The Open Ophthalmology Journal, 2011, 5, 35-41

35

Open Access

Pseudophakic Cystoid Macular Edema Associated with Extrafoveal

Vitreoretinal Traction
Michael R. Martinez1 and Avinoam Ophir*,1,2
1

Division of Ophthalmology, Hillel-Yaffe Medical Center, Hadera and 2The Ruth and Bruce Rappaport Faculty of
Medicine, The Technion, Haifa, Israel
Abstract: Purpose: To describe an association between extrafoveal vitreoretinal traction and intractable chronic
pseudophakic cystoid macular edema (CME) by the use of optical coherence tomography (OCT).
Methods: In a retrospective case series study, charts and OCT findings of patients who had postoperative recalcitrant
pseudophakic CME for at least 6 months and vitreoretinal traction membranes were analyzed. Excluded were eyes that
either had another vitreoretinopathy that could affect the analysis or had undergone an intravitreal intervention.
Results: Three eyes (three patients) with macular edema following uneventful cataract surgery were detected to be
associated with multifocal extrafoveal vitreoretinal traction sites in each. Retinal edema that was underlying each of the
traction sites in all eyes was in continuum in at least one site per eye with the central macular edema, thus manifesting as
diffuse macular edema.
Conclusion: Chronic pseudophakic macular edema may be related to extrafoveal vitreoretinal traction.

Keywords: Pseudophakic macular edema, macular edema, vitreous traction, extrafoveal traction, OCT.
INTRODUCTION
Cystoid macular edema (CME) is the most common
retinal cause of vision impairment after uncomplicated
cataract surgery [1]. Pseudophakic CME develops angiographically in up to 20% to 30% of patients after uneventful
extracapsular cataract extraction/phacoemulsification, and it
usually takes six to eight weeks to develop [2-4]. In most
patients, pseudophakic CME resolved spontaneously, with
50% to 75% of patients achieving improved vision within six
months. However, clinically significant CME, defined as a
Snellen visual acuity of 20/40 or worse, accompanied by
cystoid spaces or retinal edema, has been reported to occur in
2.35% of these cases [5].
Most investigators agree that inflammatory mediators
(e.g., prostaglandins) and vascular endothelial growth factor
(VEGF) may be associated with disruption of the bloodretinal barrier, with resultant fluid accumulation in the
perifoveal area [6, 7]. Vitreous traction at the anterior
segment structures and ocular hypotony are other factors that
have been related to the occurrence of pseudophakic CME
[8]. Prompt treatment of the disorder is required since
irreversible macular changes might occur if macular edema
is present for several months [9]. Several pharmacologic
agents are commonly used to treat this condition, including
topical, sub-Tenon's, intravitreal and systemic corticosteroids, as well as oral and topical nonsteroidal antiinflammatory agents (NSAIDs), but some patients do not
respond to these medications [10]. Recently, antiangiogenic
agents such as bevacizumab (Avastin) have been implicated
*Address correspondence to this author at the Division of Ophthalmology,
Hillel-Yaffe Medical Center, Hadera, Israel; Tel: 972-547-222688; Fax:
972-35409222; E-mail: ophthalmology@hy.health.gov.il
1874-3641/11

in the treatment of pseudophakic CME [11]. However, the

benefit of the anti-VEGF agents for pseudophakic CME,
which are widely applied for most forms of macular edema
is somewhat controversial [11, 12]. In a study that presented
a positive beneficial outcome of intravitreal bevacizumab
[11], it was so in 72.2% (26/ 31) of the eyes, but the benefit
was, by and large, temporary, whereas the remaining 27.8%
did not respond to that therapy. As for surgery, Harbour et al. (n
= 24) and Pendergast and associates (n = 23) reported on the
outcome of pars plana vitrectomy (PPV) in eyes with
recalcitrant pseudophakic CME [13, 14]. In both studies,
diminution of the macular edema was substantial, but while
there was marked improvement in Snellen best-corrected visual
acuity (BCVA) in the former study, it was mild in the latter.
Similarly, refractory chronic macular edema may occur
in a variety of other pathologic conditions, such as diabetic
retinopathy, retinal vein occlusion (RVO) and posterior
uveitis [15-17]. Using optical coherence tomography (OCT),
which provides an optical biopsy of the macula and the
posterior pole in a histological level of resolution, enabled
the establishment of vitreofoveal traction as another
documented cause of macular edema in these ocular diseases
[18]. Recently, vitreous traction membranes that are located
extrafoveally, either retinal or at the optic nerve head (ONH;
i.e. vitreopapillary traction), have also been found to be
associated with macular edema in eyes with diabetic
retinopathy using spectral-domain (SD)-OCT [19], as well as
in non-diabetic eyes using time-domain (TD)-OCT [20]. The
retinal edema that underlined the extrafoveal traction site in
these studies was commonly in a continuum with the
macular edema, thus presenting as diffuse macular edema.
This study presents (for the first time, to the best of our
knowledge; search via Entrez PubMed), a small series of
2011 Bentham Open

