eMedicine Specialties > Ophthalmology > Vitreous

Vitreous Wick Syndrome

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
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
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Updated: Dec 20, 2007

Introduction

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.

Clinical

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

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