Age of onset of posterior vitreous detachment

Vision degrading myodesopsia from vitreous floaters in the young: An important aspect of myopia

Vitreous floaters are visual phenomena resulting from floating opacities inside the eye that disturb vision. The opacities consist of microscopic collagen fibers that aggregate in myopia and during aging. These collagen fibers are then seen as irregular, sometimes worm-like shadows or structures of a translucent to black color. Because of the floating aspect, they tend to follow the movements of the eye, causing distress and having a negative impact on a patient's quality of life due to degradation in contrast sensitivity function. This is referred to as vision degrading myodesopsia (VDM). The overall importance of floaters and their effect on quality of life gained attention in recent years. While the existence of floaters alone is labeled as harmless, there is an increasing group of young people suffering from VDM. This coincides with the growing prevalence of myopia. Indeed, myopia and myopic vitreopathy are the major causes of VDM in the young. This aspect of myopia, however, is often overlooked. We review the current research status in floater formation, quality of life impact, symptom assessment, localization and therapeutic options for vitreous floaters from the perspective of a myopic, potentially younger patient group.

International incidence and temporal trends for rhegmatogenous retinal detachment: A systematic review and meta-analysis

We set out to estimate the international incidence of rhegmatogenous retinal detachment (RRD) and to evaluate its temporal trend over time. There is a lack of robust estimates on the worldwide incidence and trend for RRD, a major cause of acute vision loss. We conducted a systematic review of RRD incidence. The electronic databases PubMed, Scopus, and Thomson Reuters' Web of Science were searched from inception through 2nd June 2022. Random-effects meta-analysis model with logit transformation was performed to obtain pooled annual incidence estimates of RRD. Pooled analysis was performed to evaluate the temporal trend of RRD incidence of the 20,958 records identified from the database searches; 33 studies from 21 countries were included for analysis (274,836 cases of RRD in 273,977 persons). Three of the 6 global regions as defined by WHO had studies that met the inclusion and exclusion criteria of the study. The annual international incidence of RRD was estimated to be 12.17 (95% confidence interval [CI] 10.51-14.09) per 100,000 population; with an increasing temporal trend of RRD at 5.4 per 100,000 per decade (p 0.001) from 1997 to 2019. Amongst world regions, the RRD incidence was highest in Europe (14.52 [95% CI 11.79 - 17.88] per 100,000 population), followed by Western Pacific (10.55 [95% CI 8.71-12.75] per 100,000 population) and Regions of Americas (8.95 [95% CI 6.73-11.92] per 100,000 population). About one in 10,000 persons develop RRD each year. There is evidence of increasing trend for RRD incidence over time, with possibly doubling of the current incidence rate within the next 2 decades.

Trends in Volume and Charges of Retinal Tear Patients in the Emergency Department

PURPOSE

To characterize retinal tears (RTs) and calculate the economic burden of RTs that present to the emergency department (ED) in the US.

METHODS

We used a large national ED database to retrospectively analyze RTs that presented to the ED from 2006 to 2019. Using extrapolation methods, national of the RT patient ED volume, demographics, comorbidities, disposition, inpatient (IP) charges, and ED charges were calculated.

RESULTS

During the period between 2006 and 2019, 15841 ED encounters had RT listed as the primary diagnosis. The average annual RT ED encounters was 2,640 ± 856 and comprised an average of 6.4 × 10 - 5 % of all ED visits annually. The number and ED percentage of RT encounters did not change during this time period (p = .22, p = .67, respectively). Most patients were males, Caucasian, paid with private insurance, and admitted to EDs in the Northeast. The most common comorbidities were hypertension (19%), a history of cataracts (15%), and diabetes (7.2%). During this time period, RTs charges added up to more than $79 million and $33 million in the ED and IP settings, respectively. Mean per-encounter ED and IP charges increased by 145% (p = .0008) and 86% (p = .0047), respectively.

