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Posterior Segment Age-related Macular Degeneration Tractional Maculopathies in Age-related Macular Degeneration C y n t h i a X Q i a n , M D , 1 W i l l i a m J F o s t e r , M D , P h D 2,3,4 a n d F l a v i o A R e z e n d e , M D , P h D 1,5 1. Chief Resident, Department of Ophthalmology, University of Montreal, Quebec, Canada; 2. Associate Professor, Department of Ophthalmology, Weill-Cornell Medical College at The Methodist Hospital, Houston, US; 3. Associate Professor, Department of Physics, The University of Houston, Texas, US; 4. Associate Professor, The Methodist Hospital Research Institute, Houston, Texas, US; 5. Associate Professor, Department of Ophthalmology, University of Montreal, Quebec, Canada; 6. Associate Professor, Pontifícia Universidade Católica, Rio de Janeiro, Brazil Abstract Age-related macular degeneration (AMD) is the leading cause of blindness among the elderly in developed countries. Much progress has been and continues to be made in search of better visual outcomes for dry and exudative AMD. Over the past decade, the importance of vitreomacular attachments has been recognized in AMD. In this article, we better characterize and describe vitreomacular and photoreceptor-retinal pigment epithelium interface relationships in AMD among treated and untreated patients and describe the surgical options available as well as their outcomes and possible complications. Keywords Age-related macular degeneration, tractional maculopathy, posterior vitreous detachment, macular hole, epiretinal membrane, Müller cells, reactive gliosis, vitreoretinal adhesion, vitreomacular traction syndrome Disclosure: This work did not receive funding from any source. None of the authors have any proprietary or financial interest in the products discussed in this article. Received: November 14, 2011 Accepted: December 13, 2011 Citation: US Ophthalmic Review, 2012;5(2):119–25 Correspondence: Flavio A Rezende, MD, PhD, Department of Ophthalmology, University of Montreal, Montreal, QC, Canada. E: Age-related macular degeneration (AMD) is an insidious progressive loss of visual function that occurs with aging, and is the leading cause of visual loss in the Western Hemisphere in the elderly. 1,2 Although common, the pathways mediating its onset and progression are complex and multifactorial. While many studies have looked at the pathogenesis and physiological changes that occur at the outer retina during AMD, research on inner retinal changes is less common. More specifically, when AMD is compounded by degenerative tractional changes at the vitreomacular interface and inner retina, the problem becomes greater than the sum of its parts. In this article, we address the different etiologies of vitreomacular interface pathologies found in association with both dry and exudative AMD, their pathogenesis, and how their pharmacological and surgical treatment responses differ from the presentation and treatment of either condition alone. Vitreomacular Adhesions Vitreomacular adhesion (VMA) defines a condition in which the vitreous gel and posterior hyaloid are abnormally adherent to the retina. When a posterior vitreous detachment (PVD) is incomplete and does not undergo a normal synchronous sequence of synchisis and syneresis, a taut anterior/posterior traction on the underlying macula can be created. 3,4 This leads to vitreomacular traction (VMT) and subsequent visual degradation, now identifiable and characterizable on a more regular basis through advances in time- and spectral-domain optical coherence tomography (OCT) imaging. 5,6 More commonly, traction can lead to a spectrum of retinal architectural distortions, ranging from © TOUCH BRIEFINGS 2012 cystoid macular edema, epiretinal membrane (ERM), and macular holes up to macular and retinal pigment epithelium (RPE) detachments. 7 Vitreomacular Adhesions and Age-related Macular Degeneration The current prevalence of tractional maculopathy is estimated to be 6.4  % within the American population over the age of 50. Recent data have corroborated previous ultrasound findings that incomplete abnormal PVD is more common than was previously thought and that associated posterior VMA seems to be more common among patients with AMD than in age-matched controls, placing prevalence at 22–36 %. 8–11 In particular, this seems to be the case more often in advanced exudative cases than in patients with non-exudative AMD. 8,10–13 Frequently, vitreous attachment sites to the macula correspond to areas of choroidal neovascularization (CNV), suggesting a direct relationship. 4,8 Mojana and colleagues imaged VMA in AMD, showing a 27.8 % prevalence in exudative cases and 24.5 % in non-exudative cases. In this study, traction was identified on OCT in 59 % and 13 % of patients in each group, respectively, showing a strong direct correlation between adhesion and traction. 12 These abnormal vitreomacular interactions in AMD seem to be present in different populations in the world. In a cohort of Brazilian patients of 204 eyes with AMD imaged with time-domain OCT, 16.7 % had VMT, 7.8 % had ERM, 1 % had macular holes, and 15.2 % had incomplete perifoveal PVD. 14 When using spectral domain OCT imaging, the number of patients with VMA identified may increase up to 73 %. 15 Given that patients with AMD have a higher likelihood of partial PVD, it is often difficult to tell whether their 119