Transcript Diapositiva 1 - ASCRS/ASOA 2008

Povisa
Hospital
Vigo,
Vigo Spain
Spain
UNIVERSIDAD DE VIGO
Bilateral vitreopapillary
traction syndrome after
cataract surgery
Monica Cid, MD
Jose Lorenzo, MD
Authors have no financial interest in any of the procedures or treatments mentioned
Povisa
Hospital
Vigo Spain
Purpose
To describe a case of
Vitreopapillary
traction syndrome
bilateral optic nerve
head elevation,
simulating optic disc
edema that presented
following uncomplicated
cataract surgery and
was felt to be caused by
vitreopapillary tractional
forces.
Povisa
Hospital
Vigo Spain
Vitreopapillary
traction
syndrome
Methods: Case Report
• 73 yo WM underwent uneventful faco +IOL
OS with a normal postop course
• 1 wk postop complained of seeing a floater.
Dilated fundus exam revealed a partial PVD,
rest was normal
• At 2 month routine postop visit the patient
was asymptomatic, happy with visual result.
• His BCVA was OD 20/25, and OS 20/20.
• SLE revealed bilateral pseudophakia, nl IOP
Povisa
Hospital
Methods: case report
Vigo Spain
•Fundus exam
revealed bilateral
Vitreopapillary
traction
syndrome
elevated optic
nerves, with no
hemorrhages or
vascular congestion.
OD had a partial
posterior vitreous
detachment, and an
epiretinal membrane
across the macula
•Pupil exam nl
Povisa
Hospital
Methods: Case Report
Vigo Spain
Vitreopapillary
traction
syndrome
•Past Medical History: medically
controlled HTN
•Past Ocular History: OD HSV queratitis
reolved with acyclovir ointment 1999
Uneventful cataract surgery (faco) OD
2005.
•Review of systems: Patient denied
headache, jaw claudication, or joint pain
Povisa
Hospital
RESULTS
Vigo Spain
Vitreopapillary
traction
syndrome
•Emergent head CT was normal
•Sed rate and C reactive protein were
normal
•VEP: consistent with bilateral severe
neuropathy
•Visual field: nonspecific nasal defects,
not altitudinal!
•B scan U/S: No ON drusen seen; +
vitreopapillary traction and ON elevation
Povisa
Povisa
Hospital Vigo
Hospital
Spain
Vigo1: Spain
Figure
OD
Red arrow:
Posterior hyaloid,
partial PVD
Yellow arrow:
adherence of
vitreous to papila,
causing traction on
optic nerve, and
elevation
Figure 2: OS
Red arrow:
Posterior hyaloid
with partial PVD
Yellow arrow:
Persistent adherence
of vitreous to papila
causing
vitreopapillary
traction, and ON
elevation
Bscan U/S on presentation
Figure 1
Figure 2
Povisa
Hospital
Vigo Spain
Vitreopapillary
traction
syndrome
Clinical Course: 2 months later
• Given the pt´s good VA we elected to observe.
• The optic nerve elevation nearly resolved in a 2
month period
• Patient maintained the same VA
• OD developed optic atrophy as evidenced by the ON
pallor
• A RAPD became apparent in OD
• Color vision was compromised in OD only
• Repeat PEV revealed a severe optic neuropathy in
OD and a mild optic neuropathy in OS
• VF: OD had a dense nasal and cecocentral defect.
OS had a small nasal defect.
• B scan U/S: OD had partial PVD with persistent
vitreous attachment to the optic nerve. OS had
complete PVD with relief of the papillary traction.
B scan 2 months later
Povisa
Hospital
Vigo Spain
Figure 1: OD
Red arrow:
partial PVD
Yellow arrow:
Persistent
adherence to
optic nerve
Figure 2: OS
Red arrow:
complete PVD
Yellow arrow:
relief of
vitreopapillary
traction
Figure 1
Figure 2
Povisa
Hospital
Optic nerves 2 months later
Vigo Spain
Vitreopapillary
traction
syndrome
OD pale.
OS good color, elevation
nearly resolved.
Povisa
Hospital
Vigo Spain
Vitreopapillary
traction
syndrome
Conclusion
It is documented that the vitreous undergoes changes after cataract
surgery at the molecular level 1. These changes seem to facilitate
the event of a PVD2. If a partial PVD occurs one can see
vitreomacular traction exerted and also, as already described,
vitreopapillary traction causing optic nerve head elevation3.Our
case is different to those previously reported in that our patient
was not diabetic so the ON elevation cannot be attributable to
DM papillopathy, and in that it was a bilateral case.
Vitrectomy for the release of the presumed epipapillary vitreous
traction has been proposed to treat the neuropathy associated
with a partial PVD in an interesting study by Modarres et. al.4 We
kept this in mind in our patient but did not intervene given his
good VA. It does however seem like a very reasonable
approach, and the clinical course of our patient suggests that this
was after all a NAION at least in part precipitated by
vitreopapillary traction due to a partial PVD. Our patient´s OS
evolved better than his OD thanks to a complete PVD in that eye
that relieved the traction on the ON.
Optic nerve head elevation after cataract surgery can occur due to a
partial posterior vitreous detachment with vitreopapillary
attachments causing traction and elevation of the optic nerve. We
should therefore keep this in the differential diagnosis of optic
nerve head elevation after cataract surgery.
Povisa
Hospital
Vigo Spain
Bibliography
1.Neal RE, Bettelheim FA, Lin C, et al. Alterations in human vitreous
humour following cataract extraction. Exp Eye Res 2005; 80: 337-47.
2. Ripandelli G, Coppé AM, Parisi V, et al. Posterior vitreous detachment
and retinal detachment after cataract surgery. Ophthalmology 2007; 114:
692-697.
Vitreopapillary
traction
syndrome
3.Wisotsky BJ, Magat-Gordon CB, Puklin JE. Vitreopapillary traction as a
cause of elevated optic nerve head. Am J Ophthalmol 1998; 126: 137-9.
4.Modarres M, Sanjari MS, Falavarjani KG. Vitrectomy and release of
presumed epipapillary vitreous traction for treatment of nonarteritic anterior
ischemic optic neuropathy associated with partial posterior vitreous
detachment. Ophthalmology 2007; 114: 340-344.
5. Katz B, Hoyt WF. Intrapapillary and peripapillary hemorrhage in young
patients with incomplete posterior vitreous detachment. Ophthalmology
1995; 102: 349-354.
6. Cabrera S, Katz A, Margalit E. Vitreopapillary traction: cost-effective
diagnosis by optical coherence tomography. Can J Ophthalmol 2006;
41:763-5.