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ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
Original article
Berger’s space 夽
E. Santos-Bueso
UnidaddeNeurooftalmología,ServiciodeOftalmología,InstitutodeInvestigaciónSanitariadelHospitalClínicoSanCarlos(IdISSC), Madrid,Spain
a r t i c l e i n f o
Articlehistory:
Received25April2019 Accepted20June2019 Availableonlinexxx
Keywords:
Berger Space Vitreous Wieger Egger
a bs t r a c t
IntroductionandObjective:TheBerger’sspace(BS)isaspacelocatedbetweentheposterior capsuleofthelensandtheanteriorhyaloidofthevitreous,structuresthatadhereina circularmannerbymeansoftheWiegerligament,forwhichtheouterlimitisdefinedby Egger´sline.TheaimofthisarticleistoperformareviewoftheBS,aswellastopresentthree casesinwhichthisBScouldbedemonstratedbyopticalcoherencetomography(OCT).
MaterialandMethod:Atotalof90patientsfromageneralophthalmologyclinicwerestudied, onwhomananteriorpoleOCTwasperformed(CirrusLumera700CarlZeissMedicte,Dublin, California,UnitedStates).Allpatientswereincludedconsecutively,withananalysisbeing performedonthecornea,anteriorchamber,iris,lens,andanteriorvitreous,butexcluding thoseinwhichthetestcouldnotbeperformed.
Results:Theposteriorlenscapsule,theanteriorhyaloid,andtheBSbetweenbothstructures wereobservedinthreepatients.Thisisthefirsttimeinthecurrentliteraturethatthree caseshavebeendescribed,togetherwiththeircharacteristics(onephakic–case1-andtwo pseudophakic,oneofthemvitreousdestructuring–case2-andtheotherwithopacification oftheposteriorcapsuleofthelens–case3-),usingthispreviouspoleOCTtechnique.
Conclusions: KnowledgeoftheBSisessentialtounderstandthevitreo-lenticularjunction andanycomplicationsinsomecataractsurgeries,aswellastoalsounderstandthepatho- logicaloriginofpigmentdispersionsyndrome.
©2019SociedadEspa ˜noladeOftalmolog´ıa.PublishedbyElsevierEspa ˜na,S.L.U.Allrights reserved.
EspaciodeBerger
Palabrasclave:
Berger Espacio Vítreo
r e su m e n
IntroducciónyObjetivo:ElespaciodeBerger(EB)esunespaciosituadoentrelacápsulapos- teriordelcristalinoylahialoidesanteriordelhumorvítreo,estructurasqueseadhierende formacircularmedianteelligamentodeWiegercuyolímiteexteriorestádelimitadoporla líneadeEgger.ElobjetivoesrealizarunarevisióndelEBasícomopresentartrescasosen losquesehapodidoevidenciaresteEBmediantetomografíadecoherenciaóptica(OCT).
夽Pleasecitethisarticleas:Santos-BuesoE.EspaciodeBerger.ArchSocEspOftalmol.2019.https://doi.org/10.1016/j.oftal.2019.06.006 E-mailaddress:[email protected]
2173-5794/©2019SociedadEspa ˜noladeOftalmolog´ıa.PublishedbyElsevierEspa ˜na,S.L.U.Allrightsreserved.
OFTALE-1539; No.ofPages7
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arch socesp oftalmol.2019;xxx(xx):xxx–xxxWieger Egger
MaterialyMétodo: Sehanestudiado90pacientesdeunaconsultageneraldeoftalmología, alosqueseharealizadounaOCTdepoloanterior(CirrusLumera700CarlZeissMeditec, Dublin,California,EstadosUnidos).Sehanincluidotodoslospacientesdeformaconsec- utivaanalizandocórnea,cámaraanterior,iris,cristalinoyelvítreoanterior,excluyendoa aquellosenlosquenopudorealizarselaprueba.
Resultados: Entrespacientessehapodidoevidenciarlacápsulaposteriordelcristalino,la hialoidesanterioryelEBentreambasestructuras.Describimosporprimeravezenlaliter- aturaactuallostrescasosenconjuntoyconlascaracterísticasquepresentan(unfáquico –caso1-ydospseudofáquicos,unodeelloscondesestructuraciónvítrea–caso2-yotrocon opacificacióndelacápsulaposteriordelcristalino–caso3-)medianteestatécnicadeOCT depoloanterior.