CONCLUSION

Despite the stable number of RT patients presenting to the ED, RTs place a significant economic burden to the healthcare system, which increases yearly. We recommend physicians and policy makers to work together to pass laws that could prevent the increasing healthcare charges.

Comparison of posterior vitreous detachment-related and glaucomatous optic disc hemorrhage

This study compared the characteristics of posterior vitreous detachment (PVD)-related and glaucomatous optic disc hemorrhage (DH). Fundus photographs of eyes with PVD-related DH (PVD group) and glaucomatous DH (glaucoma group) were reviewed. The shape, type, layer, location (clock-hour sector), and DH/disc area (DH/DA) ratio of DH were investigated. In the PVD group, DH presented as a flame (60.9%), splinter (34.8%), and dot or blot (4.3%) shape. However, most of the glaucomatous DH revealed a splinter shape (92.3%), followed by a flame shape (7.7%, p < 0.001). In the PVD group, the most common type of DH was cup margin type (52.2%), whereas, in the glaucoma group it was disc rim type (53.8%, p = 0.003). Both PVD-related and glaucomatous DH were most commonly observed in the 7 o'clock sector. In the PVD group, DH was also found in the 2 and 5 o'clock sectors (p = 0.010). Mean DH/DA ratio in PVD group (0.15 ± 0.19) was greater than in glaucoma group (0.04 ± 0.04, p < 0.001). PVD-related DH showed a higher frequency of flame shape, cup margin type, nasal location, and greater area compared to the glaucomatous DH.

Study of the Correlation Between Severity of Endophthalmitis and Posterior Vitreous Detachment Using a Rabbit Endophthalmitis Model

Purpose

We have reported that the absence of posterior vitreous detachment (PVD) is related to the onset and severity of infectious endophthalmitis, based on clinical experience. To demonstrate clinical findings in animal models, we created endophthalmitis models for the presence or absence of PVD and examined differences in severity.

Method

We estimated a rabbit infectious eye model with and without PVD using Pseudomonas aeruginosa (PVD(+) and PVD(-) groups). After injection of bacteria inoculation for 3, 6, 12, and 24 hours, we evaluated the clinical score of the anterior chamber (n = 14). Removing the vitreous and retina from the enucleated eyeballs, the number of bacteria was counted using each specimen (n = 12). In addition, the number of inflammatory cells approximately 3 mm2 around the optic disc and histopathologic grading of intraocular inflammation was compared from histopathologic images (n = 7). Electroretinogram (ERG) was performed in experimentally infected rabbit eyes in both groups at three times after injection of the bacterial suspension.

Results

There was no difference between the two groups in the clinical score of the anterior chamber of each time phase, but the bacterial cultures showed significantly fewer bacteria in the PVD(-) group 24 hours after bacterial inoculation (P < 0.05). Furthermore, the number of inflammatory cells was significantly less in the PVD group (P < 0.05). As a result of ERG, the decreases of a- and b-waves in amplitude were significantly greater in the PVD(-) group than in the PVD(+) group.

Conclusions

The present study confirms using animal models that the absence of PVD contributed to the severity of bacterial endophthalmitis.

Multimodal Imaging Characteristics and Presumed Cause of Intrapapillary Hemorrhage with Adjacent Peripapillary Subretinal Hemorrhage

Purpose

To describe the multimodal imaging findings of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH) and reveal the possible mechanism of this rare benign disease.

Patients and Methods

Observational study. Three eyes in three patients with intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage were evaluated at the retina division of our institution. We describe the multimodal imaging findings including visual field examination, fundus photography, fluorescein and indocyanine green angiography (FFA&ICGA), spectral-domain optical coherence tomography (OCT), and ultrasonography.

