Pathogenesis of cystoid macular edema: An anatomic consideration of vitreoretinal adhesions

doi:10.1016/0039-6257(84)90231-5

Survey of Ophthalmology

Volume 28, Supplement 2, May 1984, Pages 493-498

https://doi.org/10.1016/0039-6257(84)90231-5 Get rights and content

Abstract

Although it had been widely accepted that vitreous traction plays a key role in the pathogenesis of aphakic cystoid macular edema, vitreoretinal traction is not observable in many patients and other hypotheses have also been investigated. The authors review the present knowledge of the anatomy of the vitreoretinal interface and the pathologic findings in cystoid macular edema. A new hypothesis combining the effects of both traction and inflammation is proposed.

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Correlation of collagen fibril properties and inner limiting membrane thickness with vitreoretinal adhesion in human eyes
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Citation Excerpt :
Collagen fibrils in the vitreous cortex have been shown to penetrate the inner limiting membrane of the retina at the vitreous base (Wang et al., 2003; Gloor and Daicker, 1975) and are thought to superficially intersect the retina at the macula in the posterior pole (Foos, 1975; Sebag and Balazs, 1984, 1989). Between these anterior–posterior regions, collagen is thought to run parallel and attach to the retina with a type of extracellular matrix ‘glue’ (Foos, 1972b; Sebag and Balazs, 1984; Matsumoto et al., 1984). Collagen fibril penetration in the posterior pole may explain the disrupted ILM found by the peel tests in Creveling et al. and fibers running parallel to the equator may explain the lack of ILM disruption in the equator.
Vitreoretinal adhesive strength is thought to play a mechanical role in various retinal diseases; however, collagen fibril properties and inner limiting membrane (ILM) thickness have not been quantitatively correlated to adhesive strength. In this work, we quantified the relationship between collagen fibril density, angle, length, and ILM thickness with vitreoretinal adhesive strength to advance our understanding of structure-function relationships in vitreoretinal adhesion. Following mechanical peel tests, human retinal sections from the equator and posterior pole of donors 42-89 years of age were extracted and processed for transmission electron microscopy. Collagen fibrils at the vitreoretinal interface were segmented and fibril density, angle, length, and ILM thickness quantified. Morphological measurements were correlated with vitreoretinal adhesion measured in the same location. We found that collagen fibril density was 1.6 times greater in the equator compared to the posterior pole across all ages ( $p = 0.0305$ ). Steady-state peel force showed a slight positive correlation with increasing density in both the equator and posterior pole, but was only statistically significant in the equator ( $p < 0.05$ ). Collagen fibril angle and length did not significantly vary with age or region. ILM thickness was 3.8 times thicker in the posterior pole compared to the equator ( $p < 0.0001$ ). ILM thickness was 1.8 times greater in eyes $\leq 60$ years of age compared to eyes $> 60$ of age ( $p = 0.0136$ ). Maximum peel force was significantly correlated with increasing ILM thickness in the equator ( $p = 0.015$ ). A similar trend was seen in the posterior pole, but this was not significant. These data suggest that collagen contributes to adhesion at the vitreoretinal interface, but the structure of the ILM is more influential on the initiation of separation between the vitreous and retina.
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A slow-release intravitreal implant of 0.7 mg Dexamethasone (DEX-I) (Ozurdex, Allergan, Dublin, Republic of Ireland) is a proven therapy for DME, improving Best Corrected Visual Acuity (BCVA) and reducing Central Foveal Thickness (CFT) for up to six months,2 although in some eyes the first signs of recurrence are found after three or four months.3–5 The vitreous body, together with the posterior hyaloid and the internal limiting membrane (ILM), may be involved in the pathogenesis of DME,6–8 and pars plana vitrectomy (PPV) may have a positive functional effect especially when macular traction is evident. Nevertheless, before the advent of intravitreal therapy, many case series reported positive effects of PPV also in eyes with non-tractional DME.9–12
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Vitrectomized eyes showed a significant extension of recurrence time of diabetic macular edema, and specifically from 3.4 (3.2–3.7) to 6.5 (5.7–8.2) months after the first injection, and to 7.0 (5.7–8.2) months (p < 0.01) after the second injection (p < 0.01).
Pars plana vitrectomy with internal limiting membrane peeling seems not to influence functional and anatomical results in eyes under treatment with dexamethasone intravitreal implant injections for diabetic macular edema, but appears to significantly extend the benefit of the drug.
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Two types of the PVL configurations with liquid parts located inside a circular cavity with Ro equal to 12.5 mm (the radius of human vitreous chamber) are illustrated in Fig. 1. These two configurations are selected based on previous researches and clinical observations which have shown that vitreous liquefaction usually originates from the central and the posterior portions of the vitreous (Eisner, 1975; Tolentino et al., 1975; Sebag and Balazs, 1984; Sebag, 1987; Kishi and Shimizu, 1990). As depicted, the PVL contains two regions: one liquefied vitreous assumed as a Newtonian fluid (purely viscous fluid), and the other vitreous gel with viscoelastic properties occupying the rest of the domain.
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The present numerical model is validated in the linear regime by comparing the results with those of the analytical solution for which excellent agreement is observed. The main objective of this study is to investigate the effects of various angular frequencies, amplitudes and volume fractions on the flow dynamics of partial vitreous liquefaction in a two-dimensional model of the vitreous chamber subjected to sinusoidal motions. Concentric and eccentric configurations of the liquefaction are considered with the initial circular shape inside a cavity. Numerical results are obtained for the velocity field, shear stress, normal stress difference and streamline pattern and it is discussed how the partial vitreous liquefaction responds to the different oscillatory movements in comparison with a normal, healthy vitreous gel. It is observed that in concentric cases, the maximum values of shear stress and tangential velocity intensify by increasing angular frequency and their locations move from the wall into the domain of the cavity. In eccentric configurations significant interface deformations are observed. Moreover, the results indicate that the shear and normal stress values in the eccentric cases are higher compared to those in the concentric configurations.

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Pathogenesis of cystoid macular edema: An anatomic consideration of vitreoretinal adhesions

Abstract

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Die Mikrostruktur und Chimie des Glaskorpers

The Vitreous. Int Ophthalmol Clin

Cystic macular edema secondary to vitreoretinal traction

Surv Ophthalmol

Biomicroscopy of the peripheral fundus

Surv Ophthalmol

Clinical examination of the vitreous

Trans Ophthalmol Soc UK