Conclusiones:ElconocimientodelEBesfundamentalparacomprenderlauniónvitreolentic- ularylasposiblescomplicacionesenalgunascirugíasdecatarataasícomoparaentender ademáslaetiopatogeniadelsíndromededispersiónpigmentaria.
©2019SociedadEspa ˜noladeOftalmolog´ıa.PublicadoporElsevierEspa ˜na,S.L.U.Todos losderechosreservados.
Introduction and objective
Thevitreous-lensjoinisdevelopedthroughcircularadherence ofthevitreoustothelensposteriorcapsule,constitutingthe Wiegerligament,theoutercircumferencelimitbeingEgger’s line,leavingacentralvirtualspaceknownastheBergerspace (BS).1–4Saidspaceisnotfoundinallpatientsasinmanycases thelensposteriorcapsuleadheresthroughoutitsextension totheanteriorhyaloidofthevitreous,withrepercussionsin cataractsurgerysuchaslensposteriorcapsulerupturewith vitreorrhagia,amongothers.
Opticalcoherencetomography(OCT)andtheanteriorpole module(CirrusLumera700CarlZeissMeditec,Dublin,Califor- nia,UnitedStates)enablesavisualizationofthelens,posterior lenscapsuleandadheredvitreouswhich,inthemajorityof patients,extendsthroughoutitssurfacewithoutshowingBS.
However,somepatientsexhibitaspacebetweenbothstruc- turesbehindthe lensposterior capsuleand infrontofthe anteriorhyaloids ofthe vitreous,whichcorrespondstothe BS.
The objective of the present paper is to review the BS andresearchitspresenceinasampleofgeneralconsultation patientsthatwerestudiedwithsaidOCT.
Material and methods
Thestudyincluded90patientswhoconsecutivelyvisitedthe generalpractice,withoutexclusioncriteriawiththeexception ofpatientsthatdidnotproduceasuccessfulOCTduetoocular pathologyinvolvingmediumopacityorsystemic,neurological orosteoarticularpathologythatpreventedimagecapture.
Outofthe90patientsincludedinthestudy,3casesarepre- sentedevidencingBSbetweentheposteriorlenscapsuleand theanteriorhyaloidsofthevitreoushumor.Forthefirsttime, theBSisdescribedwiththecharacteristicsofthepresentsam- ple,i.e.,onephakic—case1—and2pseudophakics,onewith vitreousdestructuring—case2—,andonewithlensposterior capsuleopacification—case3—,applyingsaidtechniquefor
thefirsttimesincetheBSwasdescribedbyÉmileBergerin 1887.
Results
The BS is located between the lens posterior capsule and theanteriorhyaloidofthevitreous(Fig.1),althoughinmost patientsitcannotbeseenwithOCT,whichshowsbothstruc- tures(anteriorhyaloidandlensposteriorcapsule)joinedasa singlestructure(Fig.2).
Case1
Male, 54, phakic, emmetropic, without relevant general or ophthalmological history or known allergies. Examination produced avisual acuity(VA) ofoneinbotheyes(BE) and
WIEGER LIGAMENT
EGGER’S LINE
BERGER’S SPACE
Fig.1–Schemaofthevitreous-lensjoinbymeansofthe Wiegerligament(bluecircle),Egger’sline(outerlineof Wiegerligament)andBerger’sspace.Thelensisshownin redandthevitreoushumorinblue(Forinterpretationof thereferencestocolourinthisfigurelegend,thereaderis referredtothewebversionofthisarticle).
Fig.2–Opticalcoherencetomographyshowingthelensandposteriorcapsulewithvitreousadheredthroughtheanterior hyaloidsthroughoutitsextension,withoutBerger’sspace.
intraocularpressure (IOP)of16mmHginBE.Biomicroscopy showednuclearcataractindevelopmentinBEwithnormal ocularfundus(OF)inBE.OCTrevealedaspacebetweenthe anteriorhyaloidandthelensposteriorcapsule,corresponding toBS(Fig.3).
Case2
Male, 70, pseudophakic, with −2.00 previous diopters (PD) beforecataractsurgery,withoutremarkablegeneraloroph- thalmological history or any known allergy. Examination producedVAof0.8inBEandIOPof16mmHginBE.Biomi- croscopyshowedstablepseudophakiainBEandnormalOFin BE.OCTrevealedaspacebetweenthehyaloidsandthelens posteriorcapsulecorrespondingtoBS(Fig.4).
