IMAGINGIMAGING THE VITREOUS
AND VITREOMACULAR
INTERFACE
Case presentations demonstrate the utility of 3-D SD-OCT in examining in vivo detailsof the vitreous structure.
BY MANISH NAGPAL, MS, DO, FRCS(Edin), and SHISHIR SHEKHAR SINGH, MS

Detailed biomicroscopic
examination of the posterior
vitreous gel can be severelycompromised by bright, diffuse
light reflected from the fundus
and the low optical density ofvitreous structures. Even therenowned biomicroscopist
Vogt stated that, in his view, clinical observations in the posterior part of the vitreous are ‘‘illusory rather than real.’’1
As we age, biochemical and structural changes occur in the
corpus vitreous, leading to posterior vitreous detachment(PVD).2 Although generally benign, PVD can contribute tosignificant retinal morbidities, such as vitreomacular traction(VMT) syndrome, macular hole, epiretinal membrane (ERM),
and retinal tears. Furthermore, the status of the vitreous plays
a crucial role in the natural course of preexisting local andsystemic conditions (eg, uveitis and diabetes), significantly
affecting their prognosis and management.3-8
Although ultrasound has been considered the standard
imaging technique to detect and document vitreous
detachment, the higher resolution of optical coherence
tomography (OCT) offers advantages when studying any
intermediate step of this process.9-11 Time-domain OCT(TD-OCT) studies have illustrated the posterior hyaloid
and its adhesions to the retinal surface in VMT syndrome
and related diseases.12-15
Spectral-domain OCT (SD-OCT) technology allows
better visualization of the hyaloid and a more detailed
image of its structure than TD-OCT. SD-OCT provides a
dramatic increase of imaging speed, 50 times faster thanstandard-resolution OCT. A dense raster pattern withmultiple consecutive B scans taken at high speed allows comprehensive retinal coverage. It is possible to acquire complete
3-D data in a time comparable with that of standard OCT
protocols that acquire only several individual images.16 The
44 RETINA TODAY | MARCH 2016

AT A GLANCE• The status of the vitreous plays an importantrole in the natural course of local and systemic
posterior segment conditions and can thus affecttheir prognosis and management.
• 3-D SD-OCT allows systematic study of thevitreous and vitreoretinal interface and can help
the clinician to detect partial and total PVDs.
• Fine details that show how the retinal surface
interacts with and is affected by the vitreous bodycan be visualized with 3-D SD-OCT.

coupling of SD-OCT technology with 3-D imaging allows
precise focusing from deep retinal planes to the mid-vitreous
cavity. A 3-D volume of data can be viewed and rotated about
three axes. Wanting to capitalize on these advantages, we
explored the use of 3-D imaging in SD-OCT to image the vitreous architecture and the vitreomacular interface.
3-D VIEWING IN PRACTICE
Following is an observational case series of patients who
presented at our practice. All patients were scanned using the
RS-3000 Advance (Nidek). Our goal was to visualize in vivo
details of the vitreous structure during the aging process, including various vitreous and vitreomacular interface pathologies.
Case No. 1
A 55-year-old known diabetic and hypertensive woman
presented with decreased visual acuity in her right eye(OD) lasting 6 months. Her BCVA was 6/36 OD with earlyCase No. 2
A 71-year-old diabetic man, pseudophakic in eacheye (OU), presented with diminished visual acuity in his
left eye (OS) lasting 2 to 3 years. His BCVA was 6/9 OS.
Fundus examination OS showed an ERM, and SD-OCT
A

A

B

B

C
C

D

D

Figure 1. Fundus photograph OD shows asteroid hyalosis,
hard exudates, and edema at macula, neovascularization ofdisc with retinal hemorrhage, neovascularization elsewhere,
and areas of preretinal hemorrhage (A). Altered foveal contourwith ERM, cystoid spaces, and hard exudates are shownwith SD-OCT scan (B). Pseudocolor (C) and grayscale (D) 3-D
reconstructions of SD-OCT scans show hyperreflective spots
in vitreous with shadowing posterior to it, suggestive of
asteroid hyalosis.

