Vitreous detachment is the most common modification of the vitreous body, the clear, transparent gel that fills the eyeball normally attached to the retina, which occurs with senescence

It consists of the separation between the posterior vitreous and the anterior part of the retina, the important tissue of nerve origin that forms the innermost membrane of the eye, and may be localised, partial or total.

It may occur suddenly or over the course of several months.

This event can occur in a more or less traumatic manner and cause, should there be a predisposition or pathological vitreoretinal adhesion, some even serious complications such as retinal lacerations up to retinal detachment, the latter event that can lead to blindness.

In fact, retinal detachment in Italy ranges from 0.3 to 3%, with approximately 7,000 new cases per year out of approximately 60 million inhabitants.

The retina enables light and electromagnetic energy to be transformed into electrical potential for the brain to be translated into images.

When the vitreous body (or vitreous humour or, more simply, vitreous) detaches, it loses adhesion, retreating towards the centre of the eyeball.

The consequence is that the subject facing this disorder tends to see ‘moving bodies’ or myodesopias (flying flies), i.e., condensed vitreous fibrils that cast shadows on the retina with incident light, generating precisely this sensation.

Photopsias (seeing flashes and flashes of light) may also be present and in general vision may appear blurred.

This condition is very common in older people and is considered by doctors to be a normal condition, when it is obviously not caused by other situations.

Older people, however, should contact their doctor if they complain of symptoms in order to avoid complications, which, although rare, are possible.

Symptoms

Typically, a person suffering from vitreous detachment has no symptoms and no visual disturbances.

In cases where this condition is symptomatic, however, the most common sign is that the patient sees ‘moving bodies’, flying flies, moving dots or shapes such as wires and cobwebs.

The patient may also perceive flashes, circles and/or sudden lines of light (this disorder is called photopsia) probably due to a mechanical stimulus on the retina by the detached or partially detached posterior vitreous.

He may also see more blurry than usual.

These shapes are best perceived when looking at a bright surface and in bright conditions, such as looking towards the sky, a white wall, a white sheet of paper or a computer screen with a light background.

It should be emphasised that vitreous detachment does not cause loss of vision and is not painful, which is why when – as in most cases – this condition is asymptomatic people may be completely unaware that they have it.

Possibly causing a decrease in visual capacity or even blindness are the complications that may arise from vitreous detachment (however rare).

Symptoms of vitreous detachment usually last a short time, about 6 months, and in many cases may even disappear within a week.

The duration of symptoms, however, is not related to the level of severity of the disease, and a vitreous detachment that takes longer is not necessarily more dangerous.

There is no correlation.

Causes of vitreous detachment

Vitreous detachment has an incidence of 53 per cent at 50 years of age and 65 per cent in subjects over 65 years of age, with a higher frequency in women and myopic subjects; in addition, changes due to cataract extraction further increase the incidence.

The main cause is ageing.

In fact, with advancing age, the vitreous humour tends to lose some of its constituent hyaluronic acid and thus become progressively more watery (remember that it is 98-99% water).

The consistency then becomes less gelatinous than usual, retracts from the retina and moves towards the centre of the eye, losing adherence from the inner tonaca.

These processes tend to accentuate with body dehydration, justifying its higher incidence in the summer months.

It generally affects individuals over the age of 65, so ophthalmologists do not consider vitreous detachment a morbid condition, but rather a natural change that many individuals encounter sooner or later.

There are also situations that cause vitreous detachment, but which do not depend on advancing age, i.e., if previous trauma has been suffered, if, as mentioned above, the subject is dehydrated, has had surgery such as cataracts or has dealt with inflammatory processes of the eye such as uveitis (vitritis, retinitis), but these are less common.

Risk factors

As already mentioned, the main risk factor is advanced age, but there are other factors that can favour vitreous detachment, especially then in younger subjects.

