Editor's note: Vitreous opacity (Vos) is a common eye disease that is still unclear due to the lack of large-scale population studies of its surgical indications and prognosis. Researchers from the Florida Retinal Institute shared their experience and relevant recommendations on the treatment of PPV after four years of vitrectomy (PPV) for the treatment of VOs, providing a reference for more ophthalmic colleagues to carry out PPV.
PPV: a reliable option for the treatment of VOs
VOs is a common eye disease, there are both physiological and pathological, physiological VOs consciously see that the floating objects in front of the eyes are more transparent, occasionally appear, the number is small, does not affect vision. But pathological VOs are often associated with retrovitral detachment (PVD). For the vast majority of patients, VOs are annoying, but they do not significantly affect their quality of life or daily life. However, when VOs cause decreased visual function, PPV is a viable treatment option.
Recently, Professor Donald J. D Amico led a panel of vitreoretinal experts to discuss the management of symptomatic VOs cases. The panel proposed a VOs severity grading system, which could be a good basis for optometrists and ophthalmologists to monitor patients with VOs.
Asymptomatic VOs: evident on clinical examination, but do not cause visual impairment in patients.
Mild VOs: visible to patients but do not affect vision or functioning in daily life.
Medium VOs: affect vision and have some interference with daily life functions.
Severe VOs: seriously affect the quality of life, seriously interfere with the functioning of daily life.
Ophthalmologists have been exploring PPV for more than 20 years, and more evidence suggests that PPV is effective and safe for treating VOs with decreased visual function. The researchers recently published a single-center study with data from private clinics that provide only retinal services, and their 4-year experience with PPV in the treatment of visually significant VOs provides a relevant surgical reference. The patients all received PPV no. 23 or 25. All patients included in the study were intraocular lens eyes, symptoms persisted for more than 6 months, and the Weiss ring was present, according to which the researchers included 81 patients (104 eyes). The researchers found no cases of retinal tears or RDs; one patient developed vitreous bleeding, which subsided spontaneously. In addition, vision improved in all patients, with 93.3% of them achieving vision of 20/40 or better. While routinely simply educating patients that VOs are a benign disease with no other effects; many patients find that moderate to severe Vos reduces their quality of life.
With the development of PPV technology, more and more vitreoretinal surgeons are beginning to perform PPV for patients with symptomatic VOs. In fact, the results of a global online survey show that the majority of respondents believe that symptomatic VOs are a condition that requires treatment, and that surgical interventions are often straightforward and effective. The real challenge for doctors is how to select the right patients and how to effectively educate them.
How to choose the right PPV patient? These five factors need to be considered!
The following five factors need to be considered before PPV treats patients with VOs.
One
Duration of symptoms
When dealing with patients who are plagued by VOs, the duration of symptoms should first be determined. As a rule, when a patient develops acute peripheral vascular disease, the common symptoms are glare and VOs. For most patients, these symptoms disappear within 3-6 months without further intervention. If a patient develops severe VOs and still has significant symptoms after 6 months, it can be considered reasonable to undergo vitrectomy.
Two
Full informed consent
Detailed informed consent for patients who are suitable for surgery is extremely important. Patients need to understand that even if PPV is relatively simple, they must be willing to accept the inherent risks of each procedure before proceeding with surgery. These risks (including retinal tearing/detachment, bleeding, infection, etc.) need to be discussed with the patient before surgery and make sure that conversations with the patient are recorded.
Three
Refractive state
Although many patients with opacified lenses have undergone PPV over the years, it is recommended that patients undergo lens removal and intraocular lens implantation surgery before receiving PPV. Performing PPV in patients with opacified lenses usually results in incomplete vitreous resection, which remains behind the lens capsule, which can cause postoperative visual impairment in patients. However, when the patient is an intraocular lens eye, it is convenient for the ophthalmologist to perform a vitrectomy, which can remove any vitreous bodies that affect visual function.
Four
PVD
Before PPV treatment is considered, confirm the presence of PVD to avoid the possibility of intraoperative induction of PVD, which may lead to iatrogenic retinal rupture, retinal detachment, or peripheral vascular hemorrhage disease. This can usually be confirmed by preoperative testing. Various imaging modalities, such as ultrasound scans and OCT, can also help doctors confirm PVD. If the patient does not have PVD and still decides to perform PPV for the patient, the patient needs to be informed that if PVD occurs in the future, symptoms such as VOs may recur.
Five
Understand the underlying cause
Importantly, not all VOs are caused by PVD or vitreous dehydration. Severe VOs are also common in other settings, such as moderate uveitis, amyloidosis, and intraocular lymphoma. While PPV may also be required for these conditions, tissue biopsy or pathological analysis is the gold standard for diagnosis. In addition, for VOs secondary to uveitis, treatment with glucocorticoids will improve VOs and other symptoms. Therefore, it is important to consider all possible causes of patient VOs before performing PPV.
Figure 1. At 40 years of age, fundus color photographs indicate significant VOs (A), and corresponding OCT images and laser ophthalmoscopic scans confirm that VOs (B) are significant.
Patients undergo PPV, vitreous pathological analysis. Based on the results of the examination, amyloidosis of the eye is diagnosed.
Treating VOs, PPV surgery is even better!
Once the doctor has determined that the patient's symptoms have persisted for at least 6 months and discussed with the patient the possibility of PPV as a treatment option, the patient's operation is scheduled only after the patient has fully informed consent and discussed all the risks, benefits, and alternatives to the procedure. Here are some surgical recommendations to help the procedure go smoothly.
Small incision PPV surgery is recommended. One study assessed the postoperative incidence of PPV (11%) in 110 PPV-treated VOs, more than 50% of RD patients received 20 G PPV, and studies showed that small incisions of PPV were safer, more effective, and more tolerated.
After the central vitreous is removed, the vitreous behind the lens is removed, which prevents postoperative visual disturbances.
If the patient has not yet undergone YAG laser posterior capsularectomy, posterior capsular incision may be considered. If the patient develops cystic opacification after PPV surgery, YAG laser posterior cystectomy may result in a recurrence of new VOs or symptoms.
A thorough retinal examination is performed preoperatively to confirm the presence of suspicious areas around the retina (e.g., clusters, small rifts, lattices with atrophic holes) and, if necessary, laser treatment of the relevant lesions.
Performing a partial or complete gas-liquid exchange ensures that the incision is completely closed after the cannula is removed. If the incision is not well closed, sutures are required.
summary
Reflective and floating symptoms that occur in patients with PVD usually disappear within 3 to 6 months, and most patients do not require further intervention. In other cases, such as moderate uveitis, amyloidosis, and intraocular lymphoma, the common symptom is pronounced vision opacity. Detailed communication with the patient is required before surgery to select the right patient for the operation PPV and to choose the appropriate surgical method.
References: https://retinatoday.com/articles/2022-jan-feb/surgical-considerations-for-vitreous-opacities?c4src=home:feed
(Source: Editorial Board of International Ophthalmology News)