cases may resolve spontaneously—reported in approximately 20% of patients—persistent or progressive traction can lead to chronic visual symptoms, including blurred vision or macular hole formation.¹

VMA differs from VMT in that the vitreous remains attached to the macula without associated foveal distortion or visual symptoms. This distinction is clinically important, as VMA may be safely monitored, whereas symptomatic VMT warrants closer observation or intervention.

The discussed case emphasizes the importance of an OCT-driven evaluation of central visual disturbances and highlights the optometrist’s role in identifying VMT syndrome early. Prompt diagnosis and referral can significantly affect visual prognosis and patient outcomes.