These include:

• severe myopia (the elongation process typical in the eyes of those suffering from this refractive defect alters the biochemical balance of the vitreous gel)
• uveitis (inflammation of the uvea, i.e. the middle layer that lies between the sclera and retina, which causes liquefaction of the vitreal gel causing inflammation)
• having undergone intraocular laser treatment
• previous intraocular microsurgery surgery
• previous ocular trauma (as a result of shocks)

In these cases, posterior vitreous detachment is considered a complication and an ophthalmic examination should be carried out to check the integrity of the retina and avoid consequences that could be very serious.

Diagnosis

If the person notices that he or she is seeing the particular shapes and deformities given by the typical symptoms of a vitreous detachment, he or she should contact a doctor specialising in eye diseases, i.e. an ophthalmologist.

This professional performs a thorough test of the ocular fundus using the slit lamp, an instrument that allows precise identification of the internal structures of the eyeball, from the vitreous humour to the retina.

To assess its state, he uses an eye drop that dilates the pupil and acts within 30 minutes, ending its effect after 6 hours.

During this time, the patient is limited in his vision, so he should not drive.

In essence, it is a microscope that emits a powerful but completely harmless beam of light to the health of the eye.

The eye fundus test also allows the ophthalmologist to detect retinal pathologies, such as retinal tears, retinal detachment, macular holes.

The doctor can, using an ophthalmoscopic helmet and with the use of some special lenses placed or brought closer on the eye, check the entire retina including the most anterior portion and any vitreous traction.

Complications following vitreous detachment are rare but still possible

In fact, in some cases this disease causes, as already mentioned, damage to the retina.

In particular, it can lead to morbid conditions such as

• retinal rupture: this occurs when a part of the retina is damaged to a greater or lesser extent;
• retinal detachment: this occurs when the retina detaches from its supporting tissues, to which, in normal situations, it adheres perfectly;
• macular hole: a condition in which an opening forms on the macula, i.e. the central vision area of the retina, which interrupts the normal retinal continuity.

Rupture and retinal detachment are closely linked, so much so that the former very often anticipates the occurrence of the latter.

But why can vitreous detachment damage the retina?

The vitreous body, as it moves towards the centre of the eyeball, drags with it what it is attached to, i.e. the retina.

If it is particularly violent, this displacement can cause retinal tears or openings at the macula.

Interventions and therapies

Today, there is no specific treatment for vitreous detachment. Since in many cases this condition is even asymptomatic and in most cases considered completely ‘natural’ with age, there are not even ways to prevent it, i.e. eye exercises, special diets (once considered effective) and the daily intake of certain vitamins are completely useless.

In most cases, the only solution is to wait for the symptoms to disappear spontaneously, which usually happens within six months.

In fact, as time passes, the shadows appear more and more faded and are visually perceived less and less, as the brain tends to ignore the disturbing image.

In these cases, however, there are good practices one can follow to speed up the healing process: hydrating the body, drinking plenty of water, including fruit and vegetables in the diet and taking targeted and specific supplements.

These practices are most helpful in reducing symptoms related to posterior vitreous detachment, such as annoying myodesopias or vision of ‘flying flies’.

Finally, trauma and physical exertion should be avoided and periodic eye examinations should be routine in elderly subjects.

Clearly, the matter changes if the vitreous detachment leads to a complication, i.e., the onset of a macular hole or retinal injury. In this case, action must be taken as soon as possible.

In fact, failure to treat these situations in time can lead to serious loss of vision and, in some cases, even blindness.

What to do specifically?

• Retinal rupture: the most widely practised treatment is the use of lasers to seal the retinal tear and thus prevent retinal detachment.
• Retinal detachment: the treatment method adopted in this case depends on the severity of the situation. In the case of minor detachments, laser surgery, cryopexy and pneumoretinopexy may be sufficient; in the case of severe detachments, however, episcleral (cerclage) or endocular (vitrectomy) surgery must be used.
• Macular hole: there are two therapies available, vitrectomy (surgical procedure of total or partial removal of the vitreous body), which is indicated for all cases of macular hole, or ocriplasmin injection, which is only suitable for certain macular hole situations.

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