Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. However, this may be complicated by persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction; VMT). VMT itself may be associated with epiretinal membrane formation and the development of idiopathic macular holes (IMH). Such pathologies may cause visual disturbances, including metamorphopsia, photopsia, blurred vision, and decreased visual acuity, which impact an individual's quality of life. Technologies such as optical coherence tomography allow an increasingly more accurate visualisation of the macular anatomy, including quantification of macular hole characteristics, and this facilitates treatment decision-making. Pars plana vitrectomy remains the primary treatment option for many patients with VMT or IMH; for the latter, peeling of the inner limiting membrane (ILM) of the retina has shown improved outcomes when compared with no ILM peeling. The development of narrow-gauge transconjunctival vitrectomy systems has improved the rate of visual recovery following surgery. Ocriplasmin, by degrading laminin and fibronectin at the vitreoretinal interface, may allow induction of PVD in a non-invasive manner. Indeed, clinical studies have supported its use as an alternative to surgery in certain patient populations. However, further research is still needed with respect to greater understanding of the pathophysiology underlying the development of VMT and IMH.