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Ophthalmology > VITREOUS
Vitreous Wick Syndrome
Article Last Updated: Dec 20, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO, is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Coauthor(s):
Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic;
C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Editors: Jerre Freeman, MD, Founder, Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
vitreous wicks, vitrectomy, vitreous loss, vitreous prolapse, anterior segment surgery, vitreoretinal surgery, cataract surgery, endophthalmitis, intraocular inflammation, intraocular trauma, intraocular surgery, vision loss
Background
In October 1970, Ruiz and Teeters first described vitreous wick syndrome when they reported 11 cases of late complications following uneventful cataract surgeries.1 The syndrome consisted of microscopic wound breakdown, followed by a vitreous prolapse that developed into a vitreous wick, which was seen externally. They divided their cases into 3 groups. The first group included 5 patients in whom vitreous wicks developed without subsequent intraocular inflammation. The second group included 4 patients in whom vitreous wicks and intraocular inflammation developed. The third group included 2 patients who developed severe intraocular inflammation and subsequent vision loss. Since then, vitreous wick syndrome has been reported to occur after penetrating keratoplasty, discission of the posterior capsule, and corneal-relaxing incisions. Vitreous wick syndrome initially was limited to anterior segment surgeries. However, posterior fistulous tracts with vitreous entrapment have been reported following vitreoretinal surgery. Vitreous wick syndrome has also been identified as a potential cause of endophthalmitis after intravitreal injection of triamcinolone through the pars plana.
Pathophysiology
Vitreous wick syndrome is caused by trauma, either iatrogenic (eg, intraocular surgery) or noniatrogenic. Iatrogenic causes always involve poor surgical technique. It usually follows anterior segment surgery, although it has been reported to follow sub-Tenon injection and muscle surgery. All other factors being present, microscopic wound breakdown has been hypothesized as the "point of no return" for vitreous wick syndrome. Ruiz and Teeters emphasized this point in their initial description.1 Corneal wound healing has been documented to be slower on the endothelial side (inner layers). Poor suture techniques are implicated as a major factor for wound breakdown. Tightly compressed corneal wound edges may demonstrate puckering and also may lead to enlargement of suture tracts, promoting tissue necrosis within the suture loop. Once communication between the posterior wound gap and the anterior wound defect occurs (following tissue necrosis from tight sutures), anterior aqueous fluid may egress; vitreous incarceration may also occur, producing the vitreous wick. Occasionally, complete sloughing of strangulated tissue within the suture loop may occur. Noniatrogenic traumatic causes involve sharp injuries. Neetens, Rubbens, and Smets reported an 8-year-old girl who was hit by a sharp object, perforating the upper lid and causing a black eye.2 A surgeon repaired the palpebral wound, and the child was not referred to an ophthalmologist. The girl reported vision loss 2-3 weeks later. The injury resulted in a microperforation of the globe through the conjunctiva and sclera.
Frequency
United States
Rare
International
Rare
Mortality/Morbidity
- Staphylococcus epidermidis has been reported as the etiologic agent in a bacterial endophthalmitis that was associated with a vitreous wick after penetrating keratoplasty.
- Lindstrom and Doughman reported an alpha-streptococcal (not group D) and a coagulase-negative staphylococcal endophthalmitis that was associated with a vitreous wick 26 days after uncomplicated intracapsular cataract extraction.3
- Srinivasan and colleagues reported a single case of Staphylococcus aureus endophthalmitis that was associated with a vitreous wick.4
- Rice and Michels reported techniques on managing epithelial downgrowth that is associated with a vitreous wick, including excision of the tract and patch graft.5
Race
No racial predilection exists.
Sex
No gender predisposition exists.
Age
No age predisposition exists.
History
- Symptoms
- Pain
- Blurring of vision
- Itchiness/foreign body sensation
- Gush of warm fluid
- Past ocular history
- Recent eye surgery
- Recent eye trauma
Physical
- Gross observations
- Mucous threadlike substance protruding from a surgical site
- Corneal haze
- Hypopyon
- Eye redness
- Eye discharge
- Slit lamp findings
- Externalized vitreous at wound site
- Necrotic area around the vitreous wick
- Peaked pupil
- With or without cells and flare
- Positive Seidel test
- Corneal haze
- Hypopyon
Causes
Trauma, whether iatrogenic or noniatrogenic, is implicated as a cause for vitreous wick syndrome.
