- Email: [email protected]
Peripapillary vitreoretinal traction
Optometry (2011) 82, 602-606
Peripapillary vitreoretinal traction Angeline Hixson, O.D., and Sherrol Reynolds, O.D. Nova Southeastern University College of Optometry, Davie, Florida.
KEYWORDS Vitreoretinal traction; Peripapillary; Optic nerve head elevation; Posterior vitreous detachment; Pseudopapilledema
Abstract BACKGROUND: Vitreoretinal traction syndrome may occur in patients with incomplete posterior vitreous detachment. Although vitreoretinal traction of the macula is well-documented in the literature, the manifestations of peripapillary vitreoretinal traction are rarely discussed. CASE REPORT: A 62-year-old black woman presented for a comprehensive examination. She reported having uncontrolled diabetes and hypertension. Best-corrected visual acuities were 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Dilated examination found a flame-shaped hemorrhage OD. The optic nerve margins OS were blurred, with the margins appearing elevated with peripapillary intraretinal hemorrhages. Cirrus spectral domain optical coherence tomography (OCT) found the presence of peripapillary vitreoretinal traction with concurrent vitreomacular traction OS. CONCLUSION: Although the effects of vitreoretinal traction are most commonly associated with the macula or peripheral retina, residual attachment can occur at the optic nerve head. Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from sight- or health-threatening etiologies. OCT is a valuable diagnostic tool in confirming peripapillary vitreoretinal traction. Optometry 2011;82:602-606
Peripapillary vitreoretinal traction is a phenomenon associated with the development of a posterior vitreous detachment (PVD), a normal aging process during which the vitreous gradually separates from the retina. The development of a PVD is believed to be preceded by liquefaction of the vitreous gel, followed by separation of the posterior hyaloid membrane from the retinal surface. A study by Uchino et al.1 defined the individual stages of PVD development (see Table 1). Utilizing optical coherence tomography (OCT; Carl Zeiss Meditec, Dublin, California) on 209 healthy eyes, they were able to demonstrate that PVD initially results in a focal detachment in the perifoveal retina with persistent adhesion to the fovea, optic Disclosure: The author has no financial or other relationships that might lead to a conflict of interest. * Corresponding author: Angeline Hixson, O.D., Nova Southeastern University College of Optometry, 3200 S. University Drive, Davie, FL 33328. E-mail: [email protected]
nerve, and midperipheral retina. The PVD slowly evolves over time to the advanced stages with release of vitreopapillary adhesion, typically resulting in a Weiss ring over the optic nerve. The vitreous is strongly attached to the optic nerve head, and this attachment has been described as the last area of separation in the gradual process of posterior vitreous detachment.1-4 In some patients, the PVD process is incomplete and can induce a number of complications at various areas of the vitreoretinal interface. Residual attachment at the optic disc, associated with PVD stages 1 through 3, can lead to a condition known as peripapillary vitreoretinal traction syndrome.1,5,6 Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from pathologic causes of optic nerve edema. OCTevaluation is an important diagnostic tool in showing vitreous traction on the optic nerve head.7 The clinical picture of vitreopapillary traction may be associated with hemorrhages, gaze-evoked amaurosis, and
1529-1839/$ - see front matter Ó 2011 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2011.02.018
Hixson and Reynolds
Clinical Care
Table 1 Stages of posterior vitreous detachment as determined by Uchino et al.1 Stage 0
Absence of PVD
Stage 1
Focal perifoveal PVDdincomplete PVD localized in the perifovea, with persistent attachment to the fovea, optic nerve head, and midperipheral retina Perifoveal PVD across all quadrants of the retina with persistent attachment to the fovea, optic nerve head, and midperipheral retina Detachment of the posterior vitreous face from the fovea, with persistent attachment to the optic nerve head and midperipheral retina Complete PVD with presence of a Weiss ring
Stage 2
Stage 3
Stage 4
maculopathies. The hemorrhages may be intrapapillary or subretinal peripapillary, but are benign and self-resolving.8-11 Additionally, patients with peripapillary vitreoretinal traction may experience gaze-evoked amaurosis, a type of transient visual obscuration associated with eye movement.12 Concomitant maculopathies, such as vitreomacular traction (VMT), epiretinal membrane, and macular detachment, can occur associated with continuous adherence of the vitreous to the macula.13-16
