SECTION 1: THE VITREOUS

1.1.

INTRODUCTION

Unique tissue:
1. Transparent
2. Avascular (normally)
3. Visco-elastic (shock absorption)
4. Immunological properties (inhibits neovascularisation)
5. 66-75% of total globe
Physical properties:
1. Total volume = 3.9ml (2/3 volume of eye)
2. 99% water (increases with age)
3. 1% solids: (8) Proteins Hyaluronic acid Collagen filaments Hyalocytes Albumin
Glucose Ascorbic acid
Galactose
4. Other Cells: (2) Glyocells Astrocytes (mostly in cortex)
*Metabolic activity: Glucose converted to hyaluronic acid in cortical portion**
- No metabolic activity in vitreous body
**Cortical portion is denser than that which circumscribes entire vitreous
Beta Scan
Theory:
- Normal vitreous: Acoustically and radiologically empty
- Blood/retina in vitreous: Not acoustically empty > appears on Beta scan
1. Beta scan consists of focused, short wavelength, acoustic waves
2. Energy emitted as advancing acoustic wavefront to eye
3. Intraocular and orbital velocity differs as it passes through various orbital structures due to
varying density
Uses:
1.
2.
3.
4.
5.

Massive haemorrhage may indicate NV

DDx tumour from vitreous cyst
Iris dilation isnt possible
Non invasive
Can indicate: (6) trauma haemorrhage tumours blood occlusion opacities
RD

Vitreous is attached in several places:

1. Posterior lens surface
- Annulus zone = 8-9mm = Edgers line
- Via Weigers ligament
Not true ligament
Weakens with age 40+
Adhesion broken down during intracapsular cataract extraction
2. Vitreous base
- Definition: Thickened area with strong attachment; cant be separated unless trauma
Divides vitreous cortex into anterior and posterior
- Annular zone = 3-4mm = anterior and posterior to ora serrata
- Strongest attachment of vitreous in eye
Firmly attached to pars plana
Extends 1DD into peripheral retina
- Clinical:
Retinal breaks and degeneration common along posterior edge
With detachment, may result in retinal holes in extreme periphery
3. Anterior and posterior hyaloid membrane covers cortex
- AHM: Begins at ora and extends to posterior lens capsule; attached to Weigers
ligament
- PHM: Extends around vitreous cortex behind posterior edge of vitreous base, where it
contacts retina and runs to the back
4. Around margin of ONH
- 2nd strongest attachment
- Smaller ring of tissue often results with detachment
5. Around macular diameter
- 2-3mm around fovea
- Weakens with age
- Weakest attachment > macular hole

Vitreous attachments from weakest to strongest: Macula posterior lens surface ONH
pars plana

Healthy eyes > vitreous body is in contact with entire retina and attached to basement
membrane of retina by scattered collagenous filaments

Parallax procedure:
With movement = beyond nodal point > on posterior lens, capsule or vitreous
Against = before nodal point

Features of normal vitreous in youthful eye:

1. Avascular
2. Acellular
3. Fine collagen fibrils
4. Seen to move when patient moves their eyes
Syneresis:
Definition: Degenerative process of vitreous in normal ageing eye
Process:
1. Hyaluronic acid macromolecules break down and release water, which permits
collagen fibrils to coalesce into larger wispy fibres
2. Gel degeneration (syneresis) causes formation of aggregates of collagen fibres
(floaters/muscae volitantes)
3. Optically empty spaces and clefts arise (lacunae), which contain hyaluronic acid
and collagen > spaces appear black in grey vitreous background
4. Posterior lacunae enlarge and may empty into space between posterior hyaloid
and inner limiting membrane of sensory retina > separation = PVD
5. In normal eye, there is shrinkage of vitreous base and syneresis
Accelerated in:
1. High myopes
2. Aphakes
3. Inflammation
4. Peripheral uveitis
5. Retinochoroiditis
*Syneresis question
Sixty year old aphakic female > routine visual exam > things floating in front of eye particularly
when she moves them
a. Explain most likely cause associated with normal aging process (6)
- Syneresis + process
b. Additional question to assess possible causes or complications (1)
- Flashes of light
c. State possible complications (3)
- Vitreal haemorrhage
- Vitreal break
Vitreal tear
Cloquets Canal

1.2.

