BASICS

DESCRIPTION

• A posterior vitreous detachment (PVD) is the physical separation of the cortical vitreous from the internal limiting membrane (ILM) of the retina.

• With improved imaging modalities such as high-resolution optical coherence tomography (OCT), earlier stages of structural partial PVD are readily detectable before symptoms occur and before a complete PVD is present.

EPIDEMIOLOGY

Incidence

• The incidence of PVD increases with age.

• Although some estimates have indicated that 50% of phakic eyes have PVD by the age of 50 years, this has been somewhat disputed in autopsy studies.

RISK FACTORS

• Increasing age.

• Axial myopia

• Trauma

• Inflammation

• Pseudophakia

• Aphakia

• Prior surgeries (especially cataract extraction complicated by vitreous loss)

• Vitreous hemorrhage

Genetics

• Axial myopia (caused by both genetic and environmental factors) correlates with an earlier onset of vitreous liquefaction and PVD.

• An earlier onset of PVD and PVD-related complications are seen in Stickler’s and Marfan’s syndromes due to anomalous collagen metabolism.

PATHOPHYSIOLOGY

• Liquefaction of the vitreous gel is clinically evident as optically empty vacuoles within the vitreous cavity. This may be accompanied by coalescence of collagen fibrils into visible strands, which may be visualized ophthalmoscopically.

• Decreased strength of the vitreoretinal interface is also believed to precipitate PVD.

ETIOLOGY

• Vitreous liquefaction is detectable from early childhood and increases with age.

• Significant vitreous liquefaction together with loss of cohesion of the vitreoretinal interface combine to facilitate PVD formation.

• In the earliest stages of a PVD, the vitreous and the retina gradually separate. This process often starts in the macular region, but often spares the fovea until a later stage.

• Once the posterior vitreous face degrades sufficiently, liquefied vitreous can pass abruptly through even a minute defect in the posterior vitreous face into the subhyaloid space and this is known as an acute PVD (2).

• In areas where the ILM is especially thin (i.e., optic nerve, foveola, vitreous base, retinal vessels), the vitreoretinal interface is especially strong. These areas are often the last to separate from the hyaloid face.

• A Weiss ring is a clinical sign that confirms separation of the vitreopapillary junction, and it typically confirms the completion of the PVD.

COMMONLY ASSOCIATED CONDITIONS

• Early-stage PVD

– Epiretinal membrane

– Macular microhole

– Foveal red spot

– Idiopathic macular hole

– Pseudooperculum

– Inner lamellar macular hole

– Vitreofoveal traction (traction cystoid macular edema)

– Vitreomacular traction syndrome

– Traction diabetic macular edema

– Myopic traction maculopathy

– Neovascular age-related macular degeneration

– Vitreopapillary traction syndrome

• Late-stage (complete) PVD

– Retinal or optic disc hemorrhage

– Vitreous hemorrhage

– Retinal tear

– Rhegmatogenous retinal detachment (1)

DIAGNOSIS

• Ophthalmoscopy

– Visible Weiss ring seen with slit lamp biomicroscopy or with indirect ophthalmoscopy.

– Apparent separation of the vitreous from the posterior pole without the presence of a Weiss ring may be misleading and may simply represent vitreous schisis.

• Ancillary testing

– Spectral domain OCT nicely visualizes the posterior hyaloid face in PVD.

– Ultrasonographic confirmation of detachment of the peripheral vitreous together with the presence of a Weiss ring is also confirmatory of PVD in equivocal cases and is used to confirm onset of PVD for research purposes.

– Vitreous hemorrhage and/or the presence of pigment within the vitreous are highly predictive of a retinal tear (70%).

HISTORY

• Patients with early PVD can present with photopsias as the vitreous gradually separates from the retina.

• Patients with a personal or family history of retinal tears or detachments merit especially careful examination as they have an increased risk of tears being present.

PHYSICAL EXAM

• Indirect ophthalmoscopy with scleral depression

• Slit lamp biomicroscopy

• Contact lens biomicroscopy

– Goldman 3 mirror lens

– Widefield contact lens

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

• Ultrasonography

– B-scan ultrasonography should be considered in cases where media opacity precludes an adequate clinical examination.

– B-scans are also used in the context of clinical trials to accurately document the presence or absence, as well as stage, of PVD.

• OCT

– OCT (especially spectral domain OCT) can be used to document the presence or absence and the progression of early PVD.

Pathological Findings

After PVD, up to 44% of patients at autopsy have been demonstrated to have residual hyalocytes present on the macular surface.

DIFFERENTIAL DIAGNOSIS

See “Associated Conditions.”

TREATMENT

ADDITIONAL TREATMENT

General Measures

Careful extended ophthalmoscopy should be performed in those patients who report symptoms of PVD or who are noted to have a PVD.

SURGERY/OTHER PROCEDURES

• For uncomplicated PVD, no treatment is necessary.

• When a retinal tear or detachment is present, prompt treatment is imperative.

• Rarely, pars plana vitrectomy may be offered to alleviate severe PVD-related symptoms; however, this is the exception.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Prompt evaluation by an ophthalmologist or optometrist when symptoms of acute PVD occur

• Prompt referral to an ophthalmologist skilled in the treatment of retinal tears and/or detachments in the event that one is detected

PATIENT EDUCATION

• After an acute PVD, patients are often significantly bothered by floaters and flashes. It is often reassuring to let patients know that symptoms will typically lessen within months.

• Patients should be educated to report the symptoms of a retinal tear or detachment should they occur.

PROGNOSIS

• After an uncomplicated PVD, the prognosis is excellent.

• In some cases, as in eyes with vitreomacular traction, visual acuity may improve.

• After a complicated PVD (i.e., with a retinal break), there is an elevated risk of additional tears occurring.

• When a complicated PVD occurs in one eye, the fellow eye has a higher risk of complications from PVD likely due to the nature of the vitreoretinal interface.

COMPLICATIONS

• Retinal tears

• Rhegmatogenous retinal detachment

• See Commonly Associated Conditions above

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