Tração vitreomacular: novos conceitos
Arquivos
Data
2015-05-31
Autores
Bottos, Juliana Mantovani 
Orientadores
Maia, Mauricio
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
O presente estudo foi conduzido em três etapas, tendo os seguintes objetivos: 1. Estudar e revisar os principais conceitos relacionados à fisiopatologia e maculopatias associadas à tração vitreomacular. 2. Analisar a concordância entre as diferentes classificações baseadas na morfologia e no diâmetro de tração vitreomacular, assim como correlacionar as maculopatias associadas à síndrome. 3. Avaliar os diferentes tipos de tração vitreomacular para estabelecer a classificação que melhor reflita o prognóstico visual e anatômico pós-cirúrgico. A tração vitreomacular (TVM) decorre do descolamento do vítreo posterior (DVP) de forma anormal e incompleta, com persistente aderência vitreomacular, levando às alterações funcionais e estruturais de origem tracional e consequente baixa visual. O termo "aderência vitreomacular" (AVM), por si só, equivale a um estágio normal de descolamento parcial perifoveal do vítreo posterior ainda aderido à região foveal, formando um ângulo agudo entre o vítreo e a superfície interna da retina, sem implicar em alterações anatômicas da retina neurossensorial decorrentes dessa aderência. Porém, até o momento, não existe um consenso universalmente aceito para a classificação das doenças vitreomaculares. Se, no passado, a síndrome de TVM era considerada uma patogenia isolada, hoje, acredita-se que tenha participação em um enorme espectro de doenças maculares como: edema macular cistóide (EMC); buraco macular (BM) e membrana epirretiniana (MER). O reconhecimento da associação da TVM na etiologia dessas doenças é imperativo para o adequado tratamento dessas maculopatias. Entretanto, ainda é incerto o porquê pacientes com TVM desenvolvem diferentes maculopatias, e qual configuração de tração pode se beneficiar de tratamentos específicos, sejam eles expectantes, cirúrgicos ou enzimáticos. O segundo estudo analisou duas propostas de classificação para a síndrome de TVM, através da avaliação de 53 olhos de pacientes diagnosticados com essa doença. Todos os olhos foram categorizados segundo as duas propostas de classificação baseados em imagens por tomografia de coerência óptica (OCT): a classificação baseada na morfologia (tração em forma de V ou em J) e na classificação baseada no diâmetro de tração vitreomacular (focal?1500?m ou difusa>1500?m). É importante ressaltar que o termo ?diâmetro? refere-se, aqui, à maior extensão linear da área de aderência vitreomacular, não necessariamente representada por um círculo perfeito. Foi observada alta concordância entre os tipos de TVM em V e focal, e entre as TVM em J e difusa (kappa=0,850; p<0,001), exceto em 4 casos cuja aderência, apesar de maior que 1500 ?m (difusa) apresentava a forma em V. Todos esses 4 casos apresentaram características comuns às TVM difusas, e não como as TVM em V, quando consideramos as maculopatias associadas e funções visuais. TVM em V (n=29) e focais (n=25) estiveram associados à formação de EMC tracional (79,31% e 84% respectivamente) e BM (37,93% e 44%); enquanto TVM em J (n=24) e difusas (n=28) estiveram associados à presença de MER (91,66% e 92,85% respectivamente) e espessamento retiniano difuso (62,50% e 64,28%). Embora concordante, a classificação baseada no diâmetro de TVM e não na morfologia da aderência reflete de forma mais acurada as alterações maculares decorrentes dessa tração. O terceiro estudo analisou 36 olhos de pacientes com diagnóstico de síndrome de TVM submetidos à cirurgia vitreorretiniana e categorizados segundo as duas propostas de classificação (morfológica: V ou J e diâmetro: focal ou difusa). A acuidade visual corrigida (AV) pós-operatória foi muito semelhante entre os diferentes tipos de TVM (P=0,393). Entretanto, casos de TVM focais apresentaram uma variação entre a AV pré e pós-operatória maior (P=0,027), já que a AV pré-operatória era significantemente menor quando comparada à TVM difusa, alcançando AV pós-operatória final semelhante entre ambos os tipos (P=0,007). Já quando consideramos as TVM baseadas na morfologia, não observamos diferença na AV pré e pós-operatória (P=0,235). A evolução pós-operatória e as maculopatias associadas estão intimamente relacionadas ao tamanho da aderência vitreomacular. O diâmetro de aderência medido em micrômetros (focal ou difuso) e não a forma clássica relacionada à morfologia (V ou J) é o preditor mais fidedigno dos prognósticos funcionais e anatômicos pós-operatório. Concluímos, nesses estudos, que: 1. A TVM decorre do descolamento incompleto do vítreo posterior e tem participação em um espectro de doenças maculares sendo as principais o BM, o EMC tracional e a MER. 2. TVM em V e focais associam-se ao EMC tracional e BM enquanto que TVM em J e difusas relacionam-se à MER e ao espessamento retiniano difuso. A classificação baseada no diâmetro de TVM e não na morfologia da aderência reflete de forma mais acurada tais maculopatias. 3. O diâmetro de aderência medido em micrômetros (focal ou difuso) e não a forma clássica relacionada à morfologia (V ou J) reflete de forma mais fidedigna o prognóstico anatômico e funcional pós-operatório.