Case report A 62-year-old black woman presented for a comprehensive examination with no visual or ocular complaints. The patient had a dilated eye examination at the Veterans Affairs (VA) hospital clinic, and retinal photographs were
Figure 1
603 obtained a few weeks before her visit. Her medical history was significant for type 2 diabetes mellitus, hypertension, hypercholesterolemia, and anemia. The patient reported using simvastatin, atenolol, and lisinopril. She also reported her last hemoglobin A1C (HbA1C) reading was 8.0%. Best-corrected visual acuities were 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Pupils were equal and round with no afferent pupillary defect. Ocular motility, color vision, and confrontation visual field testing results were normal. In-office blood pressure measurement was 139/68 mmHg. Slit lamp evaluation found moderate cortical cataracts encroaching on the visual axis in both eyes. Intraocular pressure via Goldmann tonometry was 17 mmHg in both eyes (OU). Dilated fundus evaluation found arteriovenuous nicking in both eyes. A flame-shaped hemorrhage was noted inferior nasal to the optic disc OD. The optic nerve head in the right eye appeared pink and distinct. Evaluation of the optic nerve head OS found subtle blurred margins, which appeared elevated (see Figure 1). The maculae appeared flat and intact OU. There was no diabetic retinopathy, and the periphery was flat and intact in both eyes. The patient was referred to the VA clinic for additional systemic evaluation as well as an ophthalmologic evaluation. The patient returned 4 weeks later and dilated examination found resolution of the flame-shaped hemorrhage OD. Evaluation of the left optic nerve head found blurred margins, with the margins appearing elevated with peripapillary intraretinal hemorrhages. Cirrus OCT found an apparent vitreous band with continuous adherence to the optic nerve consistent with peripapillary vitreoretinal traction (see Figures 2 and 3). OCT evaluation also found coexisting vitreomacular traction OS (see Figure 4). Eight months after the initial visit, the patient reported noncompliance with being evaluated by the VA
Margins surrounding optic nerve head were blurred with the appearance of elevation OS.
604
Optometry, Vol 82, No 10, October 2011
Figure 2
OCT optic disc scans show vitreous bands pulling the optic disc margins temporally OS.
ophthalmologist. The vitreopapillary traction was still present, the macula was slightly thickened (see Figure 5), and visual acuity remained stable at 20/30 OD and 20/25 OS. The patient was referred once more to the VA clinic for further ophthalmologic evaluation. When last seen, the patient reported being evaluated at the Miami VA by the retinal specialist. No treatment was recommended at the time, and she was scheduled for additional follow-up evaluation.
Discussion Peripapillary vitreoretinal traction is a recently recognized clinical entity resulting secondary to traction of the optic disc from an incomplete PVD.5-7 Persistent adherence of the posterior hyaloid membrane to the optic disc may result in optic disc traction. This disorder is also thought to be caused by contraction of the fibrous tissue overlying an incompletely detached posterior hyaloid.15 Peripapillary vitreoretinal traction may cause the margin surrounding the optic nerve to appear indistinct and the peripapillary retinal tissue to appear thickened, resembling disc edema. This must be differentiated from underlying etiologies of disc edema, such as papillitis, papilledema,
Figure 3
optic nerve head drusen, optic nerve infiltration, and optic nerve or orbital masses.5 Patients with a clinical appearance of peripapillary vitreoretinal traction may undergo costly ancillary testing, such as neuroimaging, or invasive procedures, such as lumbar puncture and referrals for retinal and neuro-ophthalmic evaluations. B-scan ultrasonography and OCT are valuable diagnostic tools that can confirm the presence of vitreopapillary traction and distinguish it from other pathologies that may cause optic nerve elevation. Witosky et al.7 showed that B-scan ultrasonography identified peripapillary vitreoretinal traction as the cause of unilateral optic nerve head elevation in 2 cases. Partial separation of the posterior hyaloid with persistent vitreopapillary traction was observed on ultrasound evaluation in both cases. Katz and Hoyt,10 using slit lamp biomicroscopy and ultrasonography, observed peripapillary vitreoretinal traction in a series of 8 patients. In other cases, OCT was used to determine peripapillary vitreoretinal traction as the source of optic nerve elevation in patients referred for neuro-opthalmologic consults.5,6 The use of OCT has led to an increase in the recognition of peripapillary vitreoretinal traction. Optical coherence tomography can provide a precise diagnostic evaluation of underlying etiology that may be challenging
OCT optic disc scans show vitreous bands pulling the optic disc margins nasally OS.