Definition: S shaped optically empty space; contains less fibrils; less dense; Not a
true membrane
Presentation: Less visible with age
Position: Runs from posterior lens to disc
Clinical: Represents atrophic primary vitreous > may see remnants of hyaloid
system after regression where secondary vitreous has compressed it
DEVELOPMENTAL ABNORMALITIES OF VITREOUS

Mittendorfs dot

Bergmeisters Papilla

Persistent hyperplasic
primary vitreous

Benign
Glial vascular remnant
adherent on posterior lens
capsule where hyaloid
vascular system was once
attached

Benign
Residual glial tissue which
hasnt regressed as hyaloid
system becomes atrophied

Doesnt affect VA

Doesnt affect VA

Leucokoria:
White reflex > light blocked from entering retina
May be due to:
1. ROP
2. Retinal dysplasia
3. Congenital cataracts
4. PHPV
5. Retinoblastoma
*Leucokoria question:
Infant = 2 months old > white pupil (8)
a. Ophthalmic terminology for white pupil?
b. Differential diagnosis for white pupil
c. Non-invasive procedure to aid correct diagnosis
- B-scan

More severe
Combo of regression of
failure of regression of
hyaloid artery and
hyperplasia of posterior
portion of vascular
meshwork of embryonic
lens
VA reduced
Presentation
Usually monocular, where
affected eye is smaller
Full term infants
Pathogenesis
Initially lens is clear, but
becomes opaque
Complications
Posterior capsule may
rupture > secondary
glaucoma
Spontaneous haemorrhage
may occur into vitreous
Buphthalmos
DDx
Retinoblastoma
Retinopathy of prematurity
Retinal dysplasia
Congenital cataract
Tx: Early removal of lens

1.3.

DEGENERATION OF VITREOUS

Posterior vitreous detachment:

Prevalence: Px past middle age; 2/3 of population >80
Presentation: Benign
Clinical statistics:
- 10-15% of px with symptomatic PVD (light flashes/floaters) will develop retinal
breaks
- 5% of px with symptomatic PVD will develop vitreal haemorrhages without
significant retinal breaks
Typical Sx:
1. Light flashes > due to phosphenes produced by tractions on retina opposite to
site of retinal traction
2. Floaters > due to particles of vitreous, blood and retina that cast shadows on
retina
Clinical signs:
1. Weisss ring
2. Optically empty space between loose veil like posterior membrane with direct
focal illumination (inverted J)
3. Small floater/opacity temporal to macula
Pathogenesis
1. Hyaluronic acid separates posterior hyaloid from inner limiting membrane
2. Usually begins in upper globe and spreads forward towards vitreous base
3. Lacunae form
4. Spreads posteriorly down below disc
5. Entire vitreous cortex may detach up to vitreous base
6. Ring of attachment around disc may tear loose and float forward towards back
of lens > Weisss ring (inverted J)
7. Small ring may arise as macula attachment separates > macula floater

Asteroid Hyalosis

Presentation: Benign; asymptomatic; No Tx indicated

Clinical presentation:
1. Arranged in strands or seen as discrete bodies without orderly arrangement
2. Attach to vitreous fibrils
3. Move with excursion of vitreous and not affected by gravity > return to original
position in vitreous
4. Brilliant yellowish white spheroidal refractile bodies of variable size > bodies
shimmer when viewed by SLE or BIO
5. Visualization of fundus detail can be markedly diminished or obscured by
asteroid bodies
6. Reflects ultrasound in high echo due to high density of Ca

*Asteroid Hyalosis question

Sixty year old > routine visual exam > best correct VA 6/6 > direct ophthalmoscopy = small
discrete refractile bodies in vitreous which move but return to original position in left eye only (7)
- State diagnosis and motivate answer by explaining phenomenon
- Management strategy
Synchiasis Scintillans (Cholesterolosis bulbi)
1. Def: Crystalline bodies are composed of cholesterol
2. Aet:
- Opacities occur following severe ocular inflammation, trauma or haemorrhage
- Occurs after chronic vitreous haemorrhage
3. Presentation: Bilateral; <35y
4. Associated with fluid vitreous which accounts for settling bodies in cavity of vitreous after
eye movements

