|Year : 1953 | Volume
| Issue : 4 | Page : 110-112
Spontaneous vitreous detachment
|Date of Web Publication||12-May-2008|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lindner K. Spontaneous vitreous detachment. Indian J Ophthalmol 1953;1:110-2
In connection with detachment of the retina and Gonin's explanation of its origin the examination of the vitreous body became more and more important. However in former times we had no practical way to examine the vitreous. The use of the contact lens of Koeppe together with his silver mirror was a very difficult procedure and could not be done as a routine examination. Even with the angular microscope, which facilitated these examinations, we encountered difficulties from the side of the patients. We cannot put a contact lens into the eye of a nervous patient or of a child or of a freshly operated person. It was only after Hruby had devised his lens which has to be put in front of the patient's eye without touching it that the examination of the vitreous has become a routine procedure.
| Technique of Using the Hruby Lens|| |
At this point it would be necessary to state a few points regarding the technique of the examination of vitreous and fundus by the slit lamp. The Hruby lens must be brought quite near to the eye of the patient. This is possible on the slit-lamp of Haag-Streit. If the type of slit-lamp does not allow this as for instance in the instrument made by Zeiss, the Hruby lens should be put in a trial frame and arranged properly so that it comes as near to the eye as possible. Especially in cases with deep sunken eyes this point is of particular importance. The Zeiss slit-lamp which is superior for examination of the macula to the slitlamp of Haag-Streit should have a fixation of the Hruby lens similar to that of Haag-Streit.
Previous to this, with the angular microscope and contact lens we had realized that vitreous detachments are very common. First we were afraid that all these cases later on may turn into retinal detachments. We soon learned that this danger did not exist. In many cases of simple myopia the vitreous detaches with age and the higher the myopia the sooner the vitreous may detach (Rieger) first from above or from behind keeping its round shape or nearly so. [Figure - 1],a. Soon the detached vitreous loses its shape and breaks down into what we call collapse of vitreous ( Hruby ) and this is the most common form of vitreous detachment we encounter. [Figure - 2],a. This condition remains without any marked change for a long period. Exceptionally we find the posterior surface of the detached vitreous quite stretched. More often the detached and collapsed vitreous becomes more and more liquefied and loses the structure we are accustomed to see with the slit-lamp.
Besides these detachments in uninjured eyes we soon found out that the vitreous in nearly all cases of perforating injuries detaches, especially so in young people. In this paper we shall deal with spontaneous vitreous detachment only.
| Symptomatology|| |
These patients complain of very annoying spark figures or spots moving in front of their eyes. They describe the onset of these opacities mostly as a sudden one and educated people are especially frightened by these shadows. If we examine such a case by the slit-lamp we find a fresh vitreous detachment. [Figure - 1]a . A trained oculist may see the posterior surface of the detached vitreous often with his ophthalmoscope.
Besides the shadows many patients observe sensations of light, especially when the patient suddenly moves his eyes or covers them. The detached vitreous pulls on its adherence to the retina which causes for a moment a sensation of light, a " lightening ". The patient sees half circles or even total circles. This sensation of circles of light is not a dangerous symptom. Dangerous symptoms are isolated sparks of light which prove that the detached vitreous pulls on a single isolated spot of the retina which could be followed by a rupture of the retina. [Figure - 3] . Circles of light are caused by the pulling of the detached vitreous along the line where it is still adherent to the retina. The pull therefore is distributed along this line and does not act concentrated on one single spot.
With the passage of time the sensations of light may happen less often or may disappear. A very anxious lady I had operated for retinal detachment of her only eye recorded her " lightenings " during the 7 months following the operation. In the first month she had a daily average of 59 moments of light sensation. In the seventh month there were on an average 29 lightenings a day. Then she stopped to take notice of her sensations because recurrence of a cured detachment happens practically only during the first half year after operation. She remained cured.
When a patient after years of sensations of light does not perceive them any more at all this would prove that the vitreous has detached far in front and may pull now on the blind periphery of the retina, or the vitreous may have been liquefied. In the former case the danger of retinal detachment increases. As long as the patient sees circles of light the danger of a retinal rupture is very little because the seeing part of the retina is more resistant against a rupture than the blind degenerated peripheral area.
To resume all these observations; vitreous detachments are frequently observed in uninjured eyes especially in older myopic persons. Only a very small number of these cases will later suffer from a retinal detachment.
What could have happened if a patient complains of a sudden appearance of many black spots like soot'? Some may say that they see a rain of black spots. In such cases the detached vitreous has caused a rupture of the retina involving a break of one of the blood vessels. Occasionally we can see with the slit-lamp dots of blood on the posterior surface of the detached vitreous because the blood spreads out behind the detached vitreous. [Figure - 4]. A retinal rupture may not be a perforating one or by chance the retina is sealed, around the rupture to the choroid. Then no detachment occurs in either case. However as we cannot know this we advise the patient at once the use of a pinhole spectacle for at least 2 to 3 weeks and keep him under strict observation. Cases have been observed in which you could see the typical ruptured retinal flaphole without occurrence of a retinal detachment. Formerly these cases were used as a proof against Gonin's theory. They prove on the contrary that some force must have acted from inside to rupture a retina adherent to the choroid. When you discover a ruptured retina without detachment of the retina a prophylactic operation would be indicated. However in such a case only superficial coagulations around the hole should be performed without any perforation. A perforating coagulation could start a contraction of the vitreous and cause a true retinal detachment where it did not exist before. I know of such a case operated prophylactically by a colleague.
| Treatment of Vitreous Opacities|| |
Can we treat vitreous opacities with some result? Opacities caused by a haemorrhage will be absorbed and the absorption can be hastened by dionin drops or by subconjunctival hypertonic saline injections. However those opacities belonging to the posterior vitreous membrane will not disappear but the patient may no longer be aware of them. After a certain time the vitreous body breaks down---vitreous detachment with collapse. By this the posterior vitreous membrane will move further away from the retina and move downwards. Then the patient does not see the opacities as distinctly as before or they may disappear completely, and may be interpreted as an improvement. If any treatment has been given in such cases it appears to have been beneficial_ If the patient did not wear glasses uptil now and we correct him by proper spectacles then he will be bothered much less by these opacities because he sees now objects distinctly and the opacities less distinctly.
The causes of vitreous detachments in uninjured eyes are not known. Possibly some kind of inflammation of the retina induces this change of vitreous or senile changes cause the vitreous to shrink. We have seen so many cases of vitreous detachment in uninjured eyes without any visible change in the fundus. Vitreous detachment goes along with several fundus diseases for instance in pigment degeneration of the retina, in recurrent hemorrhages with scar tissue formation. Hemorrhages and scar tissue then lie behind the detached vitreous. Furthermore it occurs in many cases of retinochoroiditis.
| Summary|| |
A very practical interpretation of the symptomatology of vitreous detachment and its course is given.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]