Diapositiva 1

1
Povisa Hospital Vigo, 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
2
Povisa Hospital Vigo Spain
Purpose
To describe a case of 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.
Vitreopapillary traction syndrome
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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

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Methods case report

• Fundus exam revealed bilateral 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

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Methods Case Report

• 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

Vitreopapillary traction syndrome
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RESULTS

• 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

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Povisa Hospital Vigo Spain
Bscan U/S on presentation
Figure 1
Figure 1 OD
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Clinical Course 2 months later

• Given the pts 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.

Vitreopapillary traction syndrome
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B scan 2 months later
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Optic nerves 2 months later
OD pale. OS good color, elevation nearly
resolved.
Vitreopapillary traction syndrome
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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 patients 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.

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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. 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
41763-5.
Vitreopapillary traction syndrome