The present study was conducted in three steps with the following purposes: 1) to present the current information on the pathophysiology, anatomic macular abnormality associations and new concepts in vitreomacular traction (VMT) disease. 2) to analyze the agreement between the classifications based on morphology and diameter of VMT as well as to correlate the morphologic findings of VMT with specific maculopathies. 3) to analyze a variety of VMT morphologies to establish a major classification that better reflects the preoperative predictive factors of postoperative visual and anatomic outcomes. VMT is defined as the result of abnormal and incomplete PVD with persistente attachment to the macular area, leading to tractional anatomic changes, and usually resulting in reduced or distorted vision. VMA, a partial vitreofoveal separation without retinal abnormalities, is characterized by an elevation of the cortical vitreous above the retinal surface, with an acute angle between the vitreous and the inner retinal surface. This is a normal development during the natural course of PVD. Until recently, VMT was considered an isolated pathology. Nowadays, it is believed to assume a contributory role in a wide spectrum of macular diseases, including macular hole (MH), cystoid macular edema (CME) and epiretinal membrane (ERM). Each VMT configuration has unique implications concerning anatomical and functional outcomes. Although several classification systems of this syndrome have been proposed, there is currently not a consensus for classifying VMT. The recognition of the role of VMT in such macular diseases is imperative for proper diagnosis and management. However, it remains uncertain why patients with VMT have different maculopathies and which macular configurations will benefit from expectant, surgical, or enzymatic treatment. The second study analyzed fiftythree eyes with VMT syndrome. All of them were categorized into two classifications based on optical coherence tomography images: the VMT morphology (Vor Jshaped) and the diameter of adhesion (focal≤1,500 μm or broad>1,500 μm). It’s important to consider that the term “diameter” refers, here, to the higher extension of the vitreomacular adhesion area, not necessarily represented by a perfect circle. High correlation was seen between Vshaped and focalVMT and between Jshaped and broadVMT (kappa=0.850; p<0.001), except in 4 cases with broad adhesion despite the presence of a Vshaped pattern. These 4 cases had common characteristics to those with broad vitreal attachment regarding associated maculopathies and visual function. Vshaped VMT (n=29) and focalVMT (n=25) led to tractional CME (79.31% and 84% respectively) and MH (37.93% and 44%); Jshaped VMT (n=24) and broadVMT (n=28) were associated with ERM (91.66% and 92.85% respectively) and diffuse retinal thickening (62.50% and 64.28%). The study concluded that, although highly concordant, the classification based on the diameter of the adhesion and not on the classical adhesion morphology reflected more accurately the specific macular changes. The third study analyzed thirtysix eyes with the diagnosis of VMT syndrome. All of them were submitted to vitrectomy surgery and categorized with a VMT pattern (Vor Jshaped) and diameter (focal≤1,500μm or broad>1,500μm) based on optical coherence tomography. Despite similar postoperative bestcorrected visual acuity (BCVA) values (P=0.393), cases with focal VMT had greater visual improvement (P=0.027), since the preoperative BCVA was significantly lower in the focal group (P=0.007). However, the BCVA improvements did not differ between the groups regarding the classic VMT morphologic patterns (P=0.235). Postoperative outcomes and macular disorders are closely related to VMT size. The adhesion diameter (focal or broad VMT) and not the classic VMT morphologic pattern (Vor Jshaped) is a better predictor of the postoperative anatomic and functional outcomes. In conclusion: 1.VMT is the result of abnormal and incomplete PVD with persistente attachment to the macular area leading to tractional anatomic changes, including MH, CME and ERM; 2. Vshaped VMT and focalVMT led to tractional CME and MH while Jshaped VMT and broadVMT led to ERM and diffuse retinal thickening. The classification based on the diameter of the adhesion and not on the classical adhesion morphology reflected more accurately the specific macular changes; 3. The adhesion diameter measured in micrometers (focal or broad VMT) and not the classic VMT morphologic pattern (Vor Jshaped) is a better predictor of the postoperative anatomic and functional outcomes.
