Vitreoretinal Diseases

Sumit Sharma, Rishi P. Singh, Modified with permission from: Sharma S, Ventura ACM, Waheed N. Vitreoretinal disorders. Ultrasound
Clin 2008; 3(2):217–228.

Video material online 

Introduction

Vitreoretinal diseases are the most common indication for ultrasonographic

imaging of the posterior segment. Although most conditions of the posterior
segment can be directly viewed, in situations where there is media opacity, for
example due to vitreous hemorrhage, echography allows for evaluation of the
vitreous, retina, and choroid that would otherwise be impossible. 1,2 Using
ultrasonography it is possible to identify, evaluate, and follow up a large number of
posterior segment conditions such as retinal tears, 3,4 vitreous and retinal
detachments,5–8 retinoschisis,9 retinal pigment epithelium (RPE)
detachment,10 subretinal hemorrhage,11 and eccentric disciform lesions.12
Methods of ultrasonographic evaluation of the posterior segment are described
elsewhere (Chapter 3). It is imperative to conduct a thorough examination of all the
quadrants to avoid missing any pathology, and to evaluate the vitreous body,
posterior hyaloid, subvitreal space, retina, choroid, sclera, optic disc, and macular
region.

Vitreous

Vitreous hemorrhage
The vitreous is an avascular structure. Vitreous hemorrhage (VH) occurs by the
extravasation of blood into the space limited anteriorly by the posterior lens
capsule, posteriorly by the internal limiting membrane and laterally by the ciliary
body and lens zonular fibers. VH can be caused by bleeding from normal, diseased
or abnormal new retinal vessels, traumatic insult or extension of hemorrhage from
any other source. The incidence of VH in the general population is seven cases per
100 000 per year.13 The most common causes of VH vary based on the population
studied, with the two most common causes being posterior vitreous detachment
(PVD) with or without retinal tear and proliferative diabetic retinopathy, followed
by ocular trauma and neovascularization secondary to retinal vein occlusion.14–17
Dynamic A- and B-scan ultrasonographic examinations should be performed
to rule out retinal tears, detachment, or other intraocular pathology as the source of
vitreous hemorrhage.  See Clip 10.1 A fresh vitreous hemorrhage appears as
diffuse opacities of low to medium reflectivity on B-scan, with multiple low
intensity spikes on A-scan (Figure 10.1A). 18 As the blood organizes, it forms
pseudomembranous surfaces on B-scan, corresponding to slightly higher intensity
spikes on A-scan (Figure 10.1B). Signal intensity on both A- and B-scan directly
correlates with the density of the hemorrhage (Figure 10.1C). Layering of blood
inferiorly results in very high reflectivity on B-scan and in a static exam may be
mistaken for a retinal detachment (RD) (Figure 10.1D).  See Clip 10.2 In a
vitrectomized eye, blood can remain in a liquefied state and often requires the use
of high gain settings to visualize the hemorrhage (Figure 10.1E and F).
 

 
  

Figure 10.1 Fresh vitreous hemorrhage (A). Longitudinal B-scan view showing

diffuse low to medium reflective opacities in the vitreous cavity (arrowheads).
Organized vitreous hemorrhage (B). Note pseudomembranous surfaces
(arrowhead) within the vitreous cavity representing the organization of blood.
Moderately dense vitreous hemorrhage (C, VH – subhyaloid hemorrhage, ON –
optic nerve). Layered vitreous hemorrhage mimics retinal detachment (D,
arrowheads). Vitreous hemorrhage in a vitrectomized eye (E, high gain,
arrowheads – vitreous skirt). Same patient on low gain (F). The vitreous
hemorrhage is not visible as it does not organize in a vitrectomized eye. Note
discontinuities in the vitreous skirt (arrowheads).
Reproduced with permission from: Sharma S, Ventura ACM, Waheed N.
Vitreoretinal Disorders. Ultrasound Clin 2008; 3(2):217–228.
If PVD is absent, a retinal tear or rhegmatogenous retinal detachment (RD) is
unlikely and therefore, other causes of the VH must be explored. If a PVD is
present and RD is not observed, PVD is most likely not the cause of the VH.
However, a small anterior retinal detachment may not be detected by an
inexperienced ultrasonographer.19 In addition, presence of a PVD does not
exclude other causes of the VH since the PVD may have been present prior to the
VH.