Results

Three myopic patients with IHAPSH shared a similar clinical course and multimodal imaging appearance. The symptom was sudden dark shadows floating in the affected eye with mild visual blurring. Fundus photography showed hemorrhage in intrapapillary and subretinal, as well as optic disc bulges on the nasal side with local vitreoretinal separation in the affected eyes. OCT confirmed intrapapillary and subretinal hemorrhage with obviously elevated optic papilla in the affected eye and local vitreoretinal separation at the temporal side of optic disc together with vitreoretinal adhesion at the superonasal edge. FFA&ICGA ruled out optic drusen and neovascularization. B-ultrasonography in one case revealed optic disc bulge in the affected eye with tight traction by local detached vitreous posterior limiting membrane at the edge. The overall visual prognosis was excellent and the bleeding could be completely absorbed.

Conclusion

IHAPSH tends to appear in young women with myopia. The mechanism may be attributed to an incomplete posterior vitreous detachment (PVD), followed by a tightly vitreous-papilla adhesion and concentrated traction to the superonasal part of the tilted small optic disc.

Pars plana vitrectomy relieves the depression in patients with symptomatic vitreous floaters

AIM

To investigate the depressive state among the patients with symptomatic vitreous floaters (SVF), as well as its change after SVF removal via vitrectomy surgery.

METHODS

Twenty-eight eyes of 28 patients who underwent 27-gauge pars plana vitrectomy (PPV) for SVF were included. Thirty-nine eyes of 39 age- and gender-matched healthy volunteers without SVF were also recruited as a healthy control. Center for Epidemiologic Studies Depression (CES-D) was used to assess volunteers and patients' depression (before and 1wk after PPV).

RESULTS

The CES-D score was 18.3±8.6 for patients, and was 12.4±6.0 for healthy control (P=0.003). Patients were significantly more likely to be in a depressive state (53.6%, defined as CES-D score ≥16) than the healthy control (20.5%, P=0.005). For patients with SVF, the CES-D score was negatively correlated with their age (r _s=-0.42, P=0.025). After PPV, both the CES-D score (11.9±5.4 vs 18.3±8.6, P<0.001) and proportion of depressive state (18.5% vs 53.6%, P=0.005) were significantly decreased.

CONCLUSION

This study suggests that symptoms of vitreous floaters have an apparently negative impact on patients' psychological state. The PPV can effectively relieve the depressive state for patients with SVF.

Posterior segment conditions associated with myopia and high myopia

Myopia, and especially high myopia, is associated with a number of posterior segment changes that are considered to be mostly a consequence of the increased axial elongation. This can result in mechanical strain, attendant vascular changes, stretching and thinning of tissues, and atrophy/deformation of tissues in later or more advanced stages. Such myopia-related changes are observed as changes and/or abnormalities in the vitreous, choroid, retina and peripheral retina, sclera and/or optic disc. Although many of these changes are benign, at times they may be associated with significant vision impairment that either requires active intervention or may suggest future progression of the disease. This review systematically addresses the posterior segment conditions seen in myopic eyes, describes the features associated with the condition and details management pathways.

ULTRASONOGRAPHIC FINDINGS IN THE VITREOUS OF PATIENTS WITH AGE-RELATED MACULAR DEGENERATION TREATED WITH INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS

PURPOSE

We aimed to assess the relationship of repeated intravitreal injection of anti-vascular endothelial growth factor, the main treatment for exudative age-related macular degeneration, with changes in vitreous ultrasonographic findings in patients with age-related macular degeneration.

METHODS

We retrospectively collected data from 41 patients (41 age-related macular degeneration eyes, 41 control eyes) on age, sex, number of injections, and type of anti-vascular endothelial growth factor (ranibizumab, aflibercept). Ocular ultrasonography was performed with open eyelids, under topical anesthesia, and using carbomers as ultrasonographic gel. Topographic, quantitative, and kinetic ultrasonography was performed in all eye quadrants using a 10-MHz posterior pole probe, and vitreous reflectivity was assessed.

RESULTS

The mean age of patients was 79 (range: 59-94) years, with a mean of five intravitreal anti-vascular endothelial growth factor injections (range: 1-13). No significant ultrasonographic differences were found relative to the incidence of partial or complete posterior vitreous detachment. Vitreous hyperechogenicity increased in the treated eye (P < 0.001), and the vitreous reflectivity range increased with the number of injections (P = 0.041, R = 0.214). However, the type of anti-vascular endothelial growth factor used and the time elapsed since the last intravitreal injection was not significant (P > 0.05).

