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 et al 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.
Epidemiology
Frequency
United States
This condition is rare worldwide.
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 is noted.
Sex
No gender predisposition is noted.
Age
No age predisposition is known.
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].
Rouw J, Shaver JF. Vitreous wicking syndrome as a complication of extracapsular cataract extraction. Optometry. Apr 2008;79(4):193-6. [Medline].
Couch SM, Bakri SJ. Use of triamcinolone during vitrectomy surgery to visualize membranes and vitreous. Clin Ophthalmol. Dec 2008;2(4):891-6. [Medline]. [Full Text].
Schmidt JC, Chofflet J, Hörle S, Mennel S, Meyer CH. Three simple approaches to visualize the transparent vitreous cortex during vitreoretinal surgery. Dev Ophthalmol. 2008;42:35-42. [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].
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].
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