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Cisternal Anatomy of the Vitreous

edited by: J.G.F. Worst & L.I. Los

Price: € 113.00 / US $ 141.25

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Publication details: Book. 1995. xv and 148 pages. Publication date: 1995-07-31. 82 figures. Hardbound. Contains a stereoscopic viewer and 80 stereo slides.

ISBN: 978-90-6299-110-5 (ISBN 10: 90-6299-110-6; Kugler Publications)



Cisternal Anatomy is centered around the importance of the vitreous body as a separate compartment in the eye. It explains the specific properties of the vitreous making it a unique tissue of the body. The integrity of this compartment is important for the normal function of the lens and retina. The main purpose of the book is to give a general insight into the mechanisms inducing vitreous damage and the resulting pathological changes in the lens and retina. Cataract surgery is the most important cause of vitreous decompartmentalization. Strategies to limit vitreous damage induced by cataract surgery and the subsequent therapies of secondary cataract are proposed. The book discusses pathogenic mechanisms; it does not provide therapeutic regimens or technical details on intraocular surgery. The book is organized in a basic and a clinical part. Chapters 1 to 3 comprise its basic part and give information on vitreous anatomy, biochemistry and physiology. Chapters 5 to 7 form the clinical part and are devoted to a single clinicopathological entity each: aphakic cystoid macular oedema (Ch. 5), retinal detachment (Ch. 6)and diabetic retinopathy (Ch. 7). Chapter 4, by explaining mechanisms of vitreous barrier breakdown and its consequences, provides the essential link between both parts. We believe this book to be of interest to all clinicians confronted with diseases of the lens, the retina and the vitreous. Therefore, the book is primarily intended for ophthalmologists and ophthalmologists in training. It is of particular interest to cataract surgeons and vitreoretinal surgeons. It provides a sufficient amount of fundamental and clinical information to be of interest to research workers studying vitreoretinal and vitreolenticular relationships.

The authors
The subject of the vitreous in relation to the lens and retina has interested J.G.F. Worst for a long time. He began his studies on the anatomy of the vitreous in the late sixties with the serendipitous discovery of the bursa premacularis, a conspicuous intravitreal structure in front of the macula. Worst's clinical interest lies mainly in the field of intraocular surgery, in particular cataract surgery. He was one of the first ophthalmologists to start intraocular lens implantations in The Netherlands following the teaching of the originator of implantology, Dr. C.D. Binkhorst. Worst's clinical observations put him on the trail of a relationship between vitreous decompartmentalization following cataract surgery and various forms of intraocular pathology. In 1975, he summarized his anatomical and clinicopathological observations in a unifying theory, the compartmentalization concept l. Over the years he studied a large number of eye bank eyes by the ink injection technique. He has published the results obtained in this way separately 2,3. His observations were further documented in a 16 mm movie 4, several video tapes and a large number of 3D-slides. In addition, Worst did some work on the scanning electron microscopic morphology of the vitreous. The latter studies were done in collaboration with W.L. Jongebloed et al. at the Department of Histology and Cell Biology of Groningen University 5,6.Worst realized the clinical importance of the vitreous in relation to compartmentalization and decompartmentalization of the eye. This was why he attempted to introduce his observations and concepts to a wider public by giving numerous papers on this subject. Although Worst's concepts have always been appreciated by a number of ophthalmologists, for about 20 years he also met with substantial opposition. Conceptual recognition and support came when Leiden University nominated Worst, Boerhaave Professor in December 1990. On account of this professorship, Leiden University asked Worst to write a monograph on the vitreous. Even though this was in accordance with his own desire to publish his observations as a book, Worst could not effectively combine this with the full-time demands of a surgical practice. In order to ensure publication of his work, he assigned this task to L.I. Los, who was an employee of his at that time and as such familiar with his views and observations. As a result of this the study of the literature, the interpretations of Worst's views and observations in relation to those of others, the writing of the text and the composition of the book are the exclusive contribution of Ms Los. An exception is Chapter 1, which is the result of the joint efforts of both authors.

The illustrations
For good interpretation of the vitreous structure, a stereoscopic view is essential. This is why we included 80 pairs of stereo slides with making the book. A foldable viewer is provided as well. These pairs of stereo slides represent a unique selection from Worst's vast collection. The cover illustration and line drawings in the book were made by W.B. Velt. 