Case3
Female, 74, pseudophakic with −8.00 PD diopters before cataractsurgery,withoutremarkablegeneralorophthalmo- logicalhistoryoranyknownallergies.Examinationproduced VA of0.4 inBE and IOPof 16mmHg inBE. Biomicroscopy showedstablepseudophakiainBE withlens posteriorcap-
suleopacificationinBEawaitingYAGlasercapsulotomyand normalOFinBE.OCTshowedaspacebetweentheanterior hyaloid andthe lensposteriorcapsulecorrespondingtoBS (Fig.5).
Discussion
BSwasdescribedbyÉmileBerger,anAustrianophthalmolo- gist(1825–1926)in1887asaspacebetweenthelensposterior capsuleandtheanteriorhyaloidscontainedatitsouterlimit byWieger’sligamentsandEgger’sline(Fig.1).SaidBScould continuealongtheErggeletspacelocatedintheanteriorsec- tionoftheCloquetcanalortheStillingductthattraversesthe thicknessofthevitreoustowardstheMartegianispacelocated infrontoftheopticpapilla.1–3
The prevalence of BS identified by means of OCT is unknown.ThepresentpaperdescribedBSin3patientsoutof asampleof90analyzedpatients.However,itisasmallsample thatshouldbeconfirmedbyotherlargerstudiesandwiththe progressivedevelopmentofOCTtechnology.Similarly,itisnot knowneitherwhetherthedevelopmentofBSisfacilitatedby changesinthevitreouscausedbyaging1includingliquefac- tionandsyneresisoccurringinthevitreousstructure,taking
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arch socesp oftalmol.2019;xxx(xx):xxx–xxxLENS
Lens posterior capsule
Berger’s space
S S
T T
I I
N N
HYALOIDS
4 4
VITREOUS
Fig.3–(leftandright).OpticalcoherencetomographyinphakicpatientshowingBe3rger’sspacebetweenthelensposterior capsuleandanteriorhyaloid.
intoaccountthat2ofthe3patientswere70and74yearsold respectivelyandthatonehad−8.00dioptermyopia(case3).
In2016,TassignonandNíDhubhghaill4described3cases inwhichBScouldbeseeninrealtimeduringcataractsurgery by means ofan OCT device connected to the microscope (ZeissOpmiLumera700/Rescan700system;ZeissLtd.,Jena, Germany).Listet al.5 described hemorrhageinthe BSofa 4-year-oldchild,secondarytotraumatismwhoprobablyhad rupturedWieger’sligament,withbloodaccumulationinthe BS.Kimetal.6discussedonecaseofdislocationofaposterior chamberphakicintraocularlensintheBSsecondarytoclosed traumatism.Debrulleetal.7described thecaseofapatient treatedwithdexamethasoneimplantthatremainedconfined intheBS.
Theimplications ofsaid BSindailypracticeare numer- ousandgreaterknowledgeaboutitisessentialtounderstand theperformanceofsomecataractsurgerytypesamongother things.
The vitreous-lens interface through Wieger’s ligament wouldexplainthepresenceofvitreorrhagiaincataractsurgery by means of the intracapsular extraction technique.8 The adherence ofWieger’sligament would have the secondary effect of dragging the anterior hyaloids when pulling the cataract,givingrisetovitreorrhagiathatcouldreachmassive proportions. Inless intenseor age-degeneration adherence cases,the activetractionofthe cataractwouldrupture the Wiegerligamentwithoutgivingrisetovitreorrhagia.
The BS that can be appreciated inthe cases discussed hereinisitessentialtoexplainintheabsenceofvitreorrhagia inphacoemulsification complicationsthatcoursewithlens posterior capsulerupture.When thelens posteriorcapsule isadheredtotheanteriorhyaloids,saidrupturescanextend tobothstructureswithsecondaryvitreorrhagiaduetobeing closely related.InpatientswithevidenceofBS,lensposte- riorcapsulerupturesdonotnecessarilyextendtotheanterior hyaloidsbecauseBSisbetweenbothstructures,thusavoiding
S
T
I N
3
S
T
I N
3
POSTERIOR CAPSULE
CAPSULAR SAC
HYALOIDS
VITREOUS DESTRUCTURING Berger’s space
INTRAOCULAR LENS
VITREOUS
Fig.4–(leftandright).OpticalcoherencetomographyinpseudophakicpatientshowingBerger’sspacebetweenthelens posteriorcapsuleandanteriorhyaloids.
vitreorrhagiaifthetraumatismproducedbythephacoemul- sifierisnotveryintense.