The present study was conducted in three steps with the following purposes: 1) to present the current information on the pathophysiology, anatomic macular abnormality associations and new concepts in vitreomacular traction (VMT) disease. 2) to analyze the agreement between the classifications based on morphology and diameter of VMT as well as to correlate the morphologic findings of VMT with specific maculopathies. 3) to analyze a variety of VMT morphologies to establish a major classification that better reflects the preoperative predictive factors of postoperative visual and anatomic outcomes. VMT is defined as the result of abnormal and incomplete PVD with persistente attachment to the macular area, leading to tractional anatomic changes, and usually resulting in reduced or distorted vision. VMA, a partial vitreofoveal separation without retinal abnormalities, is characterized by an elevation of the cortical vitreous above the retinal surface, with an acute angle between the vitreous and the inner retinal surface. This is a normal development during the natural course of PVD. Until recently, VMT was considered an isolated pathology. Nowadays, it is believed to assume a contributory role in a wide spectrum of macular diseases, including macular hole (MH), cystoid macular edema (CME) and epiretinal membrane (ERM). Each VMT configuration has unique implications concerning anatomical and functional outcomes. Although several classification systems of this syndrome have been proposed, there is currently not a consensus for classifying VMT. The recognition of the role of VMT in such macular diseases is imperative for proper diagnosis and management. However, it remains uncertain why patients with VMT have different maculopathies and which macular configurations will benefit from expectant, surgical, or enzymatic treatment. The second study analyzed fiftythree eyes with VMT syndrome. All of them were categorized into two classifications based on optical coherence tomography images: the VMT morphology (Vor Jshaped) and the diameter of adhesion (focal≤1,500 μm or broad>1,500 μm). It’s important to consider that the term “diameter” refers, here, to the higher extension of the vitreomacular adhesion area, not necessarily represented by a perfect circle. High correlation was seen between Vshaped and focalVMT and between Jshaped and broadVMT (kappa=0.850; p<0.001), except in 4 cases with broad adhesion despite the presence of a Vshaped pattern. These 4 cases had common characteristics to those with broad vitreal attachment regarding associated maculopathies and visual function. Vshaped VMT (n=29) and focalVMT (n=25) led to tractional CME (79.31% and 84% respectively) and MH (37.93% and 44%); Jshaped VMT (n=24) and broadVMT (n=28) were associated with ERM (91.66% and 92.85% respectively) and diffuse retinal thickening (62.50% and 64.28%). The study concluded that, although highly concordant, the classification based on the diameter of the adhesion and not on the classical adhesion morphology reflected more accurately the specific macular changes. The third study analyzed thirtysix eyes with the diagnosis of VMT syndrome. All of them were submitted to vitrectomy surgery and categorized with a VMT pattern (Vor Jshaped) and diameter (focal≤1,500μm or broad>1,500μm) based on optical coherence tomography. Despite similar postoperative bestcorrected visual acuity (BCVA) values (P=0.393), cases with focal VMT had greater visual improvement (P=0.027), since the preoperative BCVA was significantly lower in the focal group (P=0.007). However, the BCVA improvements did not differ between the groups regarding the classic VMT morphologic patterns (P=0.235). Postoperative outcomes and macular disorders are closely related to VMT size. The adhesion diameter (focal or broad VMT) and not the classic VMT morphologic pattern (Vor Jshaped) is a better predictor of the postoperative anatomic and functional outcomes. In conclusion: 1.VMT is the result of abnormal and incomplete PVD with persistente attachment to the macular area leading to tractional anatomic changes, including MH, CME and ERM; 2. Vshaped VMT and focalVMT led to tractional CME and MH while Jshaped VMT and broadVMT led to ERM and diffuse retinal thickening. The classification based on the diameter of the adhesion and not on the classical adhesion morphology reflected more accurately the specific macular changes; 3. The adhesion diameter measured in micrometers (focal or broad VMT) and not the classic VMT morphologic pattern (Vor Jshaped) is a better predictor of the postoperative anatomic and functional outcomes.
Descrição
Citação
BOTTOS, Juliana Mantovani. Tração vitreomacular: novos conceitos. 2015. 64 f. Tese (Doutorado em Oftalmologia e Ciências Visuais) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2015.