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Accuracy of Spectral-Domain OCT of the Macula for Detection of Complete Posterior Vitreous Detachment

Published:November 01, 2019DOI:https://doi.org/10.1016/j.oret.2019.10.013

      Purpose

      To assess the accuracy of macular spectral-domain OCT in detecting complete posterior vitreous detachment (PVD).

      Design

      Evaluation of diagnostic test or technology using a retrospective comparative study.

      Participants

      One hundred seventy-five eyes in 175 patients (111 women and 64 men; mean age, 65 years) with preoperative OCT within 90 days of vitrectomy.

      Methods

      Posterior vitreous detachment status on preoperative macular OCT was compared with PVD determination during vitrectomy. Attached vitreous was identified on OCT by visualizing the posterior vitreous cortex or premacular bursa. Complete PVD was identified by the absence of these findings and considered a positive outcome for the purpose of analysis.

      Main Outcome Measures

      Sensitivity, specificity, positive predictive value, and negative predictive value of macular OCT for detection of complete PVD compared with findings at surgery.

      Results

      Of the 38 eyes graded as showing complete PVD on OCT, 20 eyes were found to have pre-existing PVD at the time of surgery (true-positive results), and 18 eyes were found to have attached vitreous at the time of surgery (false-positive results). Of the 137 eyes graded as showing attached vitreous on OCT, 129 eyes had attached vitreous at the time of surgery (true-negative results), and 8 eyes had pre-existing PVD at the time of surgery (false-negative results). The sensitivity of OCT for detecting complete PVD was 71% and the specificity was 88%. In the study population, the positive predictive value of an OCT scan showing complete PVD was 53%, whereas the negative predictive value of an OCT scan showing attached vitreous was 94%.

      Conclusions

      If the premacular bursa or posterior vitreous cortex are visualized on macular OCT, an accurate determination of attached vitreous can be made. The diagnosis of complete PVD by macular OCT is less accurate and requires ultrasound.

      Abbreviations and Acronyms:

      PVD (vitreous detachment)
      Posterior vitreous detachment (PVD) is the age-related separation of vitreous from retina.
      • Tozer K.
      • Johnson M.W.
      • Sebag J.
      Vitreous aging and posterior vitreous detachment.
      At birth, the vitreous body is firmly attached to the retina and there is no PVD. Age-related vitreous liquefaction and weakening of vitreoretinal adhesion lead at first to partial PVD and later to complete PVD. OCT can be used to detect eyes with no PVD by visualization of the premacular bursa and to detect eyes with partial PVD by visualization of the posterior vitreous cortex as initially described by Uchino et al
      • Uchino E.
      • Uemura A.
      • Ohba N.
      Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography.
      and refined by Johnson.
      • Johnson M.W.
      Perifoveal vitreous detachment and its macular complications.
      Posterior vitreous detachment status may be assessed by physical examination, ultrasonography, or OCT, with varying degrees of accuracy. Posterior vitreous detachment status, specifically vitreomacular adhesion, has been correlated with disease prognosis and response to anti–vascular endothelial growth factor treatment in diabetic retinopathy, exudative age-related macular degeneration, and retinal vein occlusion.
      • Mayr-Sponer U.
      • Waldstein S.M.
      • Kundi M.
      • et al.
      Influence of the vitreomacular interface on outcomes of ranibizumab therapy in neovascular age-related macular degeneration.
      • Singh R.P.
      • Habbu K.A.
      • Bedi R.
      • et al.
      A retrospective study of the influence of the vitreomacular interface on macular oedema secondary to retinal vein occlusion.
      • Ono R.
      • Kakehashi A.
      • Yamagami H.
      • et al.
      Prospective assessment of proliferative diabetic retinopathy with observations of posterior vitreous detachment.
      • Krebs I.
      • Brannath W.
      • Glittenberg C.
      • et al.
      Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration?.
      • Robison C.D.
      • Krebs I.
      • Binder S.
      • et al.
      Vitreomacular adhesion in active and end-stage age-related macular degeneration.
      • Sebag J.
      Vitreous in age-related macular degeneration therapy—the medium is the message.
      Although some studies used ultrasound to diagnose PVD,
      • Krebs I.
      • Brannath W.
      • Glittenberg C.
      • et al.
      Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration?.
      ,
      • Robison C.D.
      • Krebs I.
      • Binder S.
      • et al.
      Vitreomacular adhesion in active and end-stage age-related macular degeneration.
      many of these studies relied on OCT to assess PVD status despite the scarcity of studies validating the use of OCT in this context. Nonetheless, OCT is commonly obtained during preoperative evaluation of macular and retinal diseases and can potentially provide information about PVD status and guide presurgical planning and counseling. For example, preoperative PVD status may affect the choice among pneumatic retinopexy, scleral buckle, or vitrectomy to repair a retinal detachment,
      • Rezende F.A.
      • Kapusta M.A.
      • Costa R.A.
      • Scott I.U.
      Preoperative B-scan ultrasonography of the vitreoretinal interface in phakic patients undergoing rhegmatogenous retinal detachment repair and its prognostic significance.
      and a patient with a pre-existing PVD may have a lower risk for iatrogenic tear during macular surgery.
      • Tan H.S.
      • Mura M.
      • Smet M.D.D.E.
      Iatrogenic retinal breaks in 25-gauge macular surgery.
      Thus, the accuracy of PVD diagnosis by OCT is an important area for investigation. In this study, we evaluated the accuracy of preoperative spectral-domain OCT of the macula for determining PVD status in comparison with intraoperative findings during vitrectomy.