Figure 2. Altered foveal reflex OS with a yellow dot is seen
with ERM on fundus photograph (A). SD-OCT scan shows lost
foveal contour, focal attachments of taut posterior hyaloid
over macula, ERM, corrugations of inner retinal layers, andsubfoveal scarring (B). Pseudocolor (C) and grayscale (D) 3-D
reconstructions of SD-OCT scans show the attachments of the
thickened posterior hyaloid over the site of thick ERM, theconfiguration of the ERM at the vitreomacular interface, and theplane of detachment of posterior hyaloid at certain places overthe posterior pole. The two planes of VMT and ERM can be wellvisualized in the 3-D reconstruction of SD-OCT.

MARCH 2016 | RETINA TODAY 45

IMAGING

cataractous changes. Fundus examination revealed asteroid hyalosis with proliferative diabetic retinopathy (PDR) and clinicallysignificant macular edema (CSME) OD (Figure 1). Examination
with SD-OCT showed asteroid hyalosis, altered foveal contourwith ERM, cystoid spaces, and hard exudates OD.

IMAGING

examination OS showed lost foveal contour with VMTand ERM. Vitrectomy was advised for treatment of
VMT and ERM removal with dexamethasone intravitreal implant 0.7 mg (Ozurdex, Allergan), but the patient
declined treatment. He presented 19 months later witha BCVA of 6/12 OS. Fundus examination OS showedaltered foveal reflex OS and a yellow dot with ERM.
A

SD-OCT examination OS showed lost foveal contour,
focal attachments of taut posterior hyaloid over themacula, ERM, corrugations of inner retinal layers, andsubfoveal scarring (Figure 2).
Case No. 3
A 70-year-old woman with pseudophakia OS presented
with reduced visual acuity OS lasting 3 months. Fundus
examination showed altered foveal reflex with VMT, ERM,
and optic atrophy OS. SD-OCT examination OS revealed
altered foveal contour with a thickened hyaloid causing
traction on the macula (VMT syndrome; Figure 3).
Case No. 4
A 19-year-old man with chronic pars planitis OU
presented with complaints of floaters OD. Fundus
A

B

C

C

D

Figure 3. Fundus photograph OS shows altered fovealreflex with VMT and ERM and optic atrophy (A). Altered
foveal contour with VMT syndrome is seen on SD-OCT (B).
Pseudocolor (C) and grayscale (D) 3-D reconstructions of
SD-OCT scans show the configuration of VMT caused by traction
at fovea by the posterior hyaloid, leading to an impending
operculum formation from the inner retinal layers at fovea.

46 RETINA TODAY | MARCH 2016

B

D

E

Figure 4. Fundus photograph OD shows snowballs andareas of exudation (A, B). SD-OCT scan shows punctate
hyperreflective spots in the vitreous suggestive ofvitreous cells and the presence of active pars planitis (C).
Pseudocolor (D) and grayscale (E) 3-D reconstructions of
SD-OCT scans show multiple punctate hyperreflective spots
in the vitreous cavity suggestive of vitreous cells.

Case No. 5
A 69-year-old man, pseudophakic OU, complained ofmetamorphopsia OD lasting 7 to 8 days. His BCVA was
6/12 OD. Fundus examination showed a macular hole
OD. SD-OCT examination showed a full thickness macular hole with an operculum OD (Figure 6). The patientunderwent 25-gauge vitrectomy with intravitreal gas
injection OD. At follow-up 1 month later, his BCVA was
6/12 OD. SD-OCT at this visit showed normalization of
the foveal contour (Figure 7). Additionally, the macularhole had closed.

DISCUSSION
To date, in vivo imaging of the vitreous body has beendifficult because of its transparency and movement, but
the assessment of vitreoretinal separation is importantin many diseases. Tractional forces play major roles inthe development of retinal tears and detachments, and
it is likely that a complete PVD reduces the risk of retinal
detachment in patients with symptomatic floaters after
the acute onset of symptoms.17
Some studies also suggest that knowledge of vitreous
anatomic features may influence surgical approach andoutcome in diseases such as macular hole.18,19 The identification of vitreomacular adhesions in partial vitreous
detachment can be useful in the management of diabetic
macular edema and VMT.20-22 Unfortunately, vitreous
status can be difficult to determine clinically. Although
the detection of Weiss ring on biomicroscopy is believedto indicate a complete PVD, it may be difficult to precisely
determine the completeness of vitreoretinal detachment
or attachment using clinical observation alone.
A

B

C

D

A

B

C

Figure 5. SD-OCT scan shows normal foveal contour 5 months
after treatment (A). Pseudocolor (B) and grayscale (C) 3-D
reconstructions of SD-OCT scans show disappearance of thepunctate hyperreflective spots in the vitreous, suggestiveof resolution of activity of pars planitis.