- Iatrogenic
- Cataract surgery
- Retinal surgery
- Muscle surgery
- Penetrating keratoplasty
- Discission of the posterior capsule
- Sub-Tenon injection
- Corneal-relaxing incision
- Pars plana injection
- Noniatrogenic - Sharp object injury
Endophthalmitis, Bacterial
Endophthalmitis, Postoperative
Foreign Body, Intraocular
Iris Prolapse
Lab Studies
- Depending on presentation, obtain specimens (eg, swab, vitreous wick, aqueous) from the external and internal eye for the following studies:
- Gram stain/Giemsa stain
- Cultures and sensitivities
- Calcofluor white (suspected fungal infection)
Other Tests
- Seidel test
- A strip of fluorescein is placed on the area that is suspected for leaks, then the dye color is observed in white light. If a leak is present, the dye will change from orange (concentrated) to green (diluted) and exhibit a waterfall-like effect at the leaking zone.
- The egress of fluid is noted best under blue light.
Procedures
- The vitreous wick may appear like a mucoid substance under slit lamp biomicroscopy. The wick may be teased with a cotton applicator or a cellulose sponge while taking note of synchronous movement of the iris or of the vitreous strand in the anterior chamber.
- A peaked pupil also may indicate a vitreous strand in the anterior chamber.
Medical Care
- The type of topical antibiotics depends on the suspected infecting agent or the culture and sensitivity results.
- In cases of endophthalmitis, medical therapy is initiated that is sensitive against suspected or confirmed (via culture and sensitivity results) infecting agents. Subconjunctival and intravitreal antibiotics have been given.
- For more information on the treatment of endophthalmitis, see Endophthalmitis, Bacterial and Endophthalmitis, Postoperative.
Surgical Care
The surgical approach to properly manage vitreous wick syndrome depends on the presentation. A generalized procedure is enumerated below. - Initially, the vitreous wick is excised or severed with Vannas-type scissors by lifting the exposed vitreous strand with a cotton-tipped applicator or fine nontoothed forceps. Alternatively, a suction-cutting instrument inserted into the anterior chamber may be used.
- Vitrectomy may be performed via an anterior limbal approach or a closed posterior approach.
- It is imperative that no vitreous strand is left above the pupillary plane. To detect any remaining vitreous, sweep the anterior chamber with a spatula from a paracentesis site 90° away from the surgical wound. An immobile round pupil suggests clearance from any vitreous that is invading the anterior chamber.
- Adequate surgical closure is accomplished with nylon 10-0 sutures.
Diet
No restrictions on diet are indicted.
Activity
Strenuous activities and contact sports are restricted until recovery.
The definitive management is primarily surgical. Medical therapy is limited to broad-spectrum topical antibiotics for uncomplicated cases.
Drug Category: Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
| Drug Name | Vancomycin (Vancocin, Vancoled, Lyphocin) |
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| Description | Empiric coverage for gram-positive organisms; excellent gram-positive coverage and has added advantage of providing better coverage against resistant organisms; bactericidal against most organisms and bacteriostatic for enterococci. Inhibits cell wall biosynthesis, interfering with cell membrane permeability and RNA synthesis. DOC for intravitreal and systemic administration. After systemic administration, drug penetrates most tissues, including vitreous, especially if the blood-ocular barrier is compromised. Use creatine clearance to adjust dose in patients with renal impairment. |
|---|
| Adult Dose | Systemic: 1 g IV, infused over 1 h; repeat q12h
Intravitreal: 1 mg/0.1 mL
|
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| Pediatric Dose | Systemic: 10 mg/kg IV q6h
Intravitreal: Administer as in adults
|
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| Contraindications | Documented hypersensitivity |
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| Interactions | Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction |
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| Drug Name | Moxifloxacin (Vigamox) |
|---|
| Description | Indicated to treat bacterial conjunctivitis. Elicits antimicrobial effects. Inhibits topoisomerase II (DNA gyrase) and IV enzymes. DNA gyrase is essential in bacterial DNA replication, transcription, and repair. Topoisomerase IV plays a key role in chromosomal DNA portioning during bacterial cell division. |
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| Adult Dose | Instill 1 gtt in affected eye(s) tid for 7 d |
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| Pediatric Dose | <1 year: Not established
>1 year: Administer as in adults
|
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| Contraindications | Documented hypersensitivity |
|---|
| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Prolonged use may cause organism overgrowth and result in superinfection; do not wear contact lenses until infection clears and eye drops discontinued |
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Further Outpatient Care
- Arrange for follow-up care 1-2 days after surgery. If this initial follow-up examination is fine, schedule regular checkups for uneventful anterior segment surgeries.