      Methods

      Medical College of Wisconsin Institutional Review Board approval was obtained with a waiver of informed consent (study number, PR000031324). The study conformed to Health Insurance Portability and Accountability Act regulations and was performed in accordance with the tenets of the Declaration of Helsinki. A retrospective chart review was conducted comparing PVD status on operative notes compared with preoperative OCT scans. A total of 552 retina clinic patients older than 18 years who underwent primary vitrectomy at the Froedtert Eye Institute and the Medical College of Wisconsin Eye Institute between January 1, 2009, and December 31, 2017, were screened. Operative notes lacking clear descriptions of posterior vitreous status were excluded, as were eyes that had previously undergone vitrectomy. Operative notes were classified as either attached vitreous or pre-existing complete PVD. If a patient had 2 eyes that underwent vitrectomy during this period that met eligibility criteria, 1 eye was selected randomly. Of the initial 552 patients, 248 were included for OCT review and correlation with surgical findings.
      Spectral-domain OCT images were obtained using the Heidelberg Spectralis with 15 scans averaged (Heidelberg Engineering, Heidelberg, Germany), the Topcon 3DOCT (Topcon, Tokyo, Japan), and the Cirrus 5000 (Carl Zeiss Meditec, Inc, Dublin, CA). Of the total 175 eyes, 164 were imaged with the Spectralis device, 8 with the Topcon device, and 3 with the Cirrus device. Repeating the analysis with only the 164 eyes imaged with Spectralis did not affect the results significantly. Twelve 6-mm radial fovea-centered scans were obtained up to 90 days before surgery. A power calculation indicated that review of 176 OCT scans would provide 95% power with an α of 0.001 for a Fisher exact test assuming 20% prevalence of stage 4 PVD by 1 method and a difference in rates of 37% between the 2 methods.
      Two masked ophthalmologists (E.S.H. and D.V.W.) independently graded PVD status according to a decision tree (see Supplemental Fig S1, available at www.ophthalmologyretina.org). Disagreement regarding stage was resolved by joint review of the OCT scans. Although the decision tree was used to classify each eye according to PVD stages 0, 1, 2, 3, 4, and abnormal for the purposes of comparison with intraoperative findings, stages 0, 1, 2, 3, and abnormal were categorized together as attached vitreous and stage 4 was categorized separately as complete PVD. Of the eyes with attached vitreous, 3 eyes were categorized as stage 0, 24 eyes were categorized as stage 1, 44 eyes were categorized as stage 2, 51 eyes were categorized as stage 3, and 15 eyes were categorized with abnormal PVD.
      The decision tree was based on a previously published OCT staging system that uses a 9-mm OCT scan length that includes the optic nerve.
      • Ma F.
      • Arcinue C.A.
      • Barteselli G.
      • et al.
      Optical coherence tomography findings of the vitreoretinal interface in asymptomatic fellow eyes of patients with acute posterior vitreous detachment.
      Our retrospective study used a 6-mm OCT scan length, which does not include the optic nerve. To assess the potential impact of this, we performed a limited study of 63 eyes that underwent 6-mm and 16.5-mm OCT scans.
      • Hwang E.S.
      • Kraker J.A.
      Comparison of wide-field and conventional spectral domain optical coherence tomography for staging of posterior vitreous detachment. Oral presentation at American Society of Retina Specialists Annual Meeting.
      The results of this study supported our assumption that if the posterior vitreous cortex is visible on the 6-mm scan, it is attached to the optic nerve (stage 3), and that if it is not visible on the 6-mm scan and the premacular bursa is not visible, the vitreous is separated from the optic nerve (stage 4).
      Scans without visible posterior vitreous cortex or premacular bursa of Worst were classified as stage 4 if the scan position and quality were adequate to rule out the presence of the premacular bursa (as would be seen in a stage 0 eye). Eyes were judged to have an acceptable scan position if the top of the scan was at least 3 so-called retina thicknesses above the retinal pigment epithelium at the foveal center. This criterion was selected to capture the anterior edge of the premacular bursa, which was reported to be approximately 708 μm over the retina at the foveal center,
      • Itakura H.
      • Kishi S.
      Evolution of vitreomacular detachment in healthy subjects.
      based on a nasal retinal thickness on the Spectralis of 344 μm.
      • Tick S.
      • Rossant F.
      • Ghorbel I.
      • et al.
      Foveal shape and structure in a normal population.
      Retina thickness was measured at the nasal edge of the horizontal scan for each eye unless this retina was thickened or thinned pathologically, in which case a temporal edge was selected. Eyes without any scans that met the position requirement were excluded as short (“s”). Eyes with grainy-appearing vitreous on all 12 scans were excluded as poor quality (“q”). Scan position and quality were assessed only in eyes in which the premacular bursa and posterior vitreous cortex were not visible.

