Differentiating physiology from pathology in the paediatric vitreous

The second day of the International SPECTRALIS Symposium (ISS) is underway in Heidelberg, Germany. Dinah Zur, MD, presented as part of the retina session on Saturday, 14 July.

Dinah Zur, MD

Zur is an associate professor of clinical ophthalmology and head of the Center for Retinal Degenerations in the ophthalmology division of the Tel-Aviv Medical Center, Tel Aviv University, Israel. Here, she shares details from her ISS presentation, which centres on errors in optical coherence tomography (OCT) interpretation. Read on for her pearls, especially pertinent to paediatric imaging.

Ophthalmology Times Europe: Can you give a brief overview of what you’ll be presenting?

Dinah Zur, MD: I will be presenting findings from our study titled “Hyperreflective vitreous opacities in children: A key to avoiding misdiagnosis in OCT interpretation”, which was recently published in EYE Journal. Using over 12,000 [spectral domain OCT] SD-OCT images from healthy children and adults, we found that punctate hyperreflective vitreous opacities (PHVO) are not rare artifacts or signs of pathology, but ubiquitous physiological findings in healthy children. These were present in 100% of paediatric eyes versus 73% in young adults, suggesting a developmental origin, possibly hyalocytes.

OTE: Are there particular aspects of contemporary OCT imaging that make accurate diagnosis easier, or which presents pitfalls to avoid?

DZ: Modern OCT provides high-resolution, non-invasive imaging even in young children, allowing us to visualize the vitreoretinal interface in detail. However, the pitfall lies in overinterpreting findings without age-appropriate normative data. For example, PHVO can mimic signs of vitritis or inflammation. Without awareness of these normal age-related features, clinicians may overdiagnose and overtreat.

OTE: Why is so little known about the paediatric vitreous, particularly in healthy children?

DZ: Imaging the vitreous in children is limited by patient cooperation and technology. Most paediatric OCT research has focused on retinal or optic nerve parameters. Moreover, since the vitreous is often clinically “invisible,” it has been under-investigated unless pathology is suspected. Our study is among the few to systematically describe normative vitreous features in healthy children beyond infancy.

OTE: How has our understanding of posterior segment development evolved over the past decade?

DZ: With advances in OCT, particularly high resolution SD-OCT, SS-OCT, and wide field OCT we can now detect changes in vitreous configuration in young children -even from birth- such as the presence of vitreous cysterns and fissures, PHVO, the development of the premacular bursa, and changes in retinal thickness.

OTE: Are there common misdiagnoses or unnecessary interventions that this knowledge can help prevent?

DZ: Yes. PHVO in children can resemble vitreous cells seen in uveitis, potentially triggering an inflammatory workup or even treatment. This is particularly problematic in cases without supporting clinical signs of inflammation. Understanding PHVO as a normative feature can reduce diagnostic confusion and unnecessary systemic or invasive interventions.

OTE: Conversely, what features should raise concern and prompt follow-up?

DZ: Any asymmetry or of course any associated clinical findings of inflammation (e.g., AC cells, flare, vitreous haze) warrant further evaluation. In a previous study, we have shown that although Optic nerve head drusen (ONHD) were considered the most common cause for pseudopapilloedema in children, it is indeed peripapillary hyperreflective ovoid mass-like structures. This discovery was only possible with EDI-OCT.

It is really important to note that differentiating benign from pathological findings in this age group still relies on a careful combination of clinical exam and imaging interpretation.

OTE: What are the key takeaways clinicians should remember from this presentation?

DZ: PHVO are a physiologic finding in healthy children and should not be mistaken for pathology.

Age-appropriate interpretation of OCT is critical.

Awareness of developmental anatomy helps avoid overdiagnosis and unnecessary intervention. Still, further studies, especially using advanced imaging modalities and wider age cohorts, are needed to deepen our understanding of paediatric vitreous evolution.