36 The Open Ophthalmology Journal, 2011, Volume 5

patients in whom chronic macular edema of pseudophakic

origin was found to be associated with extrafoveal
vitreoretinal traction in each.
MATERIALS AND METHODOLOGY
In a retrospective case series study we analyzed the
charts and TD-OCT scans (OCT 2000, Humphrey Zeiss inc.,
San Leandro, CA, USA), and later the SD-OCT scans (SDOCT 1000, Topcon Corp., Tokyo, Japan), of patients who
had chronic (> 6 months) macular edema and vitreoretinal
traction following cataract extraction and intraocular lens
implantation. Clinical examination included BCVA and slitlamp and fundus examinations. OCT examination of all eyes
was thereafter performed through a dilated pupil by one of
two trained examiners.
Using the TD-OCT, evaluation of macular edema was
routinely initiated by using the Automatic 6-radial lines
program directed to the fixation point and focused on the
central macula. This was followed using the Line group
program, which the examiner controls manually. Scans were
taken at various angles and lengths (a shorter scan increases
resolution) to search for a vitreous traction site at both the
area centralis (between the vascular arcades) away from the
macula and the ONH site. Evidence of traction required
vitreous adherence to the retina or ONH associated with, a)
tissue elevation and deformity at the traction site, i.e., the
shape of the inner retina at the exact site of traction changed
its angle and thus was typically thicker than that of the
adjoining edematous retinal tissue and, b) the posterior
hyaloid or vitreous strand terminated or changed its angle at
that site. Vitreous traction at one site (unifocal) away from
the edematous central macula was designated as extrafoveal
traction, either at the area centralis (extrafoveal vitreoretinal traction) or at the ONH (vitreopapillary traction).
When there were two or more traction sites, traction was
designated as multifocal. Vitreous adherence (without
traction) related to those eyes in which the attachment of the
vitreous was not associated with any vitreoretinal or
vitreopapillary deformities of these tissues at that site. When
an extrafoveal vitreous traction was detected, that site was
examined to determine whether or not its underlying retinal
edema (or subretinal fluid) was in continuum with the central
macular edema.
Using the SD-OCT, 3-dimensional data sets centered on
the fovea (6mm X 6mm) were obtained for each patient. As
a rule, 3-D data sets were also centered on the ONH in
association with the central macula and were obtained using
Table 1.