Asteroid Hyalosis
Congenital
Aetiology unknown
Benign, usually asymptomatic
Composed of complex phospholipids and
calcium pyrophosphate complexes
Arranged in strands or seen as discrete
bodies, without orderly arrangement
Attach to vitreous fibrils
Move with excursion of vitreous and not
affected by gravity > return to original
location in vitreous

Synchiasis Scintillans
Acquired > Bilateral presentation in px
under 35
Occurs after severe ocular inflammation,
trauma or haemorrhage
Less benign
Composed of cholesterol
Crystalline bodies
Associated with fluid vitreous
Settling of bodies in vitreous cavity after
eye movement

Vitreous haemorrhage

Aetiology: Retinal break, proliferative retinopathy, PVD

Definition: Unclotted/finely clumped blood in vitreous that clears within weeksmonths
Complication: Dense clots may never absorb > synchiasis results
Clinical appearance: red, hazy or very dense opacification
Management:
1. Expect retinal break until proven otherwise
2. Patients should avoid heavy lifting or bending over
3. Bed rest with head elevation
4. B-scan to rule out retinal detachment
5. If retinal haemorrhage doesnt clear up significantly in 5-6 months, consider
vitrectomy
6. Avoid aspirin (blood thinner)
7. Vessel leakage > Fluorescein angiography

Other causes:
1. Haemopoetic disease (leukemia, anemia)
2. Trauma
3. Menstruation
4. Macroaneurism
5. Telangiectasia (abnormal blood vessels that over grow)
6. Torrison syndrome
7. Shake and baby syndrome
8. Fibroblastic adhesions
9. Haemolytic glaucoma
10. Subarachnoid haemorrhage
11. Neovascularization

a.

1.4. PARTICLES
Pigment in vitreous (from retina)
Called Schaffers Sign or tobacco dusting
May result from retinal detachment or tear (at RPE) > if seen, make sure no retinal
haemorrhages, and look for retinal break
May occur post-surgically

Cells

in vitreous (aet)
May indicate posterior uveitis
Retinal inflammation
Retinal tear
Choroiditis

Vitreous adhesion syndromes (pathogenesis)

Abnormal adhesion between retina and vitreous

Traction upon retinal area concerned
Retinal tears formed (operculum > fluid filters through plug and can detach)

Muscae Volitantes (refer to second year clinical)

Vitreous membranes
1. Def: Thick, rubbery well-defined structures lining posterior surface of detached vitreous
2. Colour: Mostly yellow-ochre; can be brownish from migrating pigment (RPE) cells
composed of degenerating RBCs and collagen matrix
3. Clinical: Retinal detail may be obscured

1.5.
1.
2.
3.
4.

VITREOUS PROLAPSE
Def: Vitreous moves forward, through pupil, and may adhere to anterior structures.
Aet: Trauma (surgical or other)
Ass with: rupture of posterior capsule
Signs:
a. Updrawn pupil > Peaked pupil
b. Iris prolapse
c. Vitreous touch syndrome
5. Result:
a. Associated uveitis
b. Retinal detachment
c. Chronic cystoid macular oedema

1.6. VITRECTOMY
1. Def: Partial or total surgical removal of vitreous; Replacement with various density gases
which determines absorption times and maintains globe volume; Silicone fluid or oils used
in past, which were later removed and replaced with saline
2. Risks: Invasive; not performed unnecessarily
3. Used for:
a. Vitreous detachment > look for lacunae (looks black) and Weisss ring (floater around
ONH; appears reddish).

1.7. VITRITIS
1. Treatment:
a. Steroids to control inflammation > topical, locally injected, or systemic corticosteroids
b. Topical cycloplegic-mydriatics to make eye comfortable or prevent complications
c. Intravitreal triamcinolone acetonide in selected cases > modality has rapid effect and
may lower use of systemic agents
d. Dosage and length of time varies
e. Vitritis can return after medication stops, thus look for reoccurrence and manage
appropriately (immediately refer)
f. Treatment depends on cause
2. Complications: If present for extended time, glaucoma or cataracts may occur