  1. Worst JGR: Biotoxizität des Kammerwassers, eine vereinheitlichende pathologische Theorie, begründet auf hypothetische Kammerwasserfaktoren. Klin Mbl Augenheilk 167:376-384, 1975
  2. Worst JGR: The bursa intravitrealis premacularis. New Developments in Ophthalmology, Nijmegen, Oct 13-16  1975. Doc Ophthalmol Proc: Ser, pp 275-279. The Hague: Junk Publ 1976
  3. Worst JGR: Cisternal systems of the fully developed vitreous body in the young adult. Trans Ophthalmol Soc UK 97:550-554, 1977
  4. Worst JGR: Anatomy of the invisible. Cannes Award Film, 1985
  5. Jongebloed M, Humalda D, Worst JGR: A SEM- correlation of the anatomy of the vitreous body: visible the invisible. Doc Ophthalmol 64:11-127, 1986
  6. Jongebloed M, Worst JGR: The cisternal anatomy of the vitreous body. Doc Ophthalmol 67:18-196, 1987


It is a high honour and a sincere joy to write an introduction to this book of my teacher and friend, Professor Jan Worst. The majority of the world's population goes through life without having one single idea. Most of the rest may have one idea in a lifetime. Roosevelt said about Churchill that he had a hundred a day and at least four of them were good. The same can be said about Jan Worst. This book is the testimony to one of those significant ideas he can produce almost daily. His conception of the anatomy of the vitreous body - one of the controversial terra incognita of the anatomy of the eye - explains a multiplicity of pathological conditions found in the eye. His theory of ABC factors are now proven chemically. His methodology to reproduce his vitreous anatomical findings can be utilized by all who wish to take time to master it - a time very well spent, indeed. I had the joy of spending time with Jan in his basement watching with fascination how he prepared and photographed the specimens. I listened, and successfully applied his theories of pathomechanism to many of the retinal diseases: detachment, cystoid macular oedema and others. His anatomical discoveries are proof that his 'theories' are now mostly facts and explain a great many conditions that baffled us in the past. I am sure this book, like so many things in Jan Worst's teaching, will generate heated controversy. This is the best thing new ideas do for the intellect and for the profession. From the debates, connections, improvements and re-examnations will emerge. But, I am also sure, the basics of this book will be upheld by the closest scrutiny. As Bernard of Chartres said: "Nos esse quasi nanos gigantium humeris insidentes, ut possimus plura eis et remotiora videre." "Like dwarfs standing on the shoulders of giants, we see farther than they," suggesting the progress of civilization. Jan Worst is a giant, and thanks to him we dwarfs will see even further than he did. Professor Worst is doing the science of ophthal�mology a very great service by sharing his tremendous knowledge and insight with us. We are greatly in debt to him.

J.J. Alpar

Table of Contents

Table of Contents

Foreword by J.J. Alpar
Preface by the authors

Ch.1  Cisternal anatomy of the vitreous
1.1     The preparation of formalin-fixed eyes
1.1.1  Results
1.2     The preparation of fresh unfixed specimens
1.2.1  Results
1.3     Interconnections
1.4     Additional preparation techniques
1.5     Pitfalls

Ch.2  Anatomy of the vitreous: Review of the literature
2.1     The tertiary vitreous
2.2     The secondary (primary?) vitreous: Fossa patellaris, Cloquet's canal and Martegiani's area
2.2.1  The fossa patellaris
2.2.2  Cloquet's canal
2.2.3  Martegiani's area
2.3     The secondary vitreous: Ciliary body region and main part of the vitreous
2.3.1  Anatomy and histology
2.3.2  In vivo slitlamp microscopy
2.3.3  In vitro slitlamp microscopy
2.4     The secondary vitreous: Premacular area

Ch.3  Functional anatomy of the vitreous
3.1     Microscopic anatomy
3.1.1  Network of fibres
3.1.2  Vitreous cells
3.2     Biochemistry
3.2.1  Macromolecular components
3.2.2  Low molecular weight solutes
3.2.3  Ascorbic acid
3.3     Barriers
3.3.1  Collagen
3.3.2  Hyaluronic acid
3.3.3  Hyaluronic acid - collagen filter
3.3.4  Lens capsule
3.3.5  Functions of the barrier
3.4     Vitreous functions
3.4.1  Transmission of light
3.4.2  Intraocular dynamics
3.4.3  Physiological functions

Ch. 4  The compartmentalization/decompartmentalization concept in relation to cataract   
4.1     Cataract surgery
4.1.1  Intracapsular cataract extraction
4.1.2  Extracapsular cataract extraction
4.1.3  Intraocular lens design
4.2     The treatment of a secondary cataract
4.3     Changes in the vitreous induced by cataract surgery
4.3.1  Mechanical
4.3.2  Biochemical
4.3.3  Transport
4.3.4  Optical/photochemical
4.4     Interrelations and clinical relevance
4.4.1  Hyaluronic acid
4.4.2  Posterior vitreous detachment

