Improvement of Scotomas with Time and Treatment
Scotomas (visual field defects) may improve with time and treatment, but this depends on the underlying cause, with some showing significant improvement while others remain stable or worsen. 1
Prognosis by Underlying Cause
Epiretinal Membrane (ERM) and Vitreomacular Traction (VMT)
- Natural History:
- Most ERMs remain relatively stable over time (39% unchanged, 26% regress, only 29% progress over 5 years) 1
- Small central scotomas associated with ERM rarely improve spontaneously without intervention 1
- For VMT with adhesions ≤1500 μm, spontaneous release occurs in 23-47% of eyes over 1-2 years, often resulting in improved vision and reduced symptoms 1
Post-Surgical Scotomas
Vitrectomy-Related Scotomas:
- Paracentral and cecocentral scotomas after pars plana vitrectomy (PPV) for retinal detachment have been reported with 6.4% incidence 2
- These typically appear within the first week after surgery and involve the inferior temporal visual field 2
- These scotomas correspond to ganglion cell loss and may persist despite successful anatomical repair 2
Silicone Oil-Related Scotomas:
Age-Related Macular Degeneration (AMD)
- Scotomas from geographic atrophy tend to be persistent 4
- Patients develop preferred retinal loci (PRLs) for fixation to compensate for central scotomas 4
- 81% of eyes retain their baseline PRL location over time (median follow-up 5.3 years) 4
- Reading rates typically decline further during follow-up 4
Treatment Options and Outcomes
Surgical Interventions
- Vitrectomy for ERM/VMT:
- Vitrectomy is highly successful for addressing worsening symptoms or decreasing visual acuity in ERM 1
- Earlier surgical intervention for ERM may result in better long-term visual acuity recovery than delayed surgery 1
- The decision for surgery should be based on symptom severity and impact on daily activities 1
Pharmacologic Treatment
- Ocriplasmin:
Vision Rehabilitation
- For persistent scotomas, vision rehabilitation helps restore functional ability 1
- Assessment of scotomas and fixation is important for understanding adaptation to central vision loss 1
- Patients with persistent scotomas should be referred for vision rehabilitation, particularly when there is residual central or paracentral scotoma 1
Monitoring and Follow-up
- Regular monocular Amsler grid testing is important to detect changes over time 1
- Patients should be educated about signs of progression (increasing metamorphopsia, development of scotoma) 1
- Macular microperimetry can accurately detect both fixation patterns and scotomas 1
- Patients should report promptly if they experience increase in floaters, loss of visual field, metamorphopsia, or decreased visual acuity 1
Important Considerations
- The invisibility of scotomas to patients can affect their perception and compliance with treatment 5
- Scotomas due to different causes (photoreceptor loss vs. ganglion cell damage) may have different appearances and prognoses 5
- Patients with central scotomas often develop compensatory viewing strategies, with right-sided or superior fixation patterns generally providing better reading outcomes 4
Conclusion
The improvement of scotomas depends primarily on their underlying cause. While some scotomas may improve with specific treatments or spontaneously resolve (particularly in VMT cases), others (especially those associated with AMD or surgical complications) often persist. Early intervention when indicated and appropriate vision rehabilitation are key to optimizing outcomes for patients with persistent scotomas.