Vitreal Opacities
Vitreal opacities refer to any clouding, debris, or particulate matter within the vitreous humor, leading to visual disturbances such as floaters, blurriness, or shadows. These opacities can be due to various pathological or physiological causes affecting the vitreous body.
Causes
1. Age-related changes
- Posterior Vitreous Detachment (PVD) – Liquefaction of the vitreous leads to separation from the retina, causing floaters.
2. Inflammatory Conditions
- Uveitis (Intermediate or Posterior) – Inflammatory cells and proteins leak into the vitreous.
- Endophthalmitis – Bacterial or fungal infection leading to pus and inflammatory debris in the vitreous.
3. Hemorrhagic Causes
- Vitreous Hemorrhage – Bleeding into the vitreous from conditions like diabetic retinopathy, retinal vein occlusion, or trauma.
4. Infectious Causes
- Toxoplasmosis – Can cause vitritis with fluffy white lesions.
- Cytomegalovirus (CMV) Retinitis – Common in immunocompromised patients.
5. Degenerative and Depositional Disorders
- Asteroid Hyalosis – Calcium-phosphate deposits floating in the vitreous.
- Amyloidosis – Accumulation of amyloid fibrils in the vitreous.
6. Trauma and Surgical Causes
- Blunt or Penetrating Ocular Trauma – Can lead to vitreous hemorrhage.
- Intraocular Surgeries – Post-surgical inflammation or hemorrhage.
Diagnosis
1. Clinical Examination
- Visual Acuity Testing – Determines the impact of opacities on vision.
- Slit Lamp Biomicroscopy (With 90D Lens or Indirect Ophthalmoscopy) – Helps visualize vitreous opacities and their characteristics.
- Direct Ophthalmoscopy – To detect floaters, hemorrhages, or inflammatory cells.
2. Investigations
- Fundus Fluorescein Angiography (FFA) – For detecting vascular abnormalities causing hemorrhages.
- Optical Coherence Tomography (OCT) – Assesses vitreoretinal interface changes (e.g., PVD, traction, edema).
- B-scan Ultrasonography – Useful if the media is hazy due to hemorrhage or dense opacities.
- Blood Investigations – If systemic involvement is suspected (e.g., ESR, CRP, blood sugar for diabetes, toxoplasma serology).
Treatment & Management
1. Observation
If the opacity is minimal and does not affect vision significantly (e.g., benign floaters), reassurance is given.
2. Medical Treatment
Inflammatory Cases (Uveitis, Endophthalmitis):
- Corticosteroids (Prednisolone 1% eye drops, oral prednisolone in severe cases)
- Immunosuppressants (Methotrexate, Cyclosporine) in refractory cases
Antibiotics/Antivirals (If infectious):
- Bacterial Endophthalmitis → Intravitreal Vancomycin + Ceftazidime
- Fungal Endophthalmitis → Intravitreal Amphotericin B or Voriconazole
- Toxoplasmosis → Sulfadiazine + Pyrimethamine + Folinic Acid
Hemorrhagic Cases:
If due to diabetes or vascular causes, manage underlying condition:
- Anti-VEGF injections (Ranibizumab, Bevacizumab, Aflibercept) for diabetic retinopathy.
- Laser photocoagulation for retinal neovascularization.
Asteroid Hyalosis & Degenerative Causes:
- Usually do not require treatment unless vision is severely affected.
3. Surgical Treatment
- Pars Plana Vitrectomy (PPV)
Indicated in:
- Non-resolving vitreous hemorrhage (>3 months).
- Severe vitreous opacities affecting vision.
- Infectious endophthalmitis not responding to medical therapy.
- Laser Therapy (YAG Laser Vitreolysis)
- Used for large symptomatic floaters when vitrectomy is not an option.
Conclusion
Vitreal opacities have a broad differential diagnosis ranging from benign floaters to sight-threatening conditions like endophthalmitis. Management depends on the cause, ranging from simple observation to aggressive antimicrobial or surgical interventions.