Inaddition,BScould accountforthelensposteriorcap- suleoscillationsinsomecataractsurgerieswithhardcores, particularlyinphacoemulsificationofthelastquadrant.The salinesolution would pass through theanterior surface of the iris, the zonule and the Petit space (a virtual space betweenthezonule and theanteriorhyaloids whichiscir- cumscribed by the Wieger ligament and the base of the vitreous),1–3 passingthroughdehiscenceoftheWiegerliga- mentstowardstheBS,raisingthe lensposteriorcapsulein wavesandapproximatingthephacoemulsificationterminal, withthepossibilityofexposingthelatterwithsecondaryrup- tureofsaidposteriorcapsule.Inthesecases,capsulerupture couldbeavoidedfillinginthecapsularsacwithviscoelastic toextract thelast quadrant, thus avoiding capsuleoscilla- tion.
In addition, in some phacoemulsification cases some remainsofacataractcouldpassthroughthezonuleandthe
PetitcanaltowardssaidBS.Theseremainscanbeseenatthe endofthephacoemulsificationprocedureapparentlyinthe vitreouswithoutproducinglens posteriorcapsuleruptures.
Due togravity,said remainsprecipitatetothe inferiorpart ofthe BS,beyondthevisualaxis, withoutproducing intra- orpostoperativecomplicationssuchasocularhypertension, hydrationorpost-surgeryuveitisintheshortaswellasinthe long-term.
Finally, Wieger’s ligament and BS are fundamental ele- ments in the etiopathogeny of the pigment dispersion syndrome. The pigment proceeding from iris-lens friction could also precipitatein the formofthe Krukenberg spin- dle,inthecornea,passingthroughthezonuleinretrograde movementtowardstheEggerlineandlinearlyprecipitating along the edge of Wieger’s ligament, constituting Scheie’s line. In some cases, said pigment can circularly surround the entire Wieger ligament, constituting the Zentmayer ring.9–11
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arch socesp oftalmol.2019;xxx(xx):xxx–xxxS
T 5 N
I
S
T 5 N
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OCPC
CAPSULAR SAC
HYALOIDS VITREOUS
INTRAOCULAR LENS POSTERIOR CAPSULE
Berger’s space
Fig.5–(leftandright).OpticalcoherencetomographyINpseudophakicpatientwithlensposteriorcapsuleopacification showingBerger’sspacebetweenthelensposteriorcapsuleandanteriorhyaloid.
Conclusions
BScanbeobservedinsomepatientsbymeansofOCT(Cir- rusLumera700CarlZeissMeditec,Dublin,California,United States)betweentheposteriorcapsuleofthelensandtheante- riorhyaloidsofthevitreoushumor.Thepresentstudyisthe first to observe and describe said BSin the literaturein 3 patientsexhibitingcompletelydifferentcharacteristicssince itsdiscovery byÉmileBergerinthe19thcentury. However, theauthorswereunabletodescribeWieger’sligament,Egger’s lineorErggelet’sspace.ThepresentstudyemphasizestheOCT imagesandtheanteriorpolemodulewithresolutiontoaccess thevitreous-lensjoinafterpenetratingthelensanditspos- teriorcapsule(case1)orintheintraocularlens,capsularsac withorwithoutlensposteriorcapsuleopacification(cases3 and2,respectively).
AdditionalstudiesarenecessarywithfutureOCTtechnol- ogydevelopmentsinorder tounderstandthe vitreous-lens
join,theprevalenceoftheseinvisiblestructuresinthegeneral populationaswellastherestofstructuresthatconstitutethis joinofthevitreoustothelensposteriorcapsule.
Knowledge ofthe vitreous-lensjoinand its characteris- tics isessential tounderstand the developmentofspecific cataractsurgerycomplicationsaswellastounderstandthe etiopathogenyofthepigmentsdispersionsyndrome.
Conflicts of interest
Noconflictofinterestwasdeclaredbytheauthors.
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