0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Enhanced Vitreous Imaging Technique With Spectral-Domain Optical Coherence Tomography for Evaluation of Posterior Vitreous Detachment FREE

Claudine E. Pang, MD1; K. Bailey Freund, MD1; Michael Engelbert, MD, PhD1
[+] Author Affiliations
1Vitreous Retina Macula Consultants of New York and LuEsther T. Mertz Retinal Research Center, Manhattan Eye Ear and Throat Hospital, New York, New York
JAMA Ophthalmol. 2014;132(9):1148-1150. doi:10.1001/jamaophthalmol.2014.1037.
Text Size: A A A
Published online

Vitreous degeneration, gradual separation of the posterior vitreous cortex (PVC), and eventual development of posterior vitreous detachment (PVD) are important in vitreoretinal interface diseases. However, determination of the stages of PVD with biomicroscopy or ultrasonography is not sufficiently sensitive and specific.1,2 Since the advent of spectral-domain (SD) optical coherence tomography (OCT), PVD detection has improved and new concepts regarding the evolution of PVD have emerged.2,3 However, SD-OCT remains underused, possibly owing to general low awareness of its potential to image the vitreoretinal interface and the vitreous itself.4,5 We aim to demonstrate the usefulness of an enhanced vitreous imaging (EVI) OCT technique in evaluating PVD.

METHODS

Six radial scans with a scan width of 30° centered at the fovea were obtained on the Heidelberg Spectralis (Heidelberg Engineering), in addition to a single 30° line scan taken with a 7° tilt, traversing both the optic disc and fovea simultaneously (Figure 1). All scans were the product of 45 to 70 averaging images by automatic real-time function, pulling back to focus on the vitreous. The retinal layers were positioned inferiorly on the image screen to obtain a maximum imaging depth of 1.5 mm into the vitreous, and the image brightness was increased slightly to improve visualization of the vitreous.

Place holder to copy figure label and caption
Figure 1.
Near-Infrared Fundus Images Showing the Enhanced Vitreous Imaging Technique With Spectral-Domain Optical Coherence Tomography

A, Six radial scans centered on the fovea with a 30° width. B, Single line scan centered on the fovea with a 7° tilt and a 30° width that traverses the optic disc and fovea.

Graphic Jump Location

RESULTS

Using EVI-OCT, we were able to demonstrate various stages of PVD. In posterior vitreous attachment, there is persistent attachment of the PVC over the entire posterior pole including the fovea and optic disc (Figure 2A). Incomplete PVD may begin with detachment of the PVC at perifoveal areas but persistent attachment over the fovea and persistent attachment at the optic disc (Figure 2B and C). With gradual release of the persistent attachment over the fovea, there is progression of the PVD, although it is incomplete due to persistent attachment at the optic disc (Figure 2D and E). Disruption of the posterior wall of the premacular bursa4 was well demonstrated with EVI-OCT (Figure 2F and G). The EVI-OCT displayed vitreous opacities and laminar structures of the posterior vitreous in the context of vitreoschisis (Figure 2G).6 Complete PVD could be appreciated as an optically empty vitreous cavity seen central to the retinal layers, and often an intact PVC was seen (Figure 2H). During the development of perifoveal PVD, strong vitreomacular adhesion may lead to macular hole formation with an operculum or vitreomacular traction syndrome (Figure 2I and J).

Place holder to copy figure label and caption
Figure 2.
Spectral-Domain Optical Coherence Tomographic Images Using the Enhanced Vitreous Imaging Technique, Showing Various Stages of Posterior Vitreous Detachment