Ch. 5  Aphakic cystoid macular oedema
5.1      Diagnosis of cystoid macular oedema
5.1.1   Subjective and objective symptoms and signs
5.1.2   Fluorescein angiography
5.1.3   Grading of cystoid macular oedema
5.2      Definitions of cystoid macular oedema
5.3      Clinical course of cystoid macular oedema
5.3.1   Incidence
5.3.2   Time of onset
5.3.3   Natural course
5.3.4   Outcome
5.4      Factors influencing the incidence of cystoid macular oedema
5.5      Inflammation and cystoid macular oedema
5.5.1   Factors influencing the release of inflammatory mediators
5.5.2   Elimination of prostaglandins
5.5.3   Pharmacological research on cystoid macular oedema
5.5.4   Prophylactic effects of NSAIDs: clinical studies
5.5.5   Treatment of chronic symptomatic cystoid macular oedema
5.6      Decompartmentalization, prostaglandins and cystoid macular oedema: a hypothesis

Ch.6  Pathogenesis of rhegmatogenous retinal detachment
6.1     Normal retinal apposition .
6.2     Factors predisposing to retinal detachment
6.2.1  Patient-related factors
6.2.2  Ocular findings
6.2.3  Interrelations .
6.3     Pathogenesis of retinal detachment
6.3.1  Gonin's theory
6.3.2  Conflicting theories
6.3.3  Gonin's theory evaluated in the light of later research
6.3.4  Additional theories: pathogenesis of aphakic versus phakic retinal detachment
6.4     Prepathogenesis of retinal detachment
6.5     Some surgical approaches towards retinal detachment
6.6     Conclusions

Ch.7  The vitreous and diabetic retinopathy
7.1     The influence of diabetes mellitus on the vitreous and vitreoretinal interface
7.1.1  Vitreous
7.1.2  Vitreoretinal interface
7.2     The influence of the vitreous on diabetic retinopathy
7.2.1  The transition of nonproliferative towards proliferative diabetic retinopathy
7.2.2  The influence of the vitreous on various aspects of haemorrhages
7.3     Neovascularization of the anterior eye segment: the importance of the vitreous-lens   
7.3.1  Anterior fibrovascular proliferation
7.3.2  Neovascularization of the iris
7.4     Angiogenic factors
7.4.1  Anti-angiogenic properties
7.5     Therapy of proliferative diabetic retinopathy
7.5.1  Scatter photocoagulation of the retina
7.5.2  Vitrectomy
7.6     Conclusions



Book reviews

British Journal of Ophthalmology Book Review - By: Prof. John V. Forrester

The first author of this interesting volume is renowned within the ophthalmological community for his unique approach to ophthalmology. He was a pioneer in the early days of intraocular lens implantation with the development of the first lens, but more importantly he is widely known for his studies of the anatomy of the vitreous gel, particularly what he terms the "cisternal anatomy". Most vitreoretinal surgeons will appreciate that the elusive gel does indeed have particular anatomical structure and indeed older anatomists describe a variety of spaces such as Berger's space, the canal of Pettit and other features of the vitreous gel. Jan Worst has added further to this knowledge. His work has been founded on the use of coloured dyes injected into the various compartments of the vitreous to identify their features. Some of the spaces have been named after himself, such as the Worst premacular bursa.

This volume is a culmination of many years work and contains a remarkable set of data which will not be repeated elsewhere. Vitreoretinal surgeons, and indeed all of those interested in the ocular physiology and anatomy, and in particular, vitreous pathology should read this book. It is organised in a series of chapters detailing the cisternal anatomy, functional anatomy and the traditional view of anatomy of the vitreous. This is followed by an interesting chapter on the decompartmentalization concept in relation to cataract surgery which is written in the context of intracapsular and extracapsular cataract extraction. This particular chapter would have benefited from an evaluation of the compartments of the vitreous in relation to phacoemulsification techniques for cataract extraction since the special forces induced on the vitreous structure during phacoemulsification within a closed compartment are likely to have major significance.

The last three chapters deal with aspects of vitreous pathology in relation to cystoid macular oedema, rhegmatogenous retinal detachment and the vitreous in diabetic retinopathy; these are interesting review chapters but are somewhat out of date.

The most interesting feature of the book is a false compartment at the end which contains a stereo viewing set and series of superb slides which are taken from Jan Worst's personal collection. These slides beautifully illustrate all the aspects of the anatomy and pathology of the vitreous which Dr Worst and his co-author Dr Los wish to draw to our attention. In this respect they have been outstandingly successful and more often than not they have been quite convincing.

John V. Forrester

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