Table Of ContentCharles L. Schepens Adolphe Neetens
Editors
THE VITREOUS
AND VITREORETINAL
INTERFACE
With 122 Illustrations. 42 in Full Color
Springer Science+Business Media, LLC
Charles L. Schepens, M.D. Adolphe Neetens, M.D., Ph.D.
Senior Scientist and President Professor and Chairman
Eye Research Institute Institute of Ophthalmology
Retina Associates Dean of the University Hospital
Professor of Ophthalmology Emeritus University of Antwerp Medical School
Harvard Medical School Antwerp, Belgium
Boston, Massachusetts, U .S.A.
Library of Congress Cataloging-in-Publication Data
The Vitreous and vitreoretinal interface.
Includes index.
1. Vitreous body. 2. Retina. 3. Eye-Diseases
and defects. 1. Schepens, Charles L. II. Neetens, A. (Adolphel
RE50l.V58 1987 617.7'46 87-12865
First published in 1987 by the Belgian Ophthalmological Society, Belgium
(Bulletin de la Societe Belge d'Ophtalmologie, VoI. 223-1).
© 1987 by Springer Science+Business Media New York
Originally published by Springer-Verlag New York Inc. in 1987
Softcover reprint ofthe hardcover Ist edition 1987
Ali rights reserved. This work may not be translated or copied in whole or in part without the
written permission of the publisher (Springer Science+Business Media, LLC), except for brief
excerpts in connection with reviews or scholarly analysis. U se in connection with any form of in
formation storage and retrieval, electronic adaptation, computer software, or by similar or dis
similar methodology now known or hereafter developed is forbidden.
The use of general descriptive names, trade names, trademarks, etc. in this publication, even if
the former are not especially identified, is not to be taken as a sign that such names, as understood
by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone.
While the advice and information of this book is believed to be true and accurate at the date of
going to press, neither the authors nor the editors nor the publisher can accept any legal responsi
bility for any errors or omissions that may be made. The publisher makes no warranty, expressed
or implied, with respect to material contained herein.
987654321
ISBN 978-1-4757-1903-1 ISBN 978-1-4757-1901-7 (eBook)
DOI 10.1007/978-1-4757-1901-7
CONTENTS
Preface 1
List of contributors 3
Chapter 1. Historical introduction 5
Rose Marie Smets and Adolphe Neetens
Chapter 2. Embryology of the vitreous. Congenital and develop-
mental anomalies 11
Delia N. Sang
Chapter 3. Structure, function, and age-related changes of the
human vitreous 37
Jerry Sebag
Chapter 4. Biochemistry of the vitreous 59
David A. Swann
Chapter 5. Clinical methods of vitreous examination 73
Alex E. Jalkh and Clement L. Trempe
Chapter 6. Vitreous changes in retinal detachment . 85
Charles L. Schepens
Chapter 7. Vitreous changes in ocular inflammation 109
Alex E. Jalkh and Clement L. Trempe
Chapter 8. Degenerative conditions of the vitreous 115
John J. Weiter and Daniel M. Albert
Chapter 9. Vitreous changes in vascular diseases 133
J. Wallace McMeel and Alex E. J alkh
Chapter 10. Vitreous changes and macular disease 155
Alex E. Jalkh and Clement L. Trempe
Chapter 11. Vitreous changes in retinopathy of prematurity 165
Tatsuo Hirose and Delia N. Sang
Chapter 12. The vitreous in ocular trauma 179
Felipe I. Tolentino
Chapter 13. Effect of aphakia upon the vitreous 197
Sheldon M. Buzney and John V. Thomas
-N-
Chapter 14. Vitreous degeneration in myopia and retinitis pig-
mentosa ............... . 211
Ronald C. Pruett and Daniel M. Albert
Chapter 15. The vitreous in idiopathic giant retinal breaks 229
H. MacKenzie Freeman
Chapter ·16. Hereditary vitreoretinal diseases 241
Adolphe Neetens
Chapter 17. Vitreous substitutes and vitreous surgery 273
Charles L. Schepens
Chapter 18. The vitreous: birds' eye view 303
Adolphe Neetens
Index ............... . 307
PREFACE
This book on the vitreous and vitreoretinal interface is a compen
dium of clinically relevant data written by vitreoretinal surgeons and
by laboratory eye researchers in the fields of biochemistry and patho
logy.
