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Vitreomacular interface disorders (macular hole, epiretinal membrane, VMT)
With age the vitreous separates from the retina; when the separation is incomplete it pulls on the macula (VMT) and may tear a full-thickness hole (macular hole), and when cells proliferate on the retinal surface an epiretinal membrane (ERM) forms that wrinkles it — all are diagnosed on OCT and, when troublesome, treated with vitrectomy.
Why it matters in the exam
Full-thickness macular hole: an older woman with reduced vision and central distortion, and a small central scotoma. OCT shows a defect through the full thickness of the retina at the fovea. On examination — the Watzke-Allen sign: a narrow light beam projected across the hole looks broken or narrowed in the centre. The classification (IVTS) by diameter: small up to 250 microns, medium above 250 and up to 400, large above 400. Treatment: vitrectomy with peeling of the internal limiting membrane (ILM) and a gas bubble, sometimes with face-down positioning; small and medium holes close in a large majority of cases, and closure is lower in large and long-standing holes.
Epiretinal membrane: usually idiopathic after age 50, and sometimes secondary — after retinal surgery, inflammation, vein occlusion or laser. A "cellophane" reflex on the macula, tortuous vessels and thickening on OCT. Many patients have no complaints and remain under follow-up; when there is distortion and reduced vision — vitrectomy with membrane peeling. VMT — the vitreous adheres to the macula and pulls on it; some cases release on their own, and others progress to a hole. It must be distinguished from a lamellar hole — a partial, not full-thickness, defect — and from a pseudohole created by a membrane.
Posterior vitreous detachment (PVD) itself is normal with age, but during the separation retinal tears can appear — so any new flashes and floaters need a dilated fundus examination. In high myopia the vitreous pulls on the macula and the retina splits (myopic traction maculopathy). After surgery with gas — face-down positioning as the surgeon instructs, no flying and no nitrous oxide anaesthesia, and later cataract develops in most phakic eyes.
Key points
- Incomplete PVD → VMT → macular hole.
- Full-thickness hole: Watzke-Allen; vitrectomy, ILM peel, gas.
- Size: small up to 250, medium up to 400, large above 400 microns.
- ERM: cellophane; surgery only with complaints.
- After gas — no flying and no nitrous oxide.
Summary table
| Condition | OCT finding | Symptoms | Treatment |
|---|---|---|---|
| VMT | Attached vitreous pulling on the fovea | Distortion, mild reduction | Follow-up; vitrectomy if it worsens |
| Full-thickness macular hole | Defect through the full foveal thickness | Central scotoma, positive Watzke-Allen | Vitrectomy, ILM peel, gas |
| ERM | Membrane on the retinal surface, thickening | Distortion, micropsia | Follow-up or membrane peel |
| Lamellar hole | Partial defect | Mild reduction | Usually follow-up |
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Sources
- AAO Preferred Practice Pattern: Idiopathic Macular Hole, 2019 — Staging and surgery
- International Vitreomacular Traction Study (IVTS) Group classification, 2013 — Vitreomacular adhesion, traction and macular hole
- AAO Basic and Clinical Science Course, Section 12: Retina and Vitreous, 2024-2025 — Diseases of the vitreous and vitreoretinal interface
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.