Chapter

Vitreous Opacities 17
Introduction 692 Asteroid hyalosis 692 Vitreous cyst 695
Muscae volitantes 692 Synchysis scintillans 692 Persistent fetal vasculature 696
Vitreous haemorrhage 692 Amyloidosis 695
692 Kanski's Clinical Ophthalmology
Introduction
The vitreous is a transparent extracellular gel consisting of col-
lagen, soluble proteins, hyaluronic acid and water. The total
vitreous volume is approximately 4.0 ml. The few cells normally
present in the gel are located predominantly in the cortex and
include hyalocytes, astrocytes and glial cells. The vitreous provides
structural support to the globe while allowing a clear and optically
uniform path to the retina. Once liquefied or surgically removed
it does not re-form. Vitreous opacities can be caused by a variety
of pathological processes primarily involving other ocular sites.
Apart from vitreous haemorrhage, the conditions discussed
below are those in which the vitreous gel is the primary site of
pathology.
Muscae volitantes
Muscae volitantes (Latin for ‘hovering flies’), commonly referred
to as ‘floaters’, is an ubiquitous entoptic phenomenon of fly-,
cobweb- or thread-like condensations that are best seen against
a pale background. It is thought to predominantly represent tiny
embryological remnants in the vitreous gel. A sudden exacerba-
tion can occur due to vitreous haemorrhage or, more commonly, a
change in the conformation of the gel, such as a posterior vitreous
detachment (see Fig. 16.15).
Vitreous haemorrhage
Vitreous haemorrhage is a common condition with many causes
(Table 17.1). Symptoms vary according to severity. Mild haemor-
rhage (Fig. 17.1A) causes sudden onset floaters and diffuse blurring
of vision, but may not affect visual acuity, whilst a dense bleed may
result in severe visual loss (Fig. 17.1B). B-scan ultrasonography in
non-clotted vitreous haemorrhage generally shows a uniform
appearance and once cellular aggregates develop, small particulate
echoes become visible (Fig. 17.1C). Ultrasonography is critical
in the evaluation of an eye with dense vitreous haemorrhage to
Table 17.1 Causes of Vitreous Haemorrhage
• Acute posterior vitreous detachment associated either
with a retinal tear or avulsion of a peripheral vessel
• Proliferative retinopathy
• Diabetic
• Retinal vein occlusion
• Sickle cell disease
• Eales disease
• Vasculitis
• Miscellaneous retinal disorders
• Macroaneurysm
• Telangiectasia
• Capillary haemangioma
• Trauma
• Systemic
• Bleeding disorders
• Terson syndrome
exclude an underlying retinal tear or detachment (Fig. 17.1D).
Treatment is dictated by severity and cause, but an increasingly
low threshold is being adopted for early vitrectomy (see Ch. 16) in
cases of dense haemorrhage.
TIP Undertake ultrasound investigation in an eye with a
dense vitreous haemorrhage to exclude a retinal detachment or
choroidal melanoma.
Terson syndrome
Terson syndrome refers to the combination of intraocular and
subarachnoid haemorrhage secondary to aneurysmal rupture,
most commonly arising from the anterior communicating artery.
However, intraocular haemorrhage may also occur with subdural
haematoma and acute elevation of intracranial pressure from
other causes. The haemorrhage is frequently bilateral and is typi-
cally intraretinal and/or preretinal (Fig. 17.2), although occasion-
ally subhyaloid blood may break into the vitreous. It is probable
that intraocular bleeding is due to retinal venous stasis secondary
to increase in cavernous sinus pressure. Vitreous haemorrhage
usually resolves spontaneously within a few months and the long-
term visual prognosis is good in most. Early vitrectomy may be
considered in some cases.
Asteroid hyalosis
Asteroid hyalosis is a common degenerative process in which
calcium pyrophosphate particles collect within the vitreous gel. It
is seen clinically as numerous tiny round yellow–white opacities
of varying size and density (Fig. 17.3A and B). These move with
the vitreous during eye movements but do not sediment inferi-
orly when the eye is immobile. Only one eye is affected in 75%
of patients. It rarely causes visual problems and the majority of
patients are asymptomatic. An association with diabetes has been
suggested, but is unproven. The prevalence of asteroid hyalosis
increases with age and affects 3% of those aged 75–86 years. It is
more common in men than in women. Optical coherence tomog-
raphy (OCT) (Fig. 17.3C) and ultrasonography (Fig. 17.3D) show
high reflectivity foci.
TIP Because asteroid hyalosis rarely causes visual
symptoms, dual pathology should be considered if the visual
acuity is reduced.
Synchysis scintillans
Synchysis (synchisis) scintillans occurs as a consequence of
chronic vitreous haemorrhage, often in a blind eye. The condi-
tion is usually discovered when frank haemorrhage is no longer
present. The crystals are composed of cholesterol and are derived
from plasma cells or degraded products of erythrocytes and lie
either freely or engulfed within foreign body giant cells. Numer-
ous flat golden-brown refractile particles are seen, which tend to
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Vitreous Opacities 693