      Results

      Two ophthalmologists independently graded pre-operative spectral-domain macular OCT scans of patients undergoing vitrectomy surgery (Fig 1). OCT scans of 247 eyes were evaluated, and 72 eyes without visible posterior vitreous cortex or premacular bursa were excluded because of inadequate OCT image quality or scan position. One hundred seventy-five eyes of 175 patients (111 women, 64 men) with an average age of 65 years were included in the analysis for comparison against intraoperative findings (Table 1). The κ statistic was 0.57, indicating moderate agreement between graders. A major source of disagreement was the scan position and quality criteria. Attached vitreous was identified on OCT by visualizing the posterior vitreous cortex or the premacular bursa. Complete PVD was identified by the absence of these findings and considered a positive outcome for the purpose of the analysis.
      Figure thumbnail gr1
      Figure 1Example 6-mm OCT scans demonstrating posterior vitreous detachment classification. Attached vitreous includes (A) stage 0, (B) stage 1, (C) stage 2, (D) stage 3, and (E) abnormal stage and was identified by either the premacular bursa (arrowheads) or posterior vitreous cortex (arrows). Complete posterior vitreous detachment is represented by (F) stage 4, in which neither the premacular bursa nor the posterior vitreous cortex were visualized. Scans were excluded if they had (G) insufficient scan height or (H) insufficient scan quality. Image brightness has been adjusted to maintain quality during printing. Staging system modified from Ma et al.
      • Ma F.
      • Arcinue C.A.
      • Barteselli G.
      • et al.
      Optical coherence tomography findings of the vitreoretinal interface in asymptomatic fellow eyes of patients with acute posterior vitreous detachment.
      Table 1Characteristics of Eyes Included in Comparison between OCT and Surgery
      CharacteristicData
      Age (yrs), mean±SD65±12
      Gender, no. (%)
       Female111 (63)
       Male64 (37)
      Race, no. (%)
       White141 (81)
       Black27 (15)
       Hispanic4 (2)
       Asian3 (2)
      Eye, no. (%)
       Right79 (45)
       Left96 (55)
      Refractive error (D), no. (%)
       High myopia (<–6)6 (3)
       Low myopia (<–1 and ≥–6)36 (20)
       Emmetropia (<+1 and ≥–1)31 (18)
       Hyperopia (≥+1)34 (19)
       Not available69 (39)
      Days between OCT and surgery, mean±SD30±19
      Intraoperative steroids used, no. (%)126 (72)
      Diagnoses, no. (%)
       Macular hole93 (53)
       Epimacular membrane with pucker37 (21)
       Proliferative diabetic retinopathy23 (13)
       Other
      Other diagnoses include age-related macular degeneration, cataract, glaucoma, retinal detachment, vitreous hemorrhage, vitreomacular traction, and vitreous opacities.
      22 (13)
      Previous intravitreal injections, no. (%)
       None164 (93.5)
       Anti–vascular endothelial growth factor8 (4.5)
       Ocriplasmin3 (2)
      Previous retinal laser, no. (%)
       None154 (88)
       Panretinal photocoagulation15 (9)
       Other retinal laser
