Gliotic opaque posterior hyaloid membrane separation: report of two cases

Background To report two cases with idiopathic unilateral diffuse opacification of the posterior hyaloid membrane (PHM) completely separated from the retina, the mechanism of which is possibly due to glial cell proliferation and migration. Case presentation Two Japanese women at age 75 and 84 with no systemic or ocular history developed diffuse opacification in one eye resembling a ground glass sheet almost all over the surface of the PHM, but not within the vitreous gel or fluid. The retinas were funduscopically normal; however, optical coherence tomography demonstrated hyperreflective icicle-like anterior protrusions from the surface of the fovea. The patients received pars plana vitrectomy, resulting in visual improvement. Cell block preparations of the vitreous in one case revealed a cluster of cells immunoreactive for glial fibrillary acidic protein in consistence with gliosis, while denying vitreoretinal lymphoma from lack of atypical cells and vitreous amyloidosis due to no staining for Congo red or direct fast scarlet. The lesions did not recur during follow-up with no new funduscopic abnormalities. Conclusions To our knowledge, this is the first to demonstrate such peculiar cases of vitreous opacity with idiopathic and unilateral onset. Histological assessments revealed the possible pathogenesis of gliotic opaque PHM separation to cause its ground-glass-sheet appearance.

The method of viscodissection with contrast enhancement of posterior hyaloid membrane for proliferative diabetic retinopathy surgery

Purpose. Study is to evaluate the efficacy of the method of viscodissection with contrast enhancement of posterior hyaloid membrane in PDR surgery. Material and methods. The study involved 26 patients with type 1 diabetes mellitus and severe PDR with the presence of tractional retinal detachment (TRD). All patients received treatment in the volume of lensectomy and IOL implantation, microinvasive vitrectomy, viscodissection with contrasting of epiretinal structures was performed, followed by segmentation and removal of membranes, endolaser coagulation followed by tamponade with sterile air of the vitreous cavity. Results. In all patients included in the study, with dynamic observation, there was a positive dynamics of morphofunctional indicators - best corrected visual acuity (BCVA) from 32.5-16.1 to 62.2-15.7 and central retinal thickness (CRT) according to optical coherence tomography (OCT) from 775.9-78.4 to 492.1-73.8 µm. Conclusion. The method of viscodissection with simultaneous contrast of the posterior hyaloid membrane facilitates the assessment of the quality of the separation of pathological membranes and improves the quality of visual control over the process of their separation, which reduces the risks of iatrogenic retinal breaks. Key words: diabetes mellitus, proliferative diabetic retinopathy, vitreoretinal surgery, viscodissection.

The role of intraocular hydrodynamics in inducing posterior hyaloid membrane detachment (preliminary report)

At present, it is believed that the detachment of the vitreous body occurs due to the contraction and liquefaction of the vitreous body, while the exit of the liquid part of the vitreum into the retrovitreal space passes passively through the formed prepapillary opening, after which the vitreous body collapses, however, more precise mechanisms have not been described. Purpose. Substantiate a hypothesis of influence of intravitreal hydrodynamics in inducing detachment of the posterior hyaloid membrane based on the analysis of OCT data. Material and methods. An OCT study was performed in 30 patients with initial detachment of the posterior hyaloid membrane (PHM) with macular adhesion, macular traction, and macular hole. The features of the location of the PHM in the region of the macula, foveola and the place of attachment of the PHM to the optic nerve were studied. Results and discussion. As a result of the analysis of OCT images, it was found that with macular holes, macular adhesion and macular traction, a closed space is formed between the posterior hyaloid membrane and the retina (subbursal space) in the form of a dome, which indirectly indicates an increase in pressure within this space. In 28 patients, the zone of dissection or thinning of the PHM was found parapapillary, through which the intraocular fluid is likely to be injected into the subbursal space. Conclusions: This study suggests the leading role of intravitreal hydrodynamics and the formation of an area of increased pressure in the subbursal space in the induction of the detachment of the PHM, the pathogenesis of vitreomacular adhesion, vitreomacular traction and macular hole. The topic requires more detailed study. Key words: posterior hyaloid membrane, OCT, vitreous body, macular hole.

