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Vitreomacular adhesion and neovascular age-related macular degeneration To the Editor: We read with interest the report of Simpson et al5 speculating upon the role of the vitreomacular interface (VMI) in the pathogenesis of age-related macular degeneration (AMD). The authors propose both vitrectomy and pharmacologic vitreolysis as therapeutic options in alteration of the VMI. There is, however, a third possibility that we believe holds equal appealddirect and indirect effects of the intravitreal injection itself. Alterations of intraocular structure and function that may result from intravitreal injection are not yet fully elucidated. Although effects upon intraocular pressure2 and anterior chamber depth3 from such injections are well documented, one must intuit that there are considerable additional mechanical changes to the vitreous and posterior segment as collateral effects of such mechanical forces. Accelerated vitreous synchysis, an increase in posterior segment volume, shearing force distortions, and reduction in retinal thickness are a few potential actors in this dynamic. In animal models, changes to the ganglion cell layer which alter its response to photocoagulation occur, even when intravitreal injection is performed without any active compound.1 Additionally, there are reported cases of successful treatment of vitreomacular traction (VMT) with intravitreal corticosteroid;4 given the presumed absence of inflammation in VMT, one must consider the possibility that the injection itself may be the actor in inducing such changes that are therapeutic, and the steroid but the passive audience. Although we commend Simpson et al for their insight, we await with anticipation further delineation of other more elusive and

overlooked vitreal mechanical changes that may also serve to induce regression of AMD.

references

1. Belokopytov M, Shulman S, Dubinsky G, et al. Intravitreal saline injection ameliorates laser-induced retinal damage in rats. Retina. 2012;32:1165e70 2. Benz MS, Albini TA, Holz ER, et al. Short-term course of intraocular pressure after intravitreal injection of triamcinolone acetonicde. Ophthalmology. 2006;113:1174e8 3. Kerimoglu H, Ozturk BT, Bozkurt B, et al. Does lens status affect the course of early intraocular pressure and anterior chamber changes after intravitreal injection? Acta Ophthalmol. 2011;89:138e42 ¨ . Resolution of  lu G, Kayıkc¸ıog  lu O, Sahin BO 4. Seymenog vitreomacular traction following intravitreal triamcinolone acetonide injection in an eye with branch retinal vein occlusion. Clin Ophthalmol. 2012;6:1239e43 5. Simpson AR, Petrarca R, Jackson TL. Vitreomacular adhesion and neovascular age-related macular degeneration. Surv Ophthalmol. 2012;57:498e509

Matthew S.J. Katz, MD Gowtham Jonna, MD David E. Fingerhut, MD Montefiore Medical CenterdAlbert Einstein College of Medicine New York, New York http://dx.doi.org/10.1016/j.survophthal.2013.06.002

Author’s response Author’s Response: We thank Katz et al for their insightful comments on the use of an intravitreal fluid injection as a potential therapy for the treatment of vitreomacular adhesion (VMA). We agree that the mechanical forces that occur when injecting saline

(or equivalent) into the vitreous cavity may well alter the vitreous, although the magnitude of the effect is difficult to quantify. Stalmans et al, on behalf of the MIVI-TRUST Study Group, showed that a 0.10 mL injection of ocriplasmin resulted in a higher rate of VMA resolution at day 28

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Vitreomacular adhesion and neovascular age-related macular degeneration.

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