Posterior vitreous detachment

Posterior vitreous detachment is a common degenerative process of the vitreous in
which the vitreous gel loses its attachment to the internal limiting membrane. The
causative factor for PVD can vary, but is most commonly senile degeneration of
the vitreous gel. The vitreous is very strongly attached (vitreous base) in a band
extending 360° around the anterior limits of the retina (ora serrata) and only
weakly adherent to the macula and optic disc; thus the site of detachment is usually
located in the posterior pole.20 In nearly half of patients the PVD is incomplete
and some portions of the vitreous remain attached to and can exert traction on the
retina.21 Retinal tears often occur just posterior to the vitreous base, due to traction
placed on the retina as the vitreous pulls away from the retina.
Clinically, vitreous detachment can be diagnosed by biomicroscopy and
observance of the posterior vitreous face. In many cases a Weiss ring, a partial or
complete grayish-brown, mobile ring indicative of PVD can be seen on fundus
examination.
Ultrasonographically, PVD appears as a thin, smooth membrane that may
retain its attachment to the retina at the site of retinal tears, areas of
neovascularization, optic disc, and/or at the vitreous base. A PVD can mimic a RD
on ultrasonography when the posterior hyaloid remains attached to the optic disc;
however, there are specific clues that can be used to differentiate these two entities
(Figure 10.2A, Table 10.1). A PVD demonstrates significant movement and after
movement on dynamic B-scan.  See Clip 10.3 In cases of inflammation and
trauma, the PVD may be much less mobile. In this situation, it is usually possible
to differentiate PVD from a RD based on the reflectivity profiles of the tissues. In
the absence of dense vitreous hemorrhage, a PVD appears as a low to medium
reflective membrane on both A and B-scan, while a retinal detachment is always
highly reflective. A PVD is visible only at high gain settings whereas the retina is
visible at low and high gain settings (Figure 10.2B, C). Layering of blood along
the surface of a PVD may result in a thickened appearance on B-scan and very
high reflectivity on A-scan (Figure 10.2D). Therefore, to differentiate a
hemorrhagic PVD from a RD, it is necessary to examine different portions of the
membrane for a decrease in reflectivity suggestive of a vitreous membrane.
Posteriorly, both the retina and vitreous membranes can appear as highly reflective
structures. Anteriorly, however, the retina is much more highly reflective than
vitreous membranes.22 In patients with vitreous hemorrhage secondary to
proliferative vitreoretinopathy (PVR), localization of focal traction on the retina
can be the differential diagnostic indicator.

 
  

Figure 10.2 PVD adherent to the optic disc (A, arrowhead). PVD high gain (B,
90 dB) and low gain (C, 39 dB). As the gain is reduced, the PVD (arrowheads)
disappear in contrast to the retina (arrow), which remains visible even at low gain
settings. Thickened PVD. B-scan axial view (D, arrowheads). Note lack of
attachment at the optic nerve.
Reproduced with permission from: Sharma S, Ventura ACM, Waheed N.
Vitreoretinal Disorders. Ultrasound Clin 2008; 3(2):217–228.
Table 10.1 Ultrasonographic differentiating features between posterior vitreous
detachment and retinal detachment.