Figure 6. Fundus photograph OD shows an altered fovealreflex, suggesting a macular hole (A). SD-OCT scan showsa stage 2 full thickness macular hole. The posterior hyaloid
is still attached to the operculum, which is only partiallydetached from the hole edge (detachment is not visible
in this scan). The cystoid space along the edges of the fullthickness macular hole are also shown (B). Pseudocolor (C)and grayscale (D) 3-D reconstruction of SD-OCT scans show
the posterior hyaloid attached to the operculum of the fullthickness macular hole. The elevation of the full thickness
macular hole’s edges can also be made out, as can the planeof the detached portion of the posterior hyaloid.

MARCH 2016 | RETINA TODAY 47

IMAGINGexamination indicated vitritis OD, and SD-OCT examination revealed punctate hyperreflective spots in thevitreous suggestive of vitreous cells, which would indicate
active pars planitis (Figure 4). Because the patient was aknown steroid responder, he was started on an oral steroid on a tapering course, immunosuppressive therapy
with azathioprine, and anti-Koch treatment. The oral
steroid was gradually tapered, but the azathioprine wascontinued. When the patient returned 5 months later,
SD-OCT showed a normal foveal contour with disappearance of vitreous cells (Figure 5).

IMAGING

Ultrasound is the traditional imaging technique fordynamic study of the posterior hyaloid, and it has been usedin clinical trials to monitor PVD induced by pharmacologic
agents.23 It has a lower depth and horizontal resolution
than SD-OCT.24 We used 3-D imaging with SD-OCT in thepatient case series described above to image the vitreousarchitecture and the vitreomacular interface. This modality
enabled visualization of details of the vitreoretinal interface
and vitreous body not discernible clinically or on B-scan OCT
images. On the retinal surface, these details included areas ofincomplete PVD, focal vitreoretinal adhesion and traction,
vitreous remnants on the foveal surface of eyes with complete PVD, and attachment of posterior hyaloid to operculaof full thickness macular holes. In the vitreous cavity, thesedetails included distinction between vitreous opacities suchas asteroid hyalosis, vitreous cells, vitreous degeneration, andvitreous hemorrhage. Use of 3-D imaging in SD-OCT canhelp to objectively assess the reduction of vitritis following
treatment in inflammatory pathologies involving the vitreous.
Other SD-OCT studies have also used 3-D reconstruction of
the retina to analyze the vitreoretinal interface.25,26
CONCLUSION
Reconstruction of 3-D volumes using SD-OCT imaging
allows systematic study of the vitreous and vitreoretinal
interface and can help clinicians to detect partial and total
PVDs. It can also enable the visualization of fine details
A

B

C

D

that show how the retinal surface interacts with and isaffected by the vitreous body. Furthermore, information
regarding hyaloid cleavage planes can be obtained fromthis imaging modality in pathologies of the vitreomacular interface, facilitating clinical and surgical decisions.
Objective assessment of different causes of vitreous
opacities is also possible using 3-D imaging in SD-OCT. n
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Manish Nagpal, MS, DO, FRCS(Edin)vitreoretinal consultant at the Retina Foundation in Ahmedabad,
Gujarat, Indian financial interest: consultant for Nidekn drmanishnagpal@yahoo.com
nFigure 7. One month post vitrectomy with intravitreal gas
injection. Fundus photograph OD shows fairly normal fovealreflex (A). Normalized foveal contour is seen on SD-OCT scan (B).
Pseudocolor (C) and grayscale (D) 3-D reconstruction of
SD-OCT scans show disappearance of the attached posterior
hyaloid and subsidence of the elevated edges of the fullthickness macular hole.

48 RETINA TODAY | MARCH 2016

Shishir Shekhar Singh, MSsecond-year vitreoretinal fellow at the Retina Foundation in
Ahmedabad, Gujarat, Indian financial interest: none acknowledgedn