The clinical fortunes of the vitreous have varied considerably with
time. Years ago the vitreous cavity was taboo to the eye surgeon, and
any vitreous loss during an intraocular procedure was considered a ser
ious complication. Then came the advent of vitreous surgery, and pret
ty soon the vitreous was treated in an off-hand manner. During that
period many vitreous surgeons maintained that the vitreous was an
embryonic remnant without postnatal physiological function. There
fore, they felt, the sooner the vitreous was removed surgically, the bet
ter off the eye would be. This attitude is still common today despite the
accumulating data that establish the very important physiological role
of the vitreous gel. The close physiological relationship between vi
treous and retina was to be expected, simply by considering vitreous
embryology.
It is now well established that the vitreous body fulfills much more
than simple biophysical functions, such as ensuring transparency and
absorbing shocks. Its importance in the physiology and biochemistry of
the inner eye, particularly the retina, is being increasingly recognized.
The bulk of the evidence, both morphological and biochemical, indi
cates that the macromolecules in the vitreous are synthesized by the
retina. It should therefore be expected that the vitreous gel is important
to retinal metabolism, mainly by preserving homeostasis in a quiescent
extravascular matrix. This quiescent medium makes it an ideal reposi
tory for metabolites to be used by hyalocytes and neighboring retinal
and lens tissue. The vitreous is a reservoir not only of various sugars,
but also of several amino acids. It is also a repository for metabolic
wastes, such as lactic acid. Finally, its high ascorbic acid content may
scavenge free radicals resulting from retinal and lens metabolism.
The crucial importance of the vitreous in several forms of retinal
pathology is also being acknowledged. Its key role in the development
of rhegmatogenous retinal detachment was known long ago. Other
-2-
examples of the close connection that exists between the vitreous gel
and retinal conditions are the role played by vitreous traction in macu
lar edema, proliferative diabetic retinopathy, retinal vascular occlu
sions, retinal inflammation, and giant retinal tears. The specific vi
treous changes that occur in aphakia, blunt and perforating truma,
myopia, and retinitis pigmentosa are also beginning to be elucidated.
The changes noted in specific vitreous degenerations such as amyloido
sis, synchysis, and asteroid bodies are already known in some detail. In
contrast, our knowledge of the vitreous changes that accompany hered
itary degenerations of the ocular fundus are still sketchy.
Recent progress in the management of retinopathy of prematurity
(ROP) has been accomplished through the development and improve
ment of open-sky vitreous surgery. Finally, attempts at finding useful
vitreous substitutes begin to yield satisfactory results after years of
research efforts in this area.
It is hoped that this book demonstrates the growing clinical impor
tance of the vitreous body in diseases of the inner eye. The days when
the vitreous was considered useless in health, damaging in disease, and
to be excised whenever possible definitely belong to the past. Vitreo
retinal surgeons who still display that attitude are poorly informed.
Since vitreous changes can now be photographed in vivo, objective
clinical observations pertaining to the vitreous gel can be recorded.
These recording techniques will no doubt be improved further and will
encourage more extensive clinical and laboratory research on the vi
treous in health and disease. This is the fondest wish of the contribu
tors to this book.
Charles L. Schepens, M.D.
Adolphe Neetens, M.D. Ph.D.
LIST OF CONTRIBUTORS
Daniel M. Albert, M.D.
Professor of Ophthalmology, Harvard Medical School
Director of Eye Pathology Laboratory, Massachusetts Eye and Ear
Infirmary, Boston
Sheldon M. Buzney, M.D.
Clinical Assistant Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Clinical Instructor in Ophthalmology, Harvard Medical School
H. MacKenzie Freeman, M.D.
Clinical Senior Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Associate Clinical Professor of Ophthalmology, Harvard Medical
School
Tatsuo Hirose, M.D.
Clinical Associate Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Associate Clinical Professor of Ophthalmology, Harvard Medical
School
Alex E. Jalkh, M.D.
Clinical Associate Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Clinical Instructor in Ophthalmology, Harvard Medical School
1. Wallace McMeel, M.D.
Clinical Senior Scientist, Eye Research Institute, Boston
Retina Associates,. Boston
Associate Clinical Professor of Ophthalmology, Harvard Medical
School
Adolphe Neetens, M.D., Ph.D.
Professor and and Chairman, Institute of Ophthalmology, and Dean of
the University Hospital, University of Antwerp Medical School
-4-
Ronald C. Pruett, M.D.
Clinical Assistant Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Assistant Clinical Professor of Ophthalmology, Harvard Medical
School
Delia N. Sang, M.D.
Clinical Instructor in Ophthalmology, Harvard Medical School
Charles L. Schepens, M.D.
Senior Scientist and President, Eye Research Institute, Boston
Retina Associates, Boston
Professor of Ophthalmology Emeritus, Harvard Medical School
1. Sebag, M.D.
Director of Ophthalmic Research, UCI-AMI Diabetes Research Center
Assistant Clinical Professor of Ophthalmology, University of Califor
nia, Irvine
Rose Marie Smets, M.D.