CONCLUSION

These preliminary results indicate a proportional increase in ultrasonographic reflectivity of vitreous gel with the number of injections.

3D Curvelet-Based Segmentation and Quantification of Drusen in Optical Coherence Tomography Images

Spectral-Domain Optical Coherence Tomography (SD-OCT) is a widely used interferometric diagnostic technique in ophthalmology that provides novel in vivo information of depth-resolved inner and outer retinal structures. This imaging modality can assist clinicians in monitoring the progression of Age-related Macular Degeneration (AMD) by providing high-resolution visualization of drusen. Quantitative tools for assessing drusen volume that are indicative of AMD progression may lead to appropriate metrics for selecting treatment protocols. To address this need, a fully automated algorithm was developed to segment drusen area and volume from SD-OCT images. The proposed algorithm consists of three parts: (1) preprocessing, which includes creating binary mask and removing possible highly reflective posterior hyaloid that is used in accurate detection of inner segment/outer segment (IS/OS) junction layer and Bruch’s membrane (BM) retinal layers; (2) coarse segmentation, in which 3D curvelet transform and graph theory are employed to get the possible candidate drusenoid regions; (3) fine segmentation, in which morphological operators are used to remove falsely extracted elongated structures and get the refined segmentation results. The proposed method was evaluated in 20 publically available volumetric scans acquired by using Bioptigen spectral-domain ophthalmic imaging system. The average true positive and false positive volume fractions (TPVF and FPVF) for the segmentation of drusenoid regions were found to be 89.15% ± 3.76 and 0.17% ± .18%, respectively.

Epiretinal membrane surgery outcomes in highly myopic eyes without traction maculopathy: long-term results of a case-control study

PURPOSE

To evaluate the outcomes of epiretinal membrane (ERM) surgery in highly myopic eyes without traction maculopathy, and to compare them with those from non-highly myopic eyes.

DESIGN

Retrospective nested case-control study from a cohort of 509 consecutive patients (509 eyes) who underwent pars plana vitrectomy with ERM removal.

METHODS

Thirty-two highly myopic eyes (with a refractive error of more than -6.00 diopters [D]), which underwent surgery for isolated ERM, were included in the study. For each case studied, we selected from the same cohort 2 age-matched controls who had ERM surgery (n = 64 non-highly myopic eyes). The best-corrected visual acuity (BCVA), the central macular thickness (CMT), and the surgical complications were analyzed.

RESULTS

The mean follow-up duration was 3.2 ± 1.5 years for the study cases and 3.4 ± 1.6 years for the control group (P = .608). At the final follow-up examination, the mean logMAR BCVA had improved significantly, from 0.56 to 0.26 (P < .001) for the case group and from 0.54 to 0.22 (P < .001) for the control group. At the final optical coherence tomography (OCT), the mean CMT had improved significantly, from 433 to 314 μm (P < .001) for the case group and from 428 to 303 μm (P < .001) for the control group. There was no significant difference between the 2 groups as regards visual or CMT improvement (P = .526 and P = .483, respectively). The incidence of surgical complications was not significant between the 2 groups.

CONCLUSIONS

The results of ERM surgery were not different in terms of anatomic and visual outcomes and surgical complication between highly myopic and non-highly myopic eyes.