      Other laser treatments include focal or grid, photodynamic therapy, and laser retinopexy.
      6 (3)
      D = diopter; SD = standard deviation.
      Other diagnoses include age-related macular degeneration, cataract, glaucoma, retinal detachment, vitreous hemorrhage, vitreomacular traction, and vitreous opacities.
      Other laser treatments include focal or grid, photodynamic therapy, and laser retinopexy.
      By OCT, we graded 137 eyes as attached vitreous and 38 eyes as complete PVD. Posterior vitreous detachment stage on OCT was compared with the surgeon’s description of vitreous status in the operative note (Table 2). The operative notes were categorized in a binary fashion as describing either attached vitreous or detached posterior vitreous. Eyes with operative notes lacking a description of the vitreous status were excluded. At surgery in the entire group, 28 eyes showed pre-existing PVD and 147 eyes showed attached vitreous.
      Table 2Results of OCT Classification of Posterior Vitreous Detachment Stage
      ClassificationNo. of Eyes
      Attached vitreous by OCT137
       Attached vitreous at surgery129
      OCT stage 01
      OCT stage 122
      OCT stage 243
      OCT stage 350
      OCT stage a13
       Complete PVD at surgery8
      OCT stage 02
      OCT stage 12
      OCT stage 21
      OCT stage 31
      OCT stage a2
      Complete PVD by OCT38
       Attached vitreous at surgery
      OCT stage 418
       Complete PVD at surgery
      OCT stage 420
      PVD = posterior vitreous detachment.
      Of the 38 eyes graded as showing complete PVD on OCT, 20 eyes were found to have pre-existing PVD at the time of surgery (true-positive results), and 18 eyes were found to have attached vitreous at the time of surgery (false-positive results). Of the 137 eyes graded as showing attached vitreous on OCT, 129 eyes showed attached vitreous at the time of surgery (true-negative results), and 8 eyes showed pre-existing PVD at the time of surgery (false-negative results). The sensitivity of OCT for detecting complete PVD was 71% and the specificity was 88%. In the study population, the positive predictive value was 53% and the negative predictive value was 94%.
      The most common diagnosis was macular hole (53%), followed by premacular membrane with pucker (21%) and proliferative diabetic retinopathy (13%). Thirteen percent of eyes demonstrated miscellaneous diagnoses (age-related macular degeneration, cataract, glaucoma, retinal detachment, vitreous hemorrhage, vitreomacular traction, and vitreous opacities). Eyes undergoing vitrectomy for macular hole and premacular membrane with pucker were compared. Attached vitreous was found significantly more frequently in eyes with macular hole (90%) compared with eyes with premacular membrane with pucker (73%; P < 0.0001, Fisher exact test). In eyes with macular hole, the sensitivity of preoperative OCT in correctly diagnosing PVD was 67%, specificity was 88%, positive predictive value was 38%, and negative predictive value was 96%. In eyes with premacular membrane with pucker, sensitivity was 20%, specificity was 85%, positive predictive value was 33%, and negative predictive value was 74%.