Clinical Senior Scientist, Institute of Ophthalmology, and Chief,
Retina Unit, University Hospital, University of Antwerp Medical
School
David A. Swann, Ph.D.
Adjunct Senior Scientist, Eye Research Institute, Boston
Principal Associate in Surgery (Biochemistry), Harvard Medical
School
John V. Thomas, M.D.
Clinical Instructor in Ophthalmology, Harvard Medical School
Felipe I. Tolentino, M.D.
Clinical Associate Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Associate Clinical Professor of Ophthalmology, Harvard Medical
School
Clement L. Trempe, M.D.
Clinical Assistant Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Assistant Clinical Professor of Ophthalmology, Harvard Medical
School
John J. Weiter, M.D., Ph.D.
Associate Scientist, Eye Research Institute, Boston
Retina Associates, Boston
Assistant Clinical Professor of Ophthalmology, Harvard Medical
School
CHAPTER 1
HISTORICAL INTRODUCTION
R. M. SMETS and A. NEETENS
Outline
Development of examination techniques
Development of surgical approaches
The vitreous body, ominously called "vile jelly" by Shakespeare, has
been of therapeutic interest since ancient times. According to Eber's
papyrus (1400 BC), the Egyptians thought that the inner part ofthe eye
communicated by a canalicular system with the inner ear cavities and
the lacrimal cavity. They hoped to restore lost vision by replacing the
inner part of the eye with a lyophilized mixture injected into the inner
ear. Eber's papyrus states that the best mixture to replace the vitreous
was also a remedy for total blindness:
"extract of pig's eye humor 1 part,
genuine Galenos 1 part,
yellow ocre 1 part,
fermented honey 1 part."
Today, the vitreous is known to provide an optically clear medium, a
mechanical buffer, and a nutrient tissue. Additional physiological func
tions of the vitreous remain largely unknown, but vitreoretinal diseases
are of growing interest and are becoming better understood. About 50
years ago, the hereditary vitreoretinal diseases were considered un
important (1), and about 20 years ago, in a monograph on chorioretinal
heredo-degenerations (2, 3), it was concluded that "the fundamental
cause of retinal detachment is degeneration of the retina and of the
vitreous body."
Decompensation of the retinal pigment epithelium, Bruch's mem
brane, or the choriocapillaris, or of all these tissues, may be responsible
-6-
for many dystrophic changes, but the vitreous itself may be the primary
cause of a number of degenerative retinal diseases (4-6).
This introductory chapter is divided into two sections, development
of examination techniques, and development of surgical approaches.
Development of examination techniques
Better instruments and improved techniques of vitreous cavity ex
amination have broadened our understanding of the interaction be
tween vitreous and retina and advanced our knowledge of the patho
genesis of diseases affecting both structures. Progress in diagnostic
instrumentation has depended almost exclusively on research in optics
applied to the human eye. In fact, it is through optics that ophthalmo
logy was elevated to a scientific discipline (7). In 1850, Helmholtz (8)
invented the direct ophthalmoscope, allowing one to observe an
upright image of the posterior pole and midperiphery of the ocular
fundus. In 1852, Ruete designed the first indirect ophthalmoscope (9).
In 1861, Giraud-Teulon described the first binocular indirect ophthal
moscope (10), an instrument now long forgotten. In the first half of this
century, even monocular indirect ophthalmoscopy was not used in the
Anglo-Saxon countries where indirect ophthalmoscopy had been super
seded by the electrical direct hand ophthalmoscope. With the latter
instrument, under conditions of maximal pupillary dilation, the useful
field of observation did not extend beyond the midperiphery.
A modern indirect binocular ophthalmoscope was designed and con
structed by Schepens (11, 12). It provided the advantage ofleaving both
hands free because it was attached to an adjustable helmet. Another
important feature was its powerful illumination. With an appropriate
scleral depressor-a technique originally developed by Trantas (l3)-it
was possible to examine the entire fundus periphery, including the pars
plana ciliaris (14, 15). The scleral depressor was later improved (16).
Pomerantzeff optimized the indirect stereoscopic ophthalmoscope
for use with pupils of different sizes and for examination of the extreme
fundus periphery (17, 18). Later, he designed and built a wide-angle
ophthalmoscope (19).
The developments in ophthalmoscopy permitted physicians to look
for the cause of rhegmatogenous retinal detachment. In 1882 Leber
emphasized not only the primary role of retinal tears in retinal detach
ment but also the importance of the vitreous (20). Research in the cen
tury that followed showed the correctness of his views. Even before