A, No posterior vitreous detachment (PVD), with complete attachment of the posterior vitreous cortex (PVC) (arrowheads) to the perifoveal area, fovea, and optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. B, Incomplete PVD with separation of the PVC (arrowheads) at the temporal perifoveal area. There is persistent vitreomacular adhesion and residual attachment of the PVC at the nasal perifoveal area and optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. C, Incomplete PVD with separation of the PVC (arrowheads) over the nasal and temporal perifoveal areas. There is persistent vitreomacular adhesion and persistent attachment at the optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. D, Incomplete PVD with shallow separation of the PVC (arrowheads) over the perifoveal areas and fovea but persistent attachment at the optic disc. The posterior wall of the premacular bursa (asterisk) is still intact. E, Incomplete PVD with separation of the PVC (arrowheads) over the perifoveal areas and fovea but persistent attachment at the optic disc. The PVC has retracted further into the vitreous cavity. The posterior wall of the premacular bursa (asterisk) is still intact. F, Incomplete PVD with separation of the PVC (arrowheads) at the perifoveal areas and fovea but residual attachment at the optic disc. There is disruption of the posterior wall of the premacular bursa (asterisk). G, Incomplete PVD with detachment of the PVC (arrowheads) at the perifoveal areas and fovea but residual attachment at the optic disc. There is disruption of the posterior wall of the premacular bursa (asterisk). Vitreous opacities appear in the vitreous gel (circles). This patient was symptomatic for vitreous floaters. H, Complete PVD with the appearance of an optically empty peripheral vitreous cavity superior to the retinal layers in all areas, including the fovea and optic disc. The PVC (arrowhead) and vitreous with vitreoschitic fissure planes (double-headed arrow) and lacunae (asterisk) are seen in the vitreous cavity. I, Incomplete PVD with separation of the PVC (white arrowheads) over the entire macula, but persistent attachment at the optic disc. A macular hole and operculum (black arrowhead) are present on the PVC at the bottom of the premacular bursa. J, Incomplete PVD with vitreomacular traction, with degradation and doubling of the vitreous interface (arrowheads) due to saccadic eye movement and consequent movement of the PVC.

Graphic Jump Location

DISCUSSION

Studies using SD-OCT for the posterior vitreous have previously been limited to vertical and horizontal scans on the Cirrus OCT machine.4,5 This article illustrates the use of radial scans on the Spectralis SD-OCT. Inclusion of both the optic disc and the fovea is critical to unequivocally stage posterior vitreous separation. With EVI-OCT, we were able to achieve adequate image resolution and depth into the vitreous by using built-in functions including defocus, scan tilt, and automatic real-time function. In our experience, the “sweet spot” for automatic real-time function lies between 45 and 65 scans, as small saccades during the lengthy scanning process lead to vitreous movement and consequent apparent doubling of the PVC (Figure 2J). This problem is obviated on swept-source OCT machines owing to the much faster image acquisition.5 The use of EVI-OCT may enhance patient counseling by demonstrating visible vitreous floaters and PVC separation to symptomatic patients, improving patient understanding and promoting greater patient satisfaction. Keeping in mind that only the posterior vitreous is visualized, supplementing with B-scan ultrasonography may be prudent to establish peripheral vitreous face status.

In summary, EVI-OCT enables more precise characterization of the PVD process, which is essential in this era of pharmacologic vitreolysis. This article aims to heighten awareness of this vitreous imaging technique and encourage its use in the appropriate clinical setting.

ARTICLE INFORMATION

Corresponding Author: Michael Engelbert, MD, PhD, Vitreous Retina Macula Consultants of New York, 460 Park Ave, Fifth Floor, New York, NY 10022 (michael.engelbert@gmail.com).

Published Online: July 10, 2014. doi:10.1001/jamaophthalmol.2014.1037.

Author Contributions: Dr Engelbert had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Pang, Engelbert.

Administrative, technical, or material support: Pang.

Study supervision: Freund, Engelbert.

Conflict of Interest Disclosures: Dr Freund is a consultant for Heidelberg Engineering, Genentech, Regeneron, and Bayer. No other disclosures were reported.

Funding/Support: This work was supported by the Macula Foundation, Inc.

Role of the Sponsor: The Macula Foundation, Inc had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

REFERENCES

Sebag  J.  Imaging vitreous. Eye (Lond). 2002;16(4):429-439.
PubMed   |  Link to Article
Johnson  MW.  Posterior vitreous detachment: evolution and complications of its early stages. Am J Ophthalmol. 2010;149(3):371-382, e1.
PubMed   |  Link to Article
Uchino  E, Uemura  A, Ohba  N.  Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol. 2001;119(10):1475-1479.
PubMed   |  Link to Article
Itakura  H, Kishi  S.  Evolution of vitreomacular detachment in healthy subjects. JAMA Ophthalmol. 2013;131(10):1348-1352.
Link to Article
Schaal  KB, Pang  CE, Pozzoni  MC, Engelbert  M.  The premacular bursa’s shape revealed in vivo by swept-source optical coherence tomography. Ophthalmology. 2014;121(5):1020-1028.
Link to Article
Sebag  J.  Vitreoschisis. Graefes Arch Clin Exp Ophthalmol. 2008;246(3):329-332.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Near-Infrared Fundus Images Showing the Enhanced Vitreous Imaging Technique With Spectral-Domain Optical Coherence Tomography