Martinez and Ophir

a raster scan program of 8.2 mm (horizontal) x 3 mm

(vertical) x 1.7 mm (axial). Volumetric rendering of the data
set was performed using image-processing software within
the SD-OCT for 3-D image reconstruction. The SD-OCT
characteristics are described elsewhere [21]. Data, including
the B-mode and 3-D mode, were evaluated later by
examining the recorded videos.
Cystoid spaces at the foveal region, as detected by the
OCT, were defined as intraretinal round hyporeflective
lacunae with well-defined boundaries and hyper-reflective
septa separating the cystoid-like cavities. Diffuse macular
edema was identified by OCT as an ill-defined and
widespread, hyporeflective, increased retinal thickness that
often attains the appearance of sponge-like cavities [22, 23].
The 6-mm Early Treatment Diabetic Retinopathy Study
(ETDRS) macular maps and the OCT false-colors maps
provided quantitative and qualitative information on the
thickness of the retinal tissue at the site in question,
respectively, and were quantitatively compared with the
normal controls. We used our normative TD-OCT (n = 12)
and SD-OCT (n = 50) database of normal macular thickness
in age-matched patients as controls. Based on these, macular
thickness using TD-OCT or SD-OCT was considered thickened when its central sub-field (CST) exceeded 200
m
(TD-OCT) or 250
m (SD-OCT), similar to data previously
reported [24, 25]. The fovea could be designated as edematous when cystoid spaces were located at its site, even if the
tissue was not abnormally thickened, due to the fact that it
could be thin due to atrophy or lamellar hole formation.
Patients were included in the study if they had both
chronic macular edema (> 6 months) that appeared following
cataract extraction and was related to vitreoretinal traction
membranes. Exclusion criteria covered eyes that had: 1)
another retinopathy that could affect the data analysis; 2)
chronic uveitis; 3) vitreoretinal adherence without signs of
retinal traction or vitreous traction without macular edema;
4) undergone vitreoretinal surgery; 5) been treated by
intravitreal administration of medication(s), or 6) eyes in
which the OCT scans were of too low a quality for a proper
diagnosis and measurements.
Research adhered to the tenets of the Declaration of
Helsinki, and the approval of the Institutional Review Board
was obtained.
RESULTS
Three patients, aged 51-78 years old, with chronic
pseudophakic CME in one eye, in which any other potential

Data of Patients with Pseudophakic Cystoid Macular Edema

Patient

A/G/E

BCVA

Central Sub-Field Thickness (in Microns)

89/F/LE

20/80

340

64/M/LE

20/60

285

53/M/RE

20/60

370

Site of Extrafoveal Traction

Comments

Three sites: 1-2) 2 sites infero-nasal to fovea;

3) at the vitreopapillary site
Two sites: 1) Inferior to the optic nerve head;
2) Inferonasal to fovea
Two sites: 1) At the papillomacular bundle;
2) superotemporal to the fovea

A=Age, G=Gender, E=Eye; BCVA=Best-corrected visual acuity; M=Male, F=Female; RE=Right eye; L=Left eye.

Pseudohole

Pseudophakic CME and Vitreoretinal Traction

clinical cause for the edema was not detected, were

diagnosed using OCT to have extrafoveal multifocal
vitreoretinal traction sites in each eye. Patients
characteristics and OCT findings are summarized in Table 1.
Both the B-mode video clips of the SD-OCT and their 3-D
image reconstructions enabled fast and unambiguous
detection of extrafoveal traction membranes in eyes No. 1 &
2 (Figs. 1, 2). The retinal edema that underlined each of the
vitreoretinal traction sites in Eye No. 1, including the edema
that was associated with the vitreopapillary traction, was in
continuum with the central macular edema, thus attaining a

The Open Ophthalmology Journal, 2011, Volume 5

37

pattern of diffuse macular edema. This observation could be

depicted from the macular maps and the 3-D image
reconstructions of the SD-OCT (Fig. 1 and supplementary
video clip 1). Eye No. 2 had Irvine-Gass syndrome with a
swollen disc at the early postoperative period. Four years
later, using SD-OCT, the perifoveal area was mildly
thickened, and a pseudohole at the central macula with adjacent ERM was apparent. The retinal edema that underlined
one of the two detectable traction sites was in continuum
with the central macular edema in that eye (Fig. 2).

Fig. (1). Extrafoveal multifocal vitreoretinal traction and pseudophakic macular edema as detected by the spectral-domain OCT (Pt. 1). A +
B. The clinical picture and macular map (the right circle map below the fundus picture) illustrate macular edema located centrally and inferonasally to the fovea (purple color). The yellow squares in A and B delineate the scanned area (6 x 6 mm). C + D. The B-mode presents two
extrafoveal vitreoretinal traction membranes, marked by arrowhead in C and by an arrow in D. The manually marked vertical yellow lines
indicate the traction sites; the OCT software automatically marks the anatomical locations in blue crosses, in A & B. Each of the underlying
retinal edema sites (asterix) is in continuum with the central macula (seen in the map in A & B). E. 3-D image reconstruction reveals a
relatively thick connection between the two vitreoretinal traction membranes associated with diffuse macular edema (asterix); the purple
vertical line marks the foveal site. The arrowhead shows the inferior membrane (shown at C) and the arrow shows the superior one (shown in
D). F. 3-D image reconstruction (area of 8.2 mm X 3 mm) includes the macula (the fovea is marked by the purple line), the superior traction
site (arrow) and the optic nerve head (ONH; star). Multifocal vitreous membranes are associated with the ONH.

38 The Open Ophthalmology Journal, 2011, Volume 5

Martinez and Ophir

Fig. (2). Extrafoveal multifocal vitreoretinal traction associated with pseudophakic CME as detected by the SD-OCT (Pt. 2). A + B. The
clinical picture and the accompanying small false-color map (below the fundus picture), as detected by 8.2mm X 3 mm scan area (the
colored rectangle) illustrate macular edema (red and yellow colors). The blue crosses, one in A and one in B, demonstrate two extrafoveal
vitreoretinal traction sites. One retinal edema site (in B) is shown by the false-color map to be in continuum with the central macula. C + D.
The B-mode (C) and the 3-D image reconstruction (D) reveal two sites under traction by one continuous vitreous membrane (arrow). Each
traction site is manually marked by a vertical white line, and its retinal location is shown automatically by yellow crosses in A & B. The
optic nerve (ON) is seen in D.

The third eye (No. 3) was examined by TD-OCT (OCT2000) and presented with diffuse macular edema
accompanied by cystoid spaces. Vitreoretinal traction
membranes were identified at two sites, one parafoveally at
the papillomacular bundle (PMB) zone and the second
temporally to the fovea (Fig. 3; a 3-D image reconstruction
is not available in the TD-OCT). The centrally fixated
Automatic 6-radial lines program of the OCT-2000 enabled
the diagnosis of extrafoveal vitreous traction, which was
located parafoveally at the PMB site. A small area of
subretinal fluid underlined this traction site. The second
traction site in this eye was detected by the Line group
program, but not by the Automatic 6-radial lines program.
The retinal edema that underlined each of the two detected
traction sites was in direct communication with the edema at
the central macula. This observation could be depicted from
the OCT B-mode and the macular map (Fig. 3C, D).

DISCUSSION
The study presents three eyes with refractory
pseudophakic diffuse macular edema that was associated
with multifocal extrafoveal vitreoretinal traction in each. The
retinal edema that was underlying at least one traction site
per eye was in continuum with the macula, manifesting in
each as diffuse macular edema.
Several studies on PPV for treating recalcitrant
pseudophakic CME have been published [13, 14, 26].
Harbour et al. reported on 24 consecutive patients who
underwent PPV for chronic pseudophakic CME that failed to
respond medically [13]. The surgery resulted in improved
visual acuity in all eyes from a mean visual acuity of 20/190
preoperatively to 20/52 postoperatively, with a mean
improvement of 4.7 Snellen lines. Peyman et al. reported on
the beneficial effect of PPV and internal limiting membrane

Pseudophakic CME and Vitreoretinal Traction

The Open Ophthalmology Journal, 2011, Volume 5

39

Fig. (3). Extrafoveal multifocal vitreoretinal traction associated with pseudophakic CME as detected by a time-domain OCT (Pt. 3). (A)
Vitreous traction membrane (asterix) located at the papillomacular bundle area, in proximity to the ONH (not shown). An underlying
localized subretinal fluid (star) and a diffuse macular edema are associated with the traction membrane. (B) A second vitreoretinal traction
membrane (arrowhead) is located temporo-superiorly to the fovea; a retinal edema underlies it. (C) The 6-mm false-color and quantitative
thickness macular maps disclose diffuse macular edema associated with two different tractions sites (marked by arrowhead and asterix). The
central sub-field thickness is 370
m. (D) The quantitative macular map of the normal controls (n = 12).

peeling, which took place in two eyes with recalcitrant

pseudophakic CME 11-22 months after cataract surgery [26].

ambiguous. The presence of extrafoveal vitreous traction in

the current study may be relevant to that issue.

