The role of vitreous cortex remnants in proliferative vitreoretinopathy formation demonstrated by histopathology: A case report

Abstract

Purpose: The pathogenesis of proliferative vitreoretinopathy (PVR), the most important cause of retinal detachment surgery failure, is still not fully understood. We previously hypothesized a causal link between vitreoschisis-induced vitreous cortex remnants (VCR) and PVR formation. The purpose of this case report is to demonstrate this association by showing the clinical occurrence of PVR in the presence of VCR across the retinal surface, illustrated by histopathological analysis.

Observations: A 69-year-old male was referred because of widespread epiretinal membrane formation after treatment of recurrent retinal detachments. During surgery with extensive membrane peeling, a large continuous membrane was peeled from the superior arcade towards the inferior temporal mid-periphery. Histopathological analysis of this membrane revealed areas with different characteristics: paucicellular laminar collagen-rich areas, suggestive for VCR, areas with increased cellularity, and more fibrotic areas with low cellularity.The immunohistochemical analysis identified cell type variety in these areas: collagen-rich areas showed glial cells and hyalocytes, while in areas with high cellularity fibroblasts, macrophages and retinal pigment epithelial cells were found, which have previously been shown to play an important role in the development of PVR as they can transdifferentiate into myofibroblasts, which were seen in the more fibrotic areas.

Conclusions and importance: These findings support the theory that VCR have a role in PVR development, where VCR can act as a scaffold for fibrocellular proliferation. We suggest that the presence of VCR over the retinal surface should be qualified as a risk factor for PVR formation. Detection and adequate removal of VCR may improve the success rate of retinal detachment surgery.

Keywords: PVR; Proliferative vitreoretinopathy; Retinal detachment surgery; VCR; Vitreoschisis; Vitreous cortex remnants.

Fig. 1

Fundus image at the beginning of the surgery (A) and during peeling of the epiretinal membrane, which extended from the superior arcade to the inferotemporal mid-peripheral retina (B). The dotted line indicates the area from where the membrane was removed. Microscopic image of the removed membrane stained with hematoxylin and eosin (C). Different continuous areas representing different stages of proliferative vitreoretinopathy can be distinguished: paucicellular, lamellar collagen-rich areas, suggestive for vitreoschisis-induced vitreous cortex remnants (C1); areas with increased cellular infiltration (C2); more fibrotic areas with low cellularity (C3). Pre-operative OCT image showing a significant pre-retinal membrane and an increased central macular thickness of 719 μm (D). Postoperative OCT image at last follow-up (12 months) showed a decreased central macular thickness of 462 μm (E). The BCVA was improved from 1.3 to 0.1 LogMAR.