A, Six radial scans centered on the fovea with a 30° width. B, Single line scan centered on the fovea with a 7° tilt and a 30° width that traverses the optic disc and fovea.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Spectral-Domain Optical Coherence Tomographic Images Using the Enhanced Vitreous Imaging Technique, Showing Various Stages of Posterior Vitreous Detachment

A, No posterior vitreous detachment (PVD), with complete attachment of the posterior vitreous cortex (PVC) (arrowheads) to the perifoveal area, fovea, and optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. B, Incomplete PVD with separation of the PVC (arrowheads) at the temporal perifoveal area. There is persistent vitreomacular adhesion and residual attachment of the PVC at the nasal perifoveal area and optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. C, Incomplete PVD with separation of the PVC (arrowheads) over the nasal and temporal perifoveal areas. There is persistent vitreomacular adhesion and persistent attachment at the optic disc. The premacular bursa (asterisk) is well visualized within the posterior vitreous. D, Incomplete PVD with shallow separation of the PVC (arrowheads) over the perifoveal areas and fovea but persistent attachment at the optic disc. The posterior wall of the premacular bursa (asterisk) is still intact. E, Incomplete PVD with separation of the PVC (arrowheads) over the perifoveal areas and fovea but persistent attachment at the optic disc. The PVC has retracted further into the vitreous cavity. The posterior wall of the premacular bursa (asterisk) is still intact. F, Incomplete PVD with separation of the PVC (arrowheads) at the perifoveal areas and fovea but residual attachment at the optic disc. There is disruption of the posterior wall of the premacular bursa (asterisk). G, Incomplete PVD with detachment of the PVC (arrowheads) at the perifoveal areas and fovea but residual attachment at the optic disc. There is disruption of the posterior wall of the premacular bursa (asterisk). Vitreous opacities appear in the vitreous gel (circles). This patient was symptomatic for vitreous floaters. H, Complete PVD with the appearance of an optically empty peripheral vitreous cavity superior to the retinal layers in all areas, including the fovea and optic disc. The PVC (arrowhead) and vitreous with vitreoschitic fissure planes (double-headed arrow) and lacunae (asterisk) are seen in the vitreous cavity. I, Incomplete PVD with separation of the PVC (white arrowheads) over the entire macula, but persistent attachment at the optic disc. A macular hole and operculum (black arrowhead) are present on the PVC at the bottom of the premacular bursa. J, Incomplete PVD with vitreomacular traction, with degradation and doubling of the vitreous interface (arrowheads) due to saccadic eye movement and consequent movement of the PVC.

Graphic Jump Location

Tables

References

Sebag  J.  Imaging vitreous. Eye (Lond). 2002;16(4):429-439.
PubMed   |  Link to Article
Johnson  MW.  Posterior vitreous detachment: evolution and complications of its early stages. Am J Ophthalmol. 2010;149(3):371-382, e1.
PubMed   |  Link to Article
Uchino  E, Uemura  A, Ohba  N.  Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol. 2001;119(10):1475-1479.
PubMed   |  Link to Article
Itakura  H, Kishi  S.  Evolution of vitreomacular detachment in healthy subjects. JAMA Ophthalmol. 2013;131(10):1348-1352.
Link to Article
Schaal  KB, Pang  CE, Pozzoni  MC, Engelbert  M.  The premacular bursa’s shape revealed in vivo by swept-source optical coherence tomography. Ophthalmology. 2014;121(5):1020-1028.
Link to Article
Sebag  J.  Vitreoschisis. Graefes Arch Clin Exp Ophthalmol. 2008;246(3):329-332.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

2,019 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Related Multimedia

Author Interview

audio player

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference