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Cisternal Anatomy of the Vitreous
Jan G.F. Worst and Leonoor I. Los
Kugler Publications, Amsterdam, 1995
Hardback
143 pages of Text and Viewer with 80 3-D slides
ISBN: 60-6299-110-6
Price: €110

If you know somebody who thinks that eyeballs are disgusting, you should show them The Vitreous Body in 3-D. This little booklet conjures up images of creatures floating undersea or unknown planets and moons spinning in outer space.

It is beautiful. It is also real human vitreous. The fact that structures with the consistency of cobwebs have been stained and captured in a photograph with stunning visual effects in three dimensions does not make them less real. And that is why this work deserves wider dissemination.

The Vitreous Body in 3-D consists of 18 pairs of images. But when seen through the viewer inserted in the back cover of the booklet, the images are transformed into in life-sized 3-D images of ocular globes - denuded of the sclera - at different stages of dissection and stained with different dyes.

Each image has a brief explanatory note of what you see, with a few numbers labelling particular structures. There are no comments or explanations of the implications of what you see, just a little assistance to help you interpret the images.

For information on dissection techniques and the importance of vitreous anatomy, the booklet refers you to the companion textbook, The Cisternal Anatomy of the Vitreous, also by Jan Worst MD, with co-author Leonoor Los.

Although these two books were published six years apart, the ideas they contain are basically the same; it makes sense to review them together.
Both reflect the ideas and lifework of Prof Worst. Born in 1928, this Dutch ophthalmologist has been an active member of the international ophthalmic community for nearly half a century.

Although often controversial, there is no doubt that he is the proud owner of an extremely fruitful mind and many innovative ideas, many of them extremely successful. Prof Worst recruited Ms Los into the project to help write and compose The Cisternal Anatomy of the Vitreous.

The book looks like a solid textbook. But perhaps as the first hint that things may not be as they appear at first sight, and that you should not take initial impressions for granted, this book has a trick. It is only half a book.
After some 140 pages of regular text, with the occasional line drawing, the book's second half is like no other ophthalmic textbook. It has a recess cut out of its middle to carry - or hide -things, like the hollowed-out Bible in Western movies that hides a pistol or flask of whiskey.

It's the type of book that explains why people without much love of reading spend some time on their own in the study room.
The secret compartment contains a viewer. It's a flat-packed plastic device with two little lenses and a slot for micro-stereo slides. It is almost like a traditional slide viewer - easy to use, just by holding it up at a short distance from your eyes.

The micro-stereo slides consist of 80 pairs of high quality slides; through the viewer, each pair of images becomes a single, 3-D globe in full colour.
The book begins with an illustrated description of how Prof Worst obtained the images. With line diagrams, the book shows, step-by-step, how Prof Worst prepared and dissected the specimens. The chapter also describes in some detail the intravitreal structures.

The second chapter reviews the literature on the anatomy of the vitreous, structured according to the different vitreal structures. Line diagrams and histological illustrations, many borrowed from other sources, help present a comprehensive overview.

A chapter on the functional anatomy of the vitreous follows. ProfWorst bases this chapter on his conviction that an ophthalmologist cannot understand the physiological functions of the vitreous body without knowledge of its microscopic structures and biochemical properties. Some beautiful electron microscope images help make the point.

The book next explores the so-called "compartmentalisation concept" as it relates to cataract surgery.

Here we get into Worst's own concept - introduced in 1975 - as a unifying theory which proposes that the disruption of the biochemical barrier of anterior and posterior compartments of the eye can explain the development macular oedema and retinal detachment following cataract surgery. You will find here a detailed explanation of the theory, and its clinical relevance.

The book next discusses aphakic cystoid macular oedema (CMO). The pathological effects of inflammatory mediators, the prophylactic effects of non-steroid anti-inflammatory drugs and possible reasons for the variable interval between cataract surgery and CMO are all here.

Rhegmatogenous retinal detachment - including a good discussion of existing theories - and diabetic retinopathies are the subjects of the last two chapters. The book approaches both conditions from a vitreous-centric point of view.

The book finishes with a figure-by-figure guide to the micro-stereo slides contained in the secret pocket, a list of abbreviations and an index. This is a book full of science, presented in the most professional and methodical way.

The basic idea of both books is that the highly complex structures of the vitreous body are difficult to study and have no easy correlation with functional aspects of the eye.
The implication of both works is that a mental switch is necessary in current clinical ophthalmology: the vitreous is not a fluid medium; it is an organ. It has its own structures and peculiarities that must have an impact on its function.

In some ways, these books are written for the future by somebody who would like to be proven right now rather than later, but who is not, in fact, in a hurry.
Whether or not you agree with Prof Worst's interpretation of the meaning and importance of the vitreous structures, seeing is a good first step towards understanding. See and judge for yourself.

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