2010 OPT - 243 Vitreous Disorders & Vitreoretinal Disorders of the Posterior Pole I Leo Semes, OD, FAAO 100% 0% 0% 0% 0% Which of these gives the best resolution for studying vitreoretinal disorders of the posterior pole? Optical coherence tomography (OCT) Ultrasound (US) Fluorescein Angiography (FA) Visual Fields (VF) Stereoscopic SLB examination 1 2 Outline Vitreous embryology / development Tertiary vitreous composition Tertiary vitreous clinical appearances A little digression for terminology sake Outline Aging of the vitreous posterior vitreous detachment (PVD) Congenital vitreous abnormalities Acquired V-R abnormalities Vitreo-macular (MH, ERM ) Peripheral vitreo-retinal disorders (later) 4 5 Vitreous Development & Anatomy EMBRYOLOGY primary vitreous secondary vitreous tertiary vitreous (zonule) Cloquet s canal 6 7 1
Vitreous Development Vitreous Development 8 9 Vitreous Development Vitreous Development 10 11 Normal Vitreous Attachments Previous notions Current thinking The vitreous is a gel Mueller cells and biological adhesive keep the retina and vitreous together 12 13 2
Clinical Vitreous Anatomy Molecular composition Water (99%) Solids Interfaces Cloquet s canal Hyaloid Lacunae Fibrils Anatomy & Physiology Abnormal clinical attachments posterior pole ERM, macular hole blood vessels radial lattice between ILM & hyaloid face cystic tuft, lattice retinal degeneration Bishop PN. Structural macromolecules and supramolecular organization of the vitreous gel. Prog Ret Eye Res 2000; 19 (3): 323-344. 14 15 Radial Lattice Vitreous Aging Changes POSTERIOR VITREOUS DETACHMENT / SEPARATION (PVD) Mechanism Consequence(s) Clinical observations Anterior vitreous - Posterior vitreous Symptoms 50% Kakehashi A, et al. Predictive value of floaters in the diagnosis of posterior vitreous detachment. AM J Ophthalmol 1998; 125 (1): 113-115 16 Van Overdam KA, et al. Symptoms predictive for the later development of retinal breaks. Arch Ophthalmol 2001; 119: 1483-1486. 17 Vitreous Liquefaction Vitreous Liquefaction 18 19 3
PVD w/ continued macular traction ERM BCVA 20/60 BCVA 20/20 20 21 Terminology Terminology 22 23 Hyaloid Membrane Terminology Examining the Vitreous At slit lamp anterior vitreous Hyaloid membrane Compacted fibers At slit lamp with PCL posterior vitreous Weiss ring * Hyaloid Detached Remaining attachments 24 25 4
ANATOMY AND PHYSIOLOGY Synchesis Senilis Normal clinical attachments vitreous base posterior pole macula along blood vessels between ILM and hyaloid face (fine fibrils) 26 27 Examining the Vitreous PVD observations Anterior Vitreous At slit lamp anterior vitreous 33 mo. Hyaloid membrane Compacted fibers At slit lamp with PCL posterior vitreous 33 yr. Weiss ring * Hyaloid old Detached Remaining attachments 28 29 PVD observations hyaloid membrane Weiss Ring Floater W/ DO 30 31 5
PVD Weiss ring Clinical Management of PVD Stereoscopic examination for complications (breaks, blood) 95% of PVD are uncomplicated!!! 50% of patients w/ acute PVD are asymptomatic 32 33 Clinical Management of PVD Classification & associated conditions Complete with collapse (age-related w/o vitreoretinal disease, high myopia) Complete without collapse (uveitis, central retinal vein obstruction) Partial with thickened cortex (proliferative diabetic retinopathy) Partial without thickened cortex (age-related w/o vitreoretinal disease) Clinical Management of PVD Patient education (SS / RD) and reassurance Follow-up in 2-6 weeks http://bjo.bmjjournals.com/cgi/reprint/84/11/1264.pdf Kakehashi A, et al. Variations of posterior vitreous detachment. Br J Ophthalmol 1997; 81 (7): 527-532. 34 36 38 40 6
Suggested Approach for Referral of Patients With Presumed Posterior Vitreous Detachment - Clinical Scenario Recommended Action Floaters and/or flashes with red flag sign of acute retinal detachment Monocular visual field loss ( curtain of darkness ) Same-day referral to retinal surgeon; high risk of having retinal detachment New-onset floaters and/or flashes with high-risk features including subjective or objective visual reduction. Vitreous hemorrhage or vitreous pigment on slitlamp examination, Same-day referral to retinal surgeon for dilated eye examination Adapted from 2248 JAMA, November 25, 2009 Vol 302, No. 20 ( 42 43 Suggested Approach for Referral of Patients With Presumed Posterior Vitreous Detachment - Clinical Scenario Recommended Action New-onset floaters and/or flashes without high-risk features Dilated eye examination within 1 to 2 weeks; counsel patient regarding high-risk features that should prompt urgent reassessment. By whom???? Recently diagnosed uncomplicated posterior vitreous detachment with out new retinal tear or detachment. New shower of floaters New subjective visual reduction Rule out high risk features The retinal surgeon or your clinical judgment should determine urgency. Adapted from 2248 JAMA, November 25, 2009 Vol 302, No. 20 Adapted from 2248 JAMA, November 25, 2009 Vol 302, No. 20 44 45 Stable symptoms of floaters and/or flashes for several weeks to months, not particularly bothersome to the patient and without highrisk features. Elective referral to retinal surgeon; counsel patient regarding highrisk features that should prompt urgent reassessment. Clinical Management of PVD Note RBCs ( Shaffer s sign tobacco dust ) Stereoscopic examination for complications (breaks, blood) SYMPTOMS and RISKS of RETINAL DETACHMENT Adapted from 2248 JAMA, November 25, 2009 Vol 302 46 47 7
Clinical Management of PVD Vitreous Disorders Contrast with pigment granules (larger and less refractile) Note RBCs ( Shaffer s sign tobacco dust ) PVD Other isolated vitreous disorders Asteroid bodies (asteroid hyalosis, asteroid hyalitis, Benson s disease, scintillatio albescens) unilateral in 75% of cases unrelated causally to systemic disease (e.g., only 5.4% of diabetics have asteroid bodies) equal distribution between males and females and among races 48 49 8