Vitreous substitutes: a comprehensive review

Vitreoretinal disorders constitute a significant portion of treatable ocular disease. Advances in vitreoretinal surgery have included the development and characterization of suitable substitutes for the vitreous. Air, balanced salt solutions, perfluorocarbons, expansile gases, and silicone oil serve integral roles in modern vitreoretinal surgery. Vitreous substitutes vary widely in their properties, serve different clinical functions, and present different shortcomings. Permanent vitreous replacement has been attempted with collagen, hyaluronic acid, hydroxypropylmethylcellulose, and natural hydrogel polymers. None, however, have proven to be clinically viable. A long-term vitreous substitute remains to be found, and recent research suggests promise in the area of synthetic polymers. Here we review the currently available vitreous substitutes, as well those in the experimental phase. We classify these compounds based on their functionality, composition, and properties. We also discuss the clinical use, advantages, and shortcomings of the various substitutes. In addition we define the ideal vitreous substitute and highlight the need for a permanent substitute with long-term viability and compatibility. Finally, we attempt to define the future role of biomaterials research and the various functions they may serve in the area of vitreous substitutes.

Pathogenesis of rhegmatogenous retinal detachment: predisposing anatomy and cell biology

BACKGROUND

The pathogenesis of rhegmatogenous retinal detachment is complex, and our knowledge of the exact mechanism of vitreoretinal attachment and detachment remains incomplete.

METHODS

We performed a Medline, Ovid, and EMBASE search using search words rhegmatogenous, retinal detachment, vitreous, and retinal adhesion. All appropriate articles were reviewed, and the evidence was compiled.

RESULTS

Cortical vitreous contains fibrillar collagens type II, V/XI, and IX. The inner limiting membrane of the retina contains collagens type I, IV, VI, and XVIII as well as numerous other glycoproteins and potential adhesion molecules. The distribution and age-related changes in the structure of these molecules play an important role in the formation of a retinal break, which may compromise and disrupt the normal mechanisms of neurosensory retinal adhesion.

CONCLUSION

Rhegmatogenous retinal detachment development is intimately related to changes in the fibrillar structure of the aging vitreous culminating in posterior vitreous detachment with regions of persistent and tangential vitreoretinal traction predisposing to retinal tear formation. A complex interplay of factors such as weakening of vitreoretinal adhesion, posterior migration of the vitreous base, and molecular changes at the vitreoretinal interface are important in predisposing to focal areas of vitreoretinal traction precipitating rhegmatogenous retinal detachment. Once formed, the passage of liquefied vitreous through a retinal break may overwhelm normal neurosensory-retinal pigment epithelium adhesion perpetuating and extending detachment and causing visual loss. To understand the molecular events underlying rhegmatogenous retinal detachment so that new therapies can be developed, it is important to appreciate the structural organization of the vitreous, the biology underlying vitreous liquefaction and posterior vitreous detachment, and the mechanisms of vitreoretinal attachment and detachment.

Optometrists' examination and referral practices for patients presenting with flashes and floaters

INTRODUCTION

Patients experiencing flashes and floaters commonly present to their optometrist. Some of these patients may have significant pathology, yet there is a great deal of variability with regard to examination technique and referral practice.

METHODS

A questionnaire survey was undertaken to determine the current management of patients presenting to their optometrist with flashes and floaters. All practising community optometrists within Southern Derbyshire received a questionnaire and 74 (56.9%) completed replies were received.

RESULTS

Optometrists estimated that an average of 14 patients per month per optometrist presented with symptoms of flashes and/or floaters. Mydriasis was utilised routinely for examination in approximately half of the patients. Mean relative confidence was 2.0 at identifying a vitreous haemorrhage and 6.5 for vitreous pigment (complete confidence = 0, complete lack of confidence = 10). Eight percent of responders were unfamiliar with the clinical sign of vitreous pigment, and 17% identifying this sign did not refer all such patients to the hospital services.

CONCLUSIONS

Patients presenting to their optometrists with flashes and/or floaters make up a sizeable part of the community optometrist's workload and the management of these patients is highly variable. A large proportion of these patients are examined without mydriasis, even in the presence of various risk factors for retinal detachment. There is a relative lack of confidence amongst optometrists with regards the detection of vitreous pigment and the prognostic implications of this finding. Educational measures such as study days may help the level of understanding and heighten the appreciation of the implications of flashes and floaters and the various clinical signs encountered.