A B

C D

Fig. 17.1 (A) Mild vitreous haemorrhage seen against the red reflex; (B) resorbing vitreous
haemorrhage; (C) B-scan image showing vitreous haemorrhage and flat retina; (D) B-scan
image showing retinal detachment
(Courtesy of C Barry – fig. B; P Terry – figs C and D)
694 Kanski's Clinical Ophthalmology

A B

Fig. 17.2 Terson syndrome. (A) Acute intra- and preretinal haemorrhages in a 48-year-old man
with subarachnoid haemorrhage; (B) macular involvement
(Courtesy of A Agarwal, from Gass’ Atlas of Macular Diseases, Elsevier 2012 – fig. A)

A B

C D

Fig. 17.3 Asteroid hyalosis. (A) Mild; (B) severe; (C) 3-dimensional OCT reconstruction;
(D) B-scan ultrasonogram
(Courtesy of S Chen – fig. C)
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Vitreous Opacities 695

and take on a characteristic sheet-like (‘glass wool’) appearance

(Fig. 17.5A). The opacities may become attached to the posterior
lens by thick footplates (Fig. 17.5B). Dense opacification resulting
in significant visual impairment may require vitrectomy.

Vitreous cyst
Vitreous cysts can be congenital or acquired, acquired cysts being
caused by a range of pathology such as trauma and inflammation.
Congenital cysts are pigmented or non-pigmented, the former
usually arising from the ciliary body pigment epithelium, the latter
from remnants of the primary hyaloid vascular system. They are
generally fixed – non-pigmented cysts are typically attached to
the optic disc – but can be found floating freely in the posterior
(occasionally anterior) segment (Fig. 17.6). Treatment is seldom

Fig. 17.4 Synchysis scintillans in the anterior chamber of a

degenerate eye
(Courtesy of P Gili)

sediment inferiorly when the eye is immobile. Occasionally the

anterior chamber may also be involved (Fig. 17.4).

Amyloidosis
Amyloidosis is a localized or systemic condition in which there
is extracellular deposition of fibrillary protein. Vitreous involve-
ment typically occurs in familial amyloidosis, also characterized
by polyneuropathy, prominent corneal nerves and pupillary light-
near dissociation. Vitreous opacities may be unilateral or bilateral
and are initially perivascular. Later they involve the anterior gel Fig. 17.6 Vitreous cyst

A B

Fig. 17.5 Amyloidosis. (A) Vitreous deposits involving the anterior gel, showing a characteris-
tic ‘glass wool’ appearance; (B) opacities attached to the posterior lens by thick footplates
696 Kanski's Clinical Ophthalmology

Fig. 17.7 Bergmeister papilla Fig. 17.8 Congenital vitreous veil

required, but laser cystotomy or vitrectomy can be performed for optic disc (Fig. 17.7), a Mittendorf dot on the posterior lens surface
troublesome symptoms. and the more marked manifestations for which the term persistent
fetal vasculature is generally reserved, previously termed persistent

Persistent fetal vasculature hyperplastic primary vitreous (see Ch. 20). A congenital vitreous
veil is a translucent, curtain-like structure found in normal vitre-
In addition to non-pigmented vitreous cysts, remnants of the ous, which may be vascularized (Fig. 17.8). It is extremely rare and
hyaloid vessels can form a Bergmeister papilla, seen as a tuft at the is of unknown aetiology. Treatment is not needed.