By contrast, Pendergast et al. reported the results of PPV

for intractable chronic pseudophakic CME in 23 consecutive
eyes with no apparent vitreoretinal disturbance. Surgery
resulted in resolution of the CME in all cases, though with
improved visual acuity in only some of the eyes [14]. This
relatively low functional benefit could be related to the
macular edema's having been present for a mean of 20
months (range, 3-110 months) prior to surgery. The
suggestion of that possibility is based on earlier studies on
PPV for diabetic macular edema (DME) [27, 28], which
suggest that a delay in performing surgery may partly
explain the permanently reduced vision in spite of marked
structural improvement [27]. Other authors who found PPV
for DME of benefit attributed it in part to the removal of
growth factors associated with macular edema from the
vitreous site [29]. However, the studies on PPV for
pseudophakic CME did not mention or rule out an existence
of extrafoveal vitreous traction, and the stated cause of
surgery's success or failure of the surgery was often

The centrally fixated Automatic 6-radial lines program of

the TD-OCT (OCT-2000) enabled unequivocal diagnosis of
one site of vitreous traction in eye No. 3, which was located
parafoveally at the PMB site (Fig. 3). Only the Line group
program enabled the detection of the second traction site in
this eye. As previously described, detection of extrafoveal
traction can often be made only with the Line group or the
Raster line programs [30]. This is due to the fact that the
length of each scan in the Automatic 6-radial lines program
is 5.9 mm, the scans are separated from each other by a 300
arc and program's output is limited to the 6 lines that are
scanned. Furthermore, the length of the arc between two
adjacent radial lines at their farthest point from the center is
>1.5mm (2R/ 12 = 2 X 3.14 X 3 / 12). Therefore, using the
Line scan or the Raster line programs to search for an
extrafoveal site is likely to require hundreds of scan lines in
order to cover every point at the area centralis. As a
consequence, many extrafoveal traction sites may be
overlooked due to omission of vitreous adherence sites that
are typically small, because of progressive patient fatigue in

40 The Open Ophthalmology Journal, 2011, Volume 5

this time-consuming search, and because of progressive

corneal epithelial drying that could result in poor scan
quality.
In contrast, two eyes (No. 1 & 2) were plainly diagnosed
to have multifocal extrafoveal traction membranes by the
SD-OCT. With a scanning time of 3.7 seconds, the SD-OCT
detected extrafoveal traction sites much faster than the TDOCT did, and is also expected to have a higher rate of
accuracy than the TD-OCT does [31]. That is, since the SDOCT screens every point at the scanned vitreous membranes
and retinal surface, acquiring an entire A-scan
simultaneously, its B-mode has 40,000 A-scans per second
(vs 400 A-scans/second in the TD-OCT), and it promises
image acquisition at 50 to 100 times the TD-OCT speed with
equal or improved spatial resolution. In addition, the
improved 6
m axial resolution of the SD-OCT over the TDOCT (10-15
m) allows better identification of morphologic
details in the retina and the vitreoretinal interface, as
previously described [32, 33]. The 3-D image reconstruction
of the SD-OCT may provide more detailed information than
its B-mode can because it reveals a real image, both
horizontally and vertically, of the whole vitreoretinal area
under study with better spatial perception of the vitreoretinal
interface. Such an image is depicted, for example, in Fig. (1)
and supplementary video clip No. 1.
Except for the potential for consideration of PPV in these
eyes, detection of extrafoveal traction should also be
important if a therapeutic agent like bevacizumab or
triamcinolone acetonide (kenalog) is planned intravitreally,
since doing so can result in worsening of traction and
subsequent traction retinal detachment [34].
Limitations of the study refer to its retrospective design
and small series. However, the study raises the possibility
that recalcitrant pseudophakic CME or macular edema may
be associated with extrafoveal vitreoretinal traction. The SDOCT detected the traction sites much faster and with a higher
rate of confidence than the TD-OCT could. Further studies
and a larger cohort are required to validate whether early
vitrectomy is the treatment of choice in these situations.

Martinez and Ophir

[6]
[7]
[8]
[9]
[10]
[11]

[12]

[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]

VIDEO CLIP NO. 1 (PATIENT NO. 1)

This article also contain supplementary material (3-D
movie clip) ans it can be viewed at publishers website.
The 3-D movie shows 2 continuous vitreoretinal traction
sites. Each of the traction sites is underlain by retinal edema
that is in continuum with the central macula, thus presenting
as diffuse macular edema (see also Fig. 1).

[23]

[24]
[25]

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Revised: January 21, 2011

Accepted: January 22, 2011

Martinez and Ophir; Licensee Bentham Open.

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