      Discussion

      We compared PVD staging on spectral-domain OCT of the macula with intraoperative findings. Because our study was retrospective, the OCT scans were not obtained with the enhanced vitreous imaging technique.
      • Kim Y.C.
      • Harasawa M.
      • Salcedo-Villanueva G.
      • et al.
      Enhanced high-density line spectral-domain optical coherence tomography imaging of the vitreoretinal interface: description of selected cases.
      • Liu J.J.
      • Witkin A.J.
      • Adhi M.
      • et al.
      Enhanced vitreous imaging in healthy eyes using swept source optical coherence tomography.
      • Spaide R.F.
      Visualization of the posterior vitreous with dynamic focusing and windowed averaging swept source optical coherence tomography.
      This technique is optimum for visualization of vitreous structures, but our findings using regular OCTs are more applicable to images obtained in routine clinical practice. We classified OCT scans of adequate scan height and image quality as consistent with complete PVD when neither the premacular bursa nor the posterior vitreous cortex were visualized. Using this strategy, we found poor sensitivity (71%) for detection of complete PVD, indicating that ultrasound is necessary to identify complete PVD accurately, confirming previous findings.
      • Arzabe C.W.
      • Akiba J.
      • Jalkh A.E.
      • et al.
      Comparative study of vitreoretinal relationships using biomicroscopy and ultrasound.
      However, we found a specificity of 88% in ruling out PVD, indicating that when the posterior vitreous cortex or premacular bursa are visualized on OCT, attached vitreous will likely be encountered during vitrectomy. Seeing an early stage PVD on OCT may guide a surgeon away from pneumatic retinopexy toward a scleral buckle for retinal detachment repair or suggest that a patient is at higher risk for an intraoperative tear developing during vitrectomy for macular pathologic features. However, if neither the premacular bursa nor the posterior vitreous cortex are visualized, spectral-domain OCT has poor predictive value.
      Using Ovid MEDLINE, we searched the terms vitreous detachment, pre-operative, OCT, and macular hole and found 1 other publication that made this comparison. Kičová et al
      • Kičová N.
      • Bertelmann T.
      • Irle S.
      • et al.
      Evaluation of a posterior vitreous detachment: a comparison of biomicroscopy, B-scan ultrasonography and optical coherence tomography to surgical findings with chromodissection.
      compared spectral-domain OCT images of the macula with intraoperative findings. They observed the posterior vitreous cortex without attachment to the retina in 8 eyes, which they interpreted as a complete PVD. In 7 of 8 eyes, they found the vitreous to be attached during vitrectomy and concluded that OCT was inaccurate. In contrast, we interpreted the presence of the posterior vitreous cortex in the scan area without visible attachment as evidence for vitreous attached only to the optic nerve (i.e., stage 3 partial PVD) and found better correlation with intraoperative findings. Our comparison of 6-mm scan length with 16.5-mm scans supported our ability to distinguish stage 3 from stage 4 PVD without visualizing the optic nerve. Kičová et al also compared intraoperative findings with preoperative ultrasound and biomicroscopy results and found that ultrasound was more accurate, although the correlation was imperfect. Thus, in patients not undergoing surgery, ultrasound is the gold standard to detect complete PVD in the clinic.
      Rahman et al
      • Rahman R.
      • Chaudhary R.
      • Anand N.
      Verification of posterior hyaloid status during pars plana vitrectomy, after preoperative evaluation on optical coherence tomography.
      published a prospective study that showed good correlation of PVD status on 3-dimensional OCT of the optic nerve head with intraoperative findings. This methodology is likely limited in its ability to distinguish an early stage of PVD (stage 0 or stage 1) from complete PVD (stage 4), because in both cases, the posterior vitreous cortex would not be seen inserting into the optic disc. The greatest challenge for OCT is to distinguish between stage 0 (completely attached vitreous) and stage 4 (complete PVD). Our strategy was to classify an eye as stage 0 if the premacular bursa was visible but the posterior vitreous cortex was not. If neither the premacular bursa nor the posterior vitreous cortex were visible, we assessed whether the scan was of adequate position and quality to be able to exclude the presence of the premacular bursa. However, very few eyes in this study were classified as stage 0, which limits our ability to assess the accuracy of visualization of this classification method but reflects the advanced age and high prevalence of at least partial PVD in the population undergoing vitrectomy. Further work should be carried out to determine under which circumstances the premacular bursa can and cannot be visualized, perhaps with swept-source OCT.
      One potential cause of discordance between OCT and surgical findings could be interval development of complete PVD between the date of the OCT and the date of surgery. The mean time between OCT and surgery was 31±19 days. In the subgroup with attached vitreous on OCT and complete PVD at surgery, the mean time was similar (33±8 days), suggesting that this was not a significant confounder.