Hixson and Reynolds
Figure 4
Clinical Care
605
OCT shows coexisting VMT OS.
to establish with clinical observation and B-scan ultrasonography.14 The OCT image of peripapillary vitreoretinal traction is visualized as a partially detached vitreal band with continuous adherence to the optic nerve, causing elevation. There are several advantages to using OCT in the demonstration of vitreopapillary traction. OCT provides a high-resolution cross-sectional image, facilitating a definite diagnosis of vitreopapillary traction, as well as clear, detailed images of associated abnormalities, such as vitreomacular traction and other associated maculopathies.14 Peripapillary traction of the optic nerve may produce intrapapillary, peripapillary, or subretinal hemorrhages. These hemorrhages have been found to be subretinal or intrapapillary and are benign and self-resolving in nature.8,10 The most common associated hemorrhages have been reported to be subretinal.8 Unlike preretinal or vitreous hemorrhages associated with an acute PVD, there is no increase in association with retinal break or detachment.11 Although these hemorrhages can occur at any age, they are associated commonly with partial PVD development in younger myopic patients.9-11 Affected patients usually are asymptomatic but can report a condition known as gaze-evoked amaurosis, a rare type of transient visual obscuration caused by changes in volitional saccades.12 This condition has been reported to be associated with peripapillary vitreoretinal traction,
Figure 5
which can cause elevation of the optic nerve head occurring only in certain gazes, with resolution of symptoms occurring with progression to complete PVD. Peripapillary vitreoretinal traction can occur in conjunction with other maculopathies, including VMT, epiretinal membrane, and macular detachment.14,15 In the case presented, the patient had concurrent VMT. Peripapillary and macular serous detachments have been reported to be associated with peripapillary traction. The serous detachment can resolve with complete detachment of the posterior vitreous.13 OCT has become a valuable tool in the diagnosis and management of peripapillary vitreoretinal traction. Close monitoring of patients with OCT, as well as timely referral to a retinal specialist, are important in the management of this condition. The traction on the optic disc may resolve with complete PVD detachment in some cases. Persistent optic disc traction, however, may result in further elevation of the disc. Optic atrophy might occur with longstanding optic disc traction caused by obstruction of axoplasmic flow or laminar flow through the peripapillary blood vessels.16 OCT evaluation is important in not only determining the prognosis, but in determining when surgical intervention with pars plana vitrectomy is necessary. Documented cases in which a pars plana vitrectomy has been performed have been solely those in which the peripapillary vitreoretinal traction involved scar tissue that formed secondary to proliferative diabetic retinopathy.16 Surgical intervention for vitreopapillary traction should be performed with caution because removal of the adherent peripapillary membranes or posterior vitreous may lead to iatrogenic excision of axons that compromise visual acuity and visual field.17
Conclusion Although the effects of vitreoretinal traction are most commonly associated with the macula or peripheral retina, residual attachment can occur at the optic nerve head. Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from sight- or health-threatening etiologies.
Vitreopapillary traction at 8 months’ follow-up OS.
606 OCT is an excellent tool to help differentiate this condition from other pathologic entities.
References 1. Uchino E, Uemura A, Ohba N. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol 2001;119:1475-9. 2. Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use in evaluation of the vitreoretinal interface: a review. Surv Ophthalmol 2007;52:397-421. 3. Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc 2005;103:537-67. 4. Schepens C. Clinical aspects of pathologic changes in the vitreous body. Am J Ophthalmol 1954;38:8-21. 5. Hedges TR. Vitreopapillary traction confirmed by optical coherence tomography. Arch Ophthalmol 2006;124:279-81. 6. Cabrera S, Katz A, Margalit E. Vitreopapillary traction: cost-effective diagnosis by optical coherence tomography. Can J Ophthalmol 2006;41:763-5. 7. Wisotsky BJ, Magat-Gordon CB, Puklin JE. Vitreopapillary traction as a cause of elevated optic nerve head. Am J Ophthalmol 1998;126:137-9. 8. Kokame GT, Yamamoto I, Kishi S, et al. Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage. Ophthalmology 2004;111:926-30.
