Proliferative Vitreoretinopathy: Diagnosis


Proliferative Vitreoretinopathy: Diagnosis 

Proliferative vitreoretinopathy (PVR), a major complication of rhegmatogenous retinal detachment (RRD), is an abnormal process whereby proliferative, contractile cellular membranes form in the vitreous and on both sides of the retina, resulting in tractional retinal detachment with fixed retinal folds. Research suggests that membranes form in response to cytokines and inflammatory mediators that arise following anatomic disruption and tissue damage caused by rhegmatogenous retinal detachment (RRD) and resultant inflammation. Treatment is principally surgical and often requires multiple procedures that, in fact, yield a high rate of retinal reattachment; nevertheless, many anatomically successful eyes do not recover good visual function.

Diagnosis of PVR is made via an in-depth patient history, i.e. evidence of longstanding primary RRD or of recent retinal reattachment surgery, and via physical examination, most importantly recognition of retinal detachment with fixed retinal folds Classification Staging Since publishing its seminal classification system in 198335, the Retinal Society Terminology Committee has updated its classification—most recently in 1991—to reflect a greater understanding of the pathogenesis of proliferative vitreoretinopathy36. Additional classification systems, specifically the classification criteria utilized in the Silicone Study37, have broadened the initial contributions structured in the seminal Retinal Society report by stratifying via: 1) membrane location, 2) clinical severity, and 3) membrane geometry.
In practice, the revised system, most notably the use of clock hours as opposed to quadrants, in addition to the segregation of membranes into anterior and posterior, allows for better understanding of the pathology of individual cases and comparison of severity of PVR among different clinical studies of PVR.
Example case: Patient presents to the clinic eight weeks post-operatively following retinal detachment repair. Patient complains of flashing lights and loss of vision. On indirect ophthalmic exam, the retina is detached with inferior starfolds and diffuse posterior contraction. Using the revised Retinal Society classification system, this patient’s presentation would be classified as CP12.

Diagnostic procedures
The diagnosis of PVR is by clinical examination in most patients; however, sometimes other diagnostic techniques become necessary. If the ocular media are opaque due to cornea, lens, vitreous or other opacities, the retina cannot be visualized and other techniques must be used. Ultrasound examination can demonstrate the presence of retinal detachment, and there are some characteristics of the retinal detachment on ultrasound that will indicate the presence of PVR. Using dynamic ultrasound (moving the eye while viewing the retinal detachment with ultrasound), compared to RRD without PVR, there is less retinal mobility in a RRD with PVR. In RRD without PVR, the retina attached to the optic nerve usually has a rounded pattern with good mobility as it approaches the disc on ultrasound; with PVR, the leaves of the retina may assume a “V” pattern at the optic disc with the retina straightened with limited mobility as they approach the optic nerve (open funnel retinal detachment). With more severe PVR, the retina may assume a “T” pattern on ultrasound at the optic disc (closed funnel retinal detachment) with the leaves of the retina fused together anterior to the disc, only opening more anterior to the disc with the anterior immobile retina completing the top bar of the “T”. OCT can be helpful if there is a question of whether the macula or other parts of the retina are detached or not.

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The Ophthalmologist: Clinical and Therapeutic Journal