      Splits within the posterior vitreous cortex (vitreoschisis) contribute to the pathogenesis of vitreomacular diseases and may confound assessment of PVD status both during surgery and by OCT.
      • Sebag J.
      Vitreoschisis.
      • Gupta P.
      • Yee K.M.P.
      • Garcia P.
      • et al.
      Vitreoschisis in macular diseases.
      • Sebag J.
      • Gupta P.
      • Rosen R.R.
      • et al.
      Macular holes and macular pucker: the role of vitreoschisis as imaged by optical coherence tomography/scanning laser ophthalmoscopy.
      During surgery, a layer of vitreous cortex can remain after an apparent complete PVD, which may be detected only when chromodissection with a dye or steroid is used.
      • Haritoglou C.
      • Sebag J.
      Indications and considerations for chromodissection.
      Steroids were used during surgery in 72% of the vitrectomies included in this study. Vitreoschisis may also be apparent on OCT, but it may also be present but undetected at times.
      • Sebag J.
      Vitreoschisis in diabetic macular edema.
      Another limitation of this study was our reliance on surgeon description of vitreous status in the operative note. The accuracy of surgeon notes could be affected by faulty assessment of vitreous status when steroids are not used, by the vitreous becoming detached in the very early part of the vitrectomy or by errors in dictation. During the screening process, 43% of eyes were excluded because of lack of surgeon description of vitreous status, which may have resulted in a bias in which more eyes with attached vitreous were included, because presumably surgeons were more likely to comment on the vitreous status if they found it to be attached and had to lift it off the retina. In addition, eyes were excluded on the basis of scan position or quality only when the scan appeared to be consistent with stage 4 complete PVD, which also may have led to overrepresentation of eyes with attached vitreous.
      During surgery, we found attached vitreous in 90% of the eyes with macular holes, consistent with the reports by others of attached vitreous (macular hole stages 1–3) in 79% of eyes by OCT
      • Jackson T.L.
      • Donachie P.H.J.
      • Sparrow J.M.
      Database Study of Vitreoretinal Surgery: report 2, macular hole.
      and 88% of eyes by ultrasound.
      • Wang M.Y.
      • Nguyen D.
      • Hindoyan N.
      • et al.
      Vitreo-papillary adhesion in macular hole and macular pucker.
      At surgery, we found attached vitreous in 61% of eyes with premacular membrane and pucker, which was more than Koizumi et al,
      • Koizumi H.
      • Spaide R.F.
      • Fisher Y.L.
      • et al.
      Three-dimensional evaluation of vitreomacular traction and epiretinal membrane using spectral-domain optical coherence tomography.
      who found attached vitreous in 17% of eyes with premacular membrane and pucker by OCT, and Wang et al,
      • Wang M.Y.
      • Nguyen D.
      • Hindoyan N.
      • et al.
      Vitreo-papillary adhesion in macular hole and macular pucker.
      who by ultrasound found no PVD in only 7% of eyes with premacular membrane and pucker. A high prevalence of vitreoschisis in eyes with premacular membrane and pucker could contribute to these discrepancies.
      • Rahman R.
      • Chaudhary R.
      • Anand N.
      Verification of posterior hyaloid status during pars plana vitrectomy, after preoperative evaluation on optical coherence tomography.
      ,
      • Sebag J.
      Vitreoschisis.
      In our study, the prevalence of pre-existing complete PVD, and therefore the positive and negative predictive values, may not reflect the population of patients undergoing vitrectomy in clinical practice.
      The depth of field of OCT is a significant limitation because after complete PVD, the vitreous cortex may be located a significant distance anterior to the retina. We relied on the absence of the premacular bursa and posterior vitreous cortex to classify OCT images as showing complete PVD but found that this method has poor sensitivity for detection of complete PVD. In contrast, we found a high specificity, suggesting that the OCT images of most eyes with attached vitreous demonstrate the premacular bursa or posterior vitreous cortex. Ultrasound has a better depth of field and the capability to evaluate movement, which facilitate assessment of vitreoretinal adhesion and separation.
      • Sebag J.
      • Silverman R.
      • Coleman D.
      To see the invisible—the quest of imaging vitreous.
      Swept-source OCT has a greater anterior depth of field and may have an improved ability to visualize the vitreous compared with spectral-domain OCT,
      • Liu J.J.
      • Witkin A.J.
      • Adhi M.
      • et al.
      Enhanced vitreous imaging in healthy eyes using swept source optical coherence tomography.
      ,
      • Spaide R.F.
      Visualization of the posterior vitreous with dynamic focusing and windowed averaging swept source optical coherence tomography.
      but the accuracy of swept-source OCT for detection of complete PVD will need to be tested against ultrasound or intraoperative findings.

      Supplementary Data

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