Optometry, Vol 82, No 10, October 2011 9. Sibony P, Fourman S, Honkanen R, et al. Asymptomatic peripapillary subretinal hemorrhage: A study of 10 cases. J Neuro-Ophthalmol 2008;28:114-9. 10. Katz B, Hoyt WF. Intrapapillary and peripapillary hemorrhage in young patients with incomplete posterior vitreous detachment. Ophthalmology 1995;102:349-54. 11. Horton RO, Potter JW, Semes LP. Peripapillary hemorrhages in acute posterior vitreous detachment. J Am Optom Assoc 1985;56: 937-9. 12. Katz B, Hoyt WF. Gaze-evoked amaurosis from vitreopapillary traction. Am J Ophthalmol 2005;139:631-7. 13. Aras A, Arici C, Akova N. Peripapillary serous retinal detachment preceding complete posterior vitreous detachment. Graefes Arch Clin Exp Ophthalmol 2008;246:927-9. 14. Rumelt S, Karatas M, Pikkelj, et al. Vitreopapillary traction syndrome associated with central retinal vein occlusion. Arch Ophthalmol 2003; 121:1093-7. 15. Koizumi H, Spaide RF, Fisher YL, et al. Three-dimensional evaluation of vitreomacular traction and epiretinal membrane using spectral-domain optical coherence tomography. Am J Ophthalmol 2008;145: 509-17. 16. Kroll P, Wiegand W, Schmidt J. Vitreopapillary traction in proliferative diabetic retinopathy. Br J Ophthalmol 1999;83:261-4. 17. Pendergast SD, Martin DF, Proia AD, et al. Removal of optic disc stalks during diabetic vitrectomy. Retina 1995;15:25-8.
Peripapillary vitreoretinal traction Angeline Hixson, O.D., and Sherrol Reynolds, O.D. Nova Southeastern University College of Optometry, Davie, Florida.
KEYWORDS Vitreoretinal traction; Peripapillary; Optic nerve head elevation; Posterior vitreous detachment; Pseudopapilledema
Abstract BACKGROUND: Vitreoretinal traction syndrome may occur in patients with incomplete posterior vitreous detachment. Although vitreoretinal traction of the macula is well-documented in the literature, the manifestations of peripapillary vitreoretinal traction are rarely discussed. CASE REPORT: A 62-year-old black woman presented for a comprehensive examination. She reported having uncontrolled diabetes and hypertension. Best-corrected visual acuities were 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Dilated examination found a flame-shaped hemorrhage OD. The optic nerve margins OS were blurred, with the margins appearing elevated with peripapillary intraretinal hemorrhages. Cirrus spectral domain optical coherence tomography (OCT) found the presence of peripapillary vitreoretinal traction with concurrent vitreomacular traction OS. CONCLUSION: Although the effects of vitreoretinal traction are most commonly associated with the macula or peripheral retina, residual attachment can occur at the optic nerve head. Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from sight- or health-threatening etiologies. OCT is a valuable diagnostic tool in confirming peripapillary vitreoretinal traction. Optometry 2011;82:602-606
Peripapillary vitreoretinal traction is a phenomenon associated with the development of a posterior vitreous detachment (PVD), a normal aging process during which the vitreous gradually separates from the retina. The development of a PVD is believed to be preceded by liquefaction of the vitreous gel, followed by separation of the posterior hyaloid membrane from the retinal surface. A study by Uchino et al.1 defined the individual stages of PVD development (see Table 1). Utilizing optical coherence tomography (OCT; Carl Zeiss Meditec, Dublin, California) on 209 healthy eyes, they were able to demonstrate that PVD initially results in a focal detachment in the perifoveal retina with persistent adhesion to the fovea, optic Disclosure: The author has no financial or other relationships that might lead to a conflict of interest. * Corresponding author: Angeline Hixson, O.D., Nova Southeastern University College of Optometry, 3200 S. University Drive, Davie, FL 33328. E-mail: [email protected]
