Approach Considerations
Treatment of vitreous wick syndrome, also known as vitreous touch syndrome, is primarily surgical but may also include medical therapy as appropriate. The surgical approach to the management of this syndrome depends on the presentation. No restrictions on diet are indicated. Participation in strenuous activities and contact sports is restricted until recovery is complete.
Pharmacologic Therapy
The type of topical antibiotics used in the treatment of vitreous wick syndrome depends on the suspected infecting agent or the culture and sensitivity results.
In cases of endophthalmitis, medical therapy is initiated that is known to be effective against the suspected or confirmed (via culture and sensitivity results) infecting agents. Subconjunctival and intravitreal antibiotics have been given. (See Bacterial Endophthalmitis and Postoperative Endophthalmitis.)
Surgical Therapy
The precise surgical treatment varies with the circumstances. The following is a generalized procedural description.
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 (see the image below).
Castroviejo sweep performed with a cyclodialysis spatula. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
Intracameral injection of pupil constrictors (carbachol intraocular solution) may help pull any remaining anterior-chamber vitreous wick back into the posterior segment. Intracameral preservative-free triamcinolone acetonide may help visualize vitreous strands. [8, 9] 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.
The patient is discharged on a regimen of topical antibiotics, either broad-spectrum or targeted on the basis of culture and sensitivity results. Nonsteroidal anti-inflammatory drug (NSAID)-containing ophthalmic drops are given to decrease cystoid macular edema. Steroid drops are given to decrease inflammation. Pilocarpine ophthalmic drops are given to maintain pupillary constriction and prevent anterior segment migration of posterior vitreous during the acute healing phase.
Patients should receive follow-up care 1-2 days after surgery. If this initial follow-up examination identifies no problems, regular checkups should be scheduled for uneventful anterior segment surgeries. The use of an eye shield, especially at night, protects the globe from any untoward traumatic episodes.
Prevention
Meticulous surgical technique is essential for all ophthalmic surgery. Fundamental surgical principles must be adhered to. All incisions must be closed securely.
In cases of broken capsules with vitreous presentation in the anterior segment, it is vital to ensure that all vitreous has been removed from the anterior segment by means of 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.
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Externalized vitreous with a peaked pupil. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
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Cellulose sponge teasing the vitreous wick. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
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Castroviejo sweep performed with a cyclodialysis spatula. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