Feature Posterior vitreous detachment Retinal detachment

Echogenicity Low–medium echogenicity High echogenicity

 Change with gain (dB) Disappears with low gain Visible with low gain

Mobility High mobility Low mobility

Optic disc attachment Present or absent Always present

Asteroid hyalosis
Asteroid hyalosis (AH) is an uncommon, predominantly unilateral, condition that
rises in prevalence with age, although a link to systemic diseases has been
suggested.23–25 Clinically, it appears as multiple small spheres scattered
throughout the vitreous consisting of condensations of calcium and phospholipid.
Most patients with AH are asymptomatic. On A-scan, asteroid hyalosis appears as
medium to highly reflective spikes that move with the vitreous. There have been a
few reports of falsely shortened axial length measurements on A-scan in eyes with
AH, but the majority of eyes will show no change in axial length measurement due
to AH.26–28 On B-scan, the asteroid bodies appear as both diffuse and focal point-
like highly reflective sources with an area of clear vitreous between the posterior
border of the asteroid bodies and the retina (Figure 10.3).
  

Figure 10.3 Asteroid hyalosis. On B-scan, the asteroid bodies appear as diffuse

and focal point-like highly reflective sources with an area of clear vitreous between
the posterior border of the asteroid bodies and the retina. The asteroid hyalosis may
partially (A) or completely involve the vitreous cavity (B).

Retinal detachment

Retinal detachments occur when the neurosensory retina separates from the
underlying retinal pigment epithelium. Retinal detachments are divided into four
main types: rhegmatogenous, tractional, exudative (serous), and combined
tractional/rhegmatogenous retinal detachment.29

Rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment is the most common type of detachment and
is characterized by the presence of a full-thickness retinal tear. There are three
prerequisites for the development of rhegmatogenous retinal detachment:
liquefaction of the vitreous gel, tractional forces to produce a retinal tear, and a
retinal tear that allows fluid access from the liquefied vitreous into the subretinal
space.29,30 The annual incidence of rhegmatogenous retinal detachments in the
general population of the United States is about 12 cases per 100 000 people
(0.01% annual risk). There are about 36 000 cases annually, with anatomic surgical
success rates up to 95%.31–33 The major risk factors are high myopia, trauma,
cataract surgery, ocular infections, lattice degeneration, and glaucoma.
In the setting of media opacity such as a vitreous hemorrhage, differentiating a
PVD from a retinal detachment can sometimes be challenging (Table 10.1). Retinal
detachments can present with variable mobility, but will always be less mobile
than vitreous membranes.34 Retinal detachments are highly reflective with a
thickened, rope-like appearance and always have optic disc attachment, while a
PVD can retain attachment to the optic disc or be completely detached (Figure
10.4A). On A-scan, the retina demonstrates close to 100% reflectivity (Figure
10.4B).

Figure 10.4 Total open funnel RD. B-scan at low gain (49 dB) shows open funnel
configuration and optic disc attachment (A). A-scan shows 100% peak
corresponding to the RD (B, S – sclera, V – vitreous, R – retina).
Reproduced with permission from: Sharma S, Ventura ACM, Waheed N.
Vitreoretinal Disorders. Ultrasound Clin 2008; 3(2):217–228.

Tractional retinal detachment

Tractional retinal detachments (TRD) are the second most common type of retinal
detachment.32 TRDs can occur due to PVR, penetrating trauma, retinopathy of
prematurity, and severe diabetic retinopathy. TRDs occur due to vitreoretinal
adhesions that cause mechanical separation of the retina from the underlying RPE
causing a retinal detachment. The detachment has a tent-like configuration that
does not extend to the ora serrata. On B-scan TRDs demonstrate reduced mobility
compared to rhegmatogenous retinal detachments due to the traction placed on the
retina (Figure 10.5).  See Clip 10.435

Figure 10.5 Tractional retinal detachment. B-scan shows a thin posterior vitreous

detachment (arrows) adherent to tent-like tractional retinal detachment
(arrowheads).
Reproduced with permission from: Sharma S, Ventura ACM, Waheed N.
Vitreoretinal Disorders. Ultrasound Clin 2008; 3(2):217–228.