nerve, and midperipheral retina. The PVD slowly evolves over time to the advanced stages with release of vitreopapillary adhesion, typically resulting in a Weiss ring over the optic nerve. The vitreous is strongly attached to the optic nerve head, and this attachment has been described as the last area of separation in the gradual process of posterior vitreous detachment.1-4 In some patients, the PVD process is incomplete and can induce a number of complications at various areas of the vitreoretinal interface. Residual attachment at the optic disc, associated with PVD stages 1 through 3, can lead to a condition known as peripapillary vitreoretinal traction syndrome.1,5,6 Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from pathologic causes of optic nerve edema. OCTevaluation is an important diagnostic tool in showing vitreous traction on the optic nerve head.7 The clinical picture of vitreopapillary traction may be associated with hemorrhages, gaze-evoked amaurosis, and
1529-1839/$ - see front matter Ó 2011 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2011.02.018
Hixson and Reynolds
Clinical Care
Table 1 Stages of posterior vitreous detachment as determined by Uchino et al.1 Stage 0
Absence of PVD
Stage 1
Focal perifoveal PVDdincomplete PVD localized in the perifovea, with persistent attachment to the fovea, optic nerve head, and midperipheral retina Perifoveal PVD across all quadrants of the retina with persistent attachment to the fovea, optic nerve head, and midperipheral retina Detachment of the posterior vitreous face from the fovea, with persistent attachment to the optic nerve head and midperipheral retina Complete PVD with presence of a Weiss ring
Stage 2
Stage 3
Stage 4
maculopathies. The hemorrhages may be intrapapillary or subretinal peripapillary, but are benign and self-resolving.8-11 Additionally, patients with peripapillary vitreoretinal traction may experience gaze-evoked amaurosis, a type of transient visual obscuration associated with eye movement.12 Concomitant maculopathies, such as vitreomacular traction (VMT), epiretinal membrane, and macular detachment, can occur associated with continuous adherence of the vitreous to the macula.13-16
Case report A 62-year-old black woman presented for a comprehensive examination with no visual or ocular complaints. The patient had a dilated eye examination at the Veterans Affairs (VA) hospital clinic, and retinal photographs were
Figure 1
603 obtained a few weeks before her visit. Her medical history was significant for type 2 diabetes mellitus, hypertension, hypercholesterolemia, and anemia. The patient reported using simvastatin, atenolol, and lisinopril. She also reported her last hemoglobin A1C (HbA1C) reading was 8.0%. Best-corrected visual acuities were 20/30 in the right eye (OD) and 20/25 in the left eye (OS). Pupils were equal and round with no afferent pupillary defect. Ocular motility, color vision, and confrontation visual field testing results were normal. In-office blood pressure measurement was 139/68 mmHg. Slit lamp evaluation found moderate cortical cataracts encroaching on the visual axis in both eyes. Intraocular pressure via Goldmann tonometry was 17 mmHg in both eyes (OU). Dilated fundus evaluation found arteriovenuous nicking in both eyes. A flame-shaped hemorrhage was noted inferior nasal to the optic disc OD. The optic nerve head in the right eye appeared pink and distinct. Evaluation of the optic nerve head OS found subtle blurred margins, which appeared elevated (see Figure 1). The maculae appeared flat and intact OU. There was no diabetic retinopathy, and the periphery was flat and intact in both eyes. The patient was referred to the VA clinic for additional systemic evaluation as well as an ophthalmologic evaluation. The patient returned 4 weeks later and dilated examination found resolution of the flame-shaped hemorrhage OD. Evaluation of the left optic nerve head found blurred margins, with the margins appearing elevated with peripapillary intraretinal hemorrhages. Cirrus OCT found an apparent vitreous band with continuous adherence to the optic nerve consistent with peripapillary vitreoretinal traction (see Figures 2 and 3). OCT evaluation also found coexisting vitreomacular traction OS (see Figure 4). Eight months after the initial visit, the patient reported noncompliance with being evaluated by the VA
Margins surrounding optic nerve head were blurred with the appearance of elevation OS.
