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Ophthalmology
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Diseases of the Vitreous

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Atul K Shankar

31

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 Astroid Hyalosis
- characterised by small, white rounded bodies suspended in a vitreous gel
- these are formed due to accumulation of calcium containing lipids
- it is a unilateral, asymptomatic condition usually seen in old patients with healthy
vitreous
- it was previously thought that there is a relationship between this condition, diabetes
mellitus and hypercholesterolaemia, but it has been subsequently disapproved.
- the pathogenesis is unknown
- there is not an effective treatment, nor is it required.

Synchysis Scintillans
- in this condition, vitreous is laden with small white angular and crystalline bodies
formed of cholesterol
- it affects the damaged eyes which have suffered from trauma, vitreous haemorrhage
or inflammatory disease in the past
- vitreous is liquid, so the crystals sink to the bottom but are stirred up with every
movement
o this phenomenon appears as a ‘shower of golden rain’ on ophthalmoscopic
examination
- since the condition occurs in a damaged eye, it may occur at any age
- condition is symptomless and untreatable

Vitreous Liquefaction
- the most common degenerative change in the vitreous
- the causes of vitreous liquefaction are:
o Age-related
o Degenerations, such as myopic degeneration
o Post-inflammatory
o Trauma to the vitreous which may be mechanical
o Thermal effects on vitreous following diathermy, photocoagulation and
cryocoagulation
o Radiation effects
- Clinical Features
o there is absence of normal fine fibrillar structure and visible pockets of
liquefaction, associated with appearance of coarse aggregate material which
moves freely in the free vitreous
o it is usually associated with collapse and opacities in the vitreous, which may be
seen subjectively as black floaters in front of the eye

Muscae Volitantes
- these are physiological opacities and represent the residues of primitive hyaloids
vasculature
- patient perceives them as fine dots and filaments
o these often drift in and out of the visual field, against a bright background
 Posterior Vitreous Detachment
- refers to the separation of the cortical vitreous from the retina posterior to the
vitreous base
- PVD with vitreous liquefaction is a common occurrence in majority of normal subjects
above 65 years
- Pathogenesis:
o collagen cross-linking and selective loss of retinal adherence rather than the cavity
formation are the primary events
o these changes occur more frequently in the aphakics than the phakics, and in the
myopes than the emmetropes
- Clinical Features
o Flashes of light and floaters are often associated
 patients may describe it as strings, spider webs, saucer-like objects or a
transparent ring in the field of vision
o Biomicroscopic examination of the vitreous shows
 collapsed vitreous behind the lens and optically clear space between the
detached posterior hyaloids face and retina
 Ring like opacity representing a ring of attachment of vitreous to the optic
disc
 Pathognomic of PVD
- Complications of PVD
o retinal breaks
o vitreous haemorrhage
o retinal haemorrhages
o cystoids maculopathy
o retinal detachment
- Management
o uncomplicated PVD requires no treatment
 reassure but give retinal detachment warning
o retinal tear complicating PVD may need to be treated by laser photocoagulation
o Vitreous haemorrhage complicating PVD needs to be managed
o Retinal detachment complicating PVD needs urgent treatment

Vitreous Degeneration aggregates and condensation with liquefaction

- commonest cause of vitreous opacities
- condensation of the collagen fibrillar network is a feature of the vitreous
degeneration whose origin may be:
o Senile
o Myopic
o Post-traumatic
o Post-inflammatory

Red Cell Opacities

- caused by small vitreous haemorrhages or leftouts of the massive vitreous
haemorrhage
 Vitreous Haemorrhage
- occurs from the retinal vessels and may present as preretinal or an intragel
haemorrhage
- the intragel haemorrhage may involve anterior, middle, posterior or the whole
vitreous body

Causes

- retinal tear, PVD and RD

- Trauma to eye,
o which may be blunt or perforating in nature
- Inflammatory Diseases
o erosion of the vessels in acute chorioretinitis and periphlebitis retinae
primary, or secondary to Uveitis
- Vascular disorders
o hypertensive retinopathy
- Exudative age-related macular degeneration
- Blood dyscrasias
o retinopathy of anaemia, leukaemias, polycythemias and sickle cell retinopathy
- Bleeding disorders
o purpura, haemophilia and scurvy
- Neoplasms
o vitreous haemorrhage may occur from rupture of vessels
o due to acute necrosis in tumours like retinoblastoma and malignant
melanoma of choroid
- Other causes include Coat’s disease, radiation retinopathy, retinal capillary
aneurysm, retinal macroaneurysm, Terson syndrome

Clinical Features

- Symptoms
o floaters of sudden onset occur when the vitreous haemorrhage is small
o sudden painless loss of vision occurs in large vitreous haemorrhage
- Signs
o Distant direct ophthalmoscopy reveals black shadows against the red glow in
small haemorrhages and no red glow in a large haemorrhage
o Direct and indirect ophthalmoscopy may show presence of blood in the
vitreous cavity in small vitreous haemorrhage and non-visualization of
fundus in large vitreous haemorrhage
o Slit-lamp examination shows normal anterior segment and reddish mass in
the vitreous
o Ultrasonography with B scan is helpful in diagnosis

Treatment

- Conservative treatment – bed rest, elevation of patient’s head

- Treatment of the cause – indirect ophthalmoscopy should be performed to locate and
manage the causative lesoion
- Victrectomy by pars plana route
 Vitrectomy
- surgical removal of the vitreous
- types of vitrectomy include
o Anterior Vitrectomy
o Core Vitrectomy
o Subtotal and Total Vitrectomy

Limbal Approach of Anterior Vitrectomy

- employed to perform only anterior vitrectomy

- Indications
o vitreous loss during cataract extraction
o Aphakic keratoplasty
o Anterior chamber reconstruction after perforating trauma with vitreous loss
o Subluxated and anteriorly dislocated lens
- Surgical Technique
o performed through the primary or new limbal or clear corneal incision to
manage the disturbed vitreous during cataract surgery or in aphakic
keratoplasty
o it should be performed using an automated vitrecomy machine
o it can be performed with the help of a triangular cellulose sponge and de
Wecker’s or Vanna’s scissors

Pars Plana Vitrectomy

- employed to perform anterior vitrectomy, core vitrectomy, subtotal and total

vitrectomy
- Indications
o Endophthalmitis with vitreous abscess
o Vitreous haemorrhage
o Proliferative retinopathies
o Complicated cases of retinal detachment
o Removal of intraocular foreign bodies
o Removal of dropped nucleus or intraocular lens from the vitreous cavity
o Persistent primary hyperplastic vitreous
o Vitreous membranes and bands
o Macular pathology like macular hole, and epiretinal membrane
- Surgical Techniques
o Three-port pars plana vitrectomy (PPV)
 3 separate incisions are given in pars plana region
 the cutting and aspiration functions are contained in 1 probe
 illumination is provided by a separate fibre optic probe
 infusion by cannula introduced through the 3rd pars plana incision
o 23, 25 and 27 gauge 3-port vitrectomy techniques
 introduced recently and becoming more popular as an alternative to the
standard 20 gauge vitrectomy
 advantages include self-sealing sclerotomy sites, improved patient
comfort, reduced postoperative inflammation