“Arcus retinalis”: A novel clinical marker of sub-internal limiting membrane hemorrhage

Introduction: Preretinal hemorrhages can be located in subhyaloid or sub-internal limiting membrane (ILM) space. Though optical coherence tomography (OCT) may help to distinguish the exact location of hemorrhage in selected cases, it is often difficult to discern clinically. The purpose is to describe a novel clinical sign named “arcus retinalis” as a clinical marker of sub-ILM hemorrhage. Methods: Retrospective observational case series. Ophthalmic records of 31 eyes with sub-ILM hemorrhage were analyzed. The sub-ILM nature of the hemorrhage was confirmed either by the presence of two distinct layers (ILM and posterior hyaloid) on OCT or on intraoperative sub-ILM localization of the hemorrhage during vitrectomy. Results: 15 out of 31 eyes with sub-ILM hemorrhage demonstrated a retinal yellowish-white arc corresponding to the outer margin of the sub-ILM hemorrhage. A complete circle was not seen in most of the cases. This arc corresponded to a vertical peg-like structure in the outer retina on OCT and had a tendency to fade away over months. In 10 eyes, it was visible at presentation and in five eyes it could only be seen after clearing of the hemorrhage. Conclusion: Retinal yellowish-white arc (“arcus retinalis”) is a useful clinical marker of sub-ILM hemorrhage with distinct OCT features that tends to disappear with time.

Acute vision loss in a patient with chronic esophageal stenosis

Purpose: To describe a unique cause of Valsalva Retinopathy (VR) with an alternative surgical approach to chronic non-clearing pre-foveal hemorrhage. Method: Case presentation. Results: A 45-year-old African American female presented with acute vision loss from 20/20 to count fingers (CF) in her right eye. Ophthalmoscopy and ocular coherence tomography (OCT) showed old yellow-red pre-retinal opacityscuring the fovea. After 1 month of conservative management with no improvement, Pars Plana Vitrectomy (PPV) with posterior hyaloid membrane removal without ILM peeling was performed with the patient’s best-corrected visual acuity (BCVA) dramatically improved to 20/25. Discussion: We raise the question regarding the role of ILM peeling in treating premacular hemorrhage. Even without ILM peeling, our patient’s hemorrhage resolved after the procedure. This suggests that PPV combined with posterior hyaloid removal is a safer and effective alternative to surgical treatment in patients with certain clinical conditions. In addition, we provide clear evidence to support the location of the hemorrhage in VR as both sub-hyaloid and sub-ILM.

Foveal cyst: Unknown etiology and unexplained response to treatment

Background: Foveal cysts have been associated with vitreous traction due to a taut posterior hyaloid. These eyes may progress to become a full-thickness macular hole, remain stable, or resolve after a posterior vitreous detachment. A foveal cyst in an eye with a complete posterior vitreous detachment and no other obvious pathology is unusual. Case presentation: A 21-year-old male presented with blurred vision in the left eye of 1-month duration. On examination his left-eye vision was 20/60, and anterior segment examination was normal. Fundus examination showed internal limiting membrane folds with a suspected lamellar macular hole. A spectral domain optical coherence scan showed a thin dome-like cyst in the sub foveal region involving the outer retinal layer with a detached posterior hyaloid face. A trial of intravitreal dexamethasone implant was given, following which there was improvement in vision and resolution of the foveal cyst. At the third-month follow-up, the patient presented with a stellate pattern of hyporeflectivity in the macular area both on spectral domain optical coherence scan and multicolor imaging with no change in visual acuity. Conclusion: The presence of a foveal cyst in a young male without any risk factors is peculiar, and the rapid response to intravitreal dexamethasone implant raises questions about the pathogenesis. The stellate pattern of hyporeflectivity on spectral domain optical coherence scan imaging with an intraretinal “filling defect”–like picture on fluorescein angiography suggests a possible ongoing ischemic pathology.