- An eye shield, especially at night, protects the globe from any untoward traumatic episodes.
In/Out Patient Meds
- Discharge on broad-spectrum (or based on culture and sensitivity results) topical antibiotics. Steroid drops may be given, depending on the amount of inflammation.
Deterrence/Prevention
- Meticulous surgical technique is essential for all ophthalmic surgery. Follow basic surgical techniques. Be sure all incisions are closed securely. In cases of broken capsules with vitreous presentation in the anterior segment, be sure all vitreous has been removed from the anterior segment by appropriate anterior vitrectomy technique. If this is not possible, consideration should be given to trans pars plana vitrectomy at a later date in consultation with a vitreoretinal surgeon.
Complications
- Unnoticed and unmanaged vitreous wick syndrome may result in sight-threatening complications, such as sterile and infectious endophthalmitis.
Prognosis
- Early identification and intervention lead to excellent results. The longer the vitreous wick is left unnoticed and unmanaged, the higher the risk for infection and inflammation.
Patient Education
- Postoperative patients should report to their ophthalmologists
, if the following are noted: delayed-onset eye redness, blurring of vision, and pain.
Medical/Legal Pitfalls
- Considering the ready availability of anterior vitrectomy capability, no eye should be left with vitreous in the anterior segment. Failure to at least attempt to clean prolapsed vitreous represents a departure from the standard of care.
- Failure to consider the diagnosis may lead to severe infection and inflammation, which may result in blindness.
The author was a fellow and affiliated with the Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, while performing this work.
| Media file 1:
Externalized vitreous with a peaked pupil. Image courtesy of Manolette Roque, MD, MBA, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. |
 |  View Full Size Image | |
Media type: Image
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| Media file 2:
Cellulose sponge teasing the vitreous wick. Image courtesy of Manolette Roque, MD, MBA, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. |
 | View Full Size Image | |
Media type: Image
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| Media file 3:
Castroviejo sweep performed with a cyclodialysis spatula. Image courtesy of Manolette Roque, MD, MBA, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic. |
 | View Full Size Image | |
Media type: Image
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- Ruiz RS, Teeters VW. The vitreous wick syndrome. A late complication following cataract extraction. Am J Ophthalmol. Oct 1970;70(4):483-90. [Medline].
- Neetens A, Rubbens MC, Smets RM. Vitreous wick syndrome. Bull Soc Belge Ophtalmol. 1987;223 Pt 2:41-5. [Medline].
- Lindstrom RL, Doughman DJ. Bacterial endophthalmitis associated with vitreous wick. Ann Ophthalmol. Nov 1979;11(11):1775-8. [Medline].
- Srinivasan BD, Hofeldt A, Coleman DJ, DeVoe AG. Vitreous wick syndrome. Am J Ophthalmol. May 1979;87(5):662-4. [Medline].
- Rice TA, Michels RG. Current surgical management of the vitreous wick syndrome. Am J Ophthalmol. May 1978;85(5 Pt 1):656-61. [Medline].
- Chen SD, Mohammed Q, Bowling B, Patel CK. Vitreous wick syndrome--a potential cause of endophthalmitis after intravitreal injection of triamcinolone through the pars plana. Am J Ophthalmol. Jun 2004;137(6):1159-60; author reply 1160-1. [Medline].
- Sheets JH, Friedberg JG. Vitreous wick syndrome following discission of the posterior capsule. Arch Ophthalmol. Feb 1980;98(2):327. [Medline].
- Stainer GA, Binder PS. Vitreous wick syndrome following a corneal relaxing incision. Ophthalmic Surg. Aug 1981;12(8):567-70. [Medline].
- Venkatesh P, Verma L, Tewari H. Posterior vitreous wick syndrome: a potential cause of endophthalmitis following vitreo-retinal surgery. Med Hypotheses. Jun 2002;58(6):513-5. [Medline].
Vitreous Wick Syndrome excerpt Article Last Updated: Dec 20, 2007
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