604
Optometry, Vol 82, No 10, October 2011
Figure 2
OCT optic disc scans show vitreous bands pulling the optic disc margins temporally OS.
ophthalmologist. The vitreopapillary traction was still present, the macula was slightly thickened (see Figure 5), and visual acuity remained stable at 20/30 OD and 20/25 OS. The patient was referred once more to the VA clinic for further ophthalmologic evaluation. When last seen, the patient reported being evaluated at the Miami VA by the retinal specialist. No treatment was recommended at the time, and she was scheduled for additional follow-up evaluation.
Discussion Peripapillary vitreoretinal traction is a recently recognized clinical entity resulting secondary to traction of the optic disc from an incomplete PVD.5-7 Persistent adherence of the posterior hyaloid membrane to the optic disc may result in optic disc traction. This disorder is also thought to be caused by contraction of the fibrous tissue overlying an incompletely detached posterior hyaloid.15 Peripapillary vitreoretinal traction may cause the margin surrounding the optic nerve to appear indistinct and the peripapillary retinal tissue to appear thickened, resembling disc edema. This must be differentiated from underlying etiologies of disc edema, such as papillitis, papilledema,
Figure 3
optic nerve head drusen, optic nerve infiltration, and optic nerve or orbital masses.5 Patients with a clinical appearance of peripapillary vitreoretinal traction may undergo costly ancillary testing, such as neuroimaging, or invasive procedures, such as lumbar puncture and referrals for retinal and neuro-ophthalmic evaluations. B-scan ultrasonography and OCT are valuable diagnostic tools that can confirm the presence of vitreopapillary traction and distinguish it from other pathologies that may cause optic nerve elevation. Witosky et al.7 showed that B-scan ultrasonography identified peripapillary vitreoretinal traction as the cause of unilateral optic nerve head elevation in 2 cases. Partial separation of the posterior hyaloid with persistent vitreopapillary traction was observed on ultrasound evaluation in both cases. Katz and Hoyt,10 using slit lamp biomicroscopy and ultrasonography, observed peripapillary vitreoretinal traction in a series of 8 patients. In other cases, OCT was used to determine peripapillary vitreoretinal traction as the source of optic nerve elevation in patients referred for neuro-opthalmologic consults.5,6 The use of OCT has led to an increase in the recognition of peripapillary vitreoretinal traction. Optical coherence tomography can provide a precise diagnostic evaluation of underlying etiology that may be challenging
OCT optic disc scans show vitreous bands pulling the optic disc margins nasally OS.
Hixson and Reynolds
Figure 4
Clinical Care
605
OCT shows coexisting VMT OS.
to establish with clinical observation and B-scan ultrasonography.14 The OCT image of peripapillary vitreoretinal traction is visualized as a partially detached vitreal band with continuous adherence to the optic nerve, causing elevation. There are several advantages to using OCT in the demonstration of vitreopapillary traction. OCT provides a high-resolution cross-sectional image, facilitating a definite diagnosis of vitreopapillary traction, as well as clear, detailed images of associated abnormalities, such as vitreomacular traction and other associated maculopathies.14 Peripapillary traction of the optic nerve may produce intrapapillary, peripapillary, or subretinal hemorrhages. These hemorrhages have been found to be subretinal or intrapapillary and are benign and self-resolving in nature.8,10 The most common associated hemorrhages have been reported to be subretinal.8 Unlike preretinal or vitreous hemorrhages associated with an acute PVD, there is no increase in association with retinal break or detachment.11 Although these hemorrhages can occur at any age, they are associated commonly with partial PVD development in younger myopic patients.9-11 Affected patients usually are asymptomatic but can report a condition known as gaze-evoked amaurosis, a rare type of transient visual obscuration caused by changes in volitional saccades.12 This condition has been reported to be associated with peripapillary vitreoretinal traction,
Figure 5
which can cause elevation of the optic nerve head occurring only in certain gazes, with resolution of symptoms occurring with progression to complete PVD. Peripapillary vitreoretinal traction can occur in conjunction with other maculopathies, including VMT, epiretinal membrane, and macular detachment.14,15 In the case presented, the patient had concurrent VMT. Peripapillary and macular serous detachments have been reported to be associated with peripapillary traction. The serous detachment can resolve with complete detachment of the posterior vitreous.13 OCT has become a valuable tool in the diagnosis and management of peripapillary vitreoretinal traction. Close monitoring of patients with OCT, as well as timely referral to a retinal specialist, are important in the management of this condition. The traction on the optic disc may resolve with complete PVD detachment in some cases. Persistent optic disc traction, however, may result in further elevation of the disc. Optic atrophy might occur with longstanding optic disc traction caused by obstruction of axoplasmic flow or laminar flow through the peripapillary blood vessels.16 OCT evaluation is important in not only determining the prognosis, but in determining when surgical intervention with pars plana vitrectomy is necessary. Documented cases in which a pars plana vitrectomy has been performed have been solely those in which the peripapillary vitreoretinal traction involved scar tissue that formed secondary to proliferative diabetic retinopathy.16 Surgical intervention for vitreopapillary traction should be performed with caution because removal of the adherent peripapillary membranes or posterior vitreous may lead to iatrogenic excision of axons that compromise visual acuity and visual field.17
Conclusion Although the effects of vitreoretinal traction are most commonly associated with the macula or peripheral retina, residual attachment can occur at the optic nerve head. Peripapillary vitreoretinal traction can cause optic nerve head elevation with the appearance of edema that must be distinguished from sight- or health-threatening etiologies.
Vitreopapillary traction at 8 months’ follow-up OS.
606 OCT is an excellent tool to help differentiate this condition from other pathologic entities.
References 1. Uchino E, Uemura A, Ohba N. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol 2001;119:1475-9. 2. Mirza RG, Johnson MW, Jampol LM. Optical coherence tomography use in evaluation of the vitreoretinal interface: a review. Surv Ophthalmol 2007;52:397-421. 3. Johnson MW. Perifoveal vitreous detachment and its macular complications. Trans Am Ophthalmol Soc 2005;103:537-67. 4. Schepens C. Clinical aspects of pathologic changes in the vitreous body. Am J Ophthalmol 1954;38:8-21. 5. Hedges TR. Vitreopapillary traction confirmed by optical coherence tomography. Arch Ophthalmol 2006;124:279-81. 6. Cabrera S, Katz A, Margalit E. Vitreopapillary traction: cost-effective diagnosis by optical coherence tomography. Can J Ophthalmol 2006;41:763-5. 7. Wisotsky BJ, Magat-Gordon CB, Puklin JE. Vitreopapillary traction as a cause of elevated optic nerve head. Am J Ophthalmol 1998;126:137-9. 8. Kokame GT, Yamamoto I, Kishi S, et al. Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage. Ophthalmology 2004;111:926-30.
Optometry, Vol 82, No 10, October 2011 9. Sibony P, Fourman S, Honkanen R, et al. Asymptomatic peripapillary subretinal hemorrhage: A study of 10 cases. J Neuro-Ophthalmol 2008;28:114-9. 10. Katz B, Hoyt WF. Intrapapillary and peripapillary hemorrhage in young patients with incomplete posterior vitreous detachment. Ophthalmology 1995;102:349-54. 11. Horton RO, Potter JW, Semes LP. Peripapillary hemorrhages in acute posterior vitreous detachment. J Am Optom Assoc 1985;56: 937-9. 12. Katz B, Hoyt WF. Gaze-evoked amaurosis from vitreopapillary traction. Am J Ophthalmol 2005;139:631-7. 13. Aras A, Arici C, Akova N. Peripapillary serous retinal detachment preceding complete posterior vitreous detachment. Graefes Arch Clin Exp Ophthalmol 2008;246:927-9. 14. Rumelt S, Karatas M, Pikkelj, et al. Vitreopapillary traction syndrome associated with central retinal vein occlusion. Arch Ophthalmol 2003; 121:1093-7. 15. Koizumi H, Spaide RF, Fisher YL, et al. Three-dimensional evaluation of vitreomacular traction and epiretinal membrane using spectral-domain optical coherence tomography. Am J Ophthalmol 2008;145: 509-17. 16. Kroll P, Wiegand W, Schmidt J. Vitreopapillary traction in proliferative diabetic retinopathy. Br J Ophthalmol 1999;83:261-4. 17. Pendergast SD, Martin DF, Proia AD, et al. Removal of optic disc stalks during diabetic vitrectomy. Retina 1995;15:25-8.