White Without Pressure (WWOP)

Retinal white without pressure (WWOP) is a common retinal condition that is reported to occur in up to 30% of the general population. One study found WWOP in 2.5% of whites and 23% of blacks. The incidence of WWOP increases with age; it has been estimated to occur in approximately 5% of eyes under age 20 years and 66% of eyes over age 70 years. Individuals with increased axial length (high degrees of nearsightedness) are more likely to develop WWOP.

Retinal WWOP appears as an area of the retina that is translucent white to gray in color and often is bounded posteriorly by a reddish-brown line. This condition can mimic the appearance of a shallow retinal detachment. WWOP may have scalloped posterior borders (suggested to be a sign of possible progression) and has been noted to be migratory in nature; sequential fundus examination reveals that the size, shape, and location of WWOP may change over time. Areas of WWOP frequently are associated with lattice degeneration and snowflake degeneration. WWOP may be circumferential and usually occurs bilaterally.

WWOP usually is associated with vitreous degeneration and posterior vitreous detachment (PVD). Horseshoe retinal tears or linear retinal tears can develop along the posterior border of WWOP, and these tears are associated with the traction of PVD.

In the management of a patient with WWOP, it is important to consider factors that are contributory to the development of retinal breaks, such as the presence of lattice degeneration, of scalloped borders (suggesting progression over time), of shrinkage of the vitreous (the jelly-like fluid filling the eye), or of an elevated tractional membrane.

Patients with WWOP should be followed at 1- to 2-year intervals, depending on the presence of other associated risk factors. The patient should be reexamined every 6 months if the posterior borders of the WWOP are scalloped and there is extensive vitreous degeneration. As patients reach their 40s and 50s, there is a general increase in the risk of associated retinal breaks and detachment because of increased vitreous liquefaction and/ or vitreous detachment (PVD). Caution should be exercised in managing patients with high myopia because of the association between increased axial length and detachment. It is important to inform patients about the signs and symptoms of retinal detachment and watch carefully for breaks that may develop at the posterior border of the lesion.

The most important consideration in the management of WWOP is the vitreoretinal traction related to this condition. Vitreoretinal traction is known to be associated with WWOP and is strongly implicated in the genesis of retinal tears and subsequent retinal detachments. Patients with this condition should know that it carries a low risk for complications but that it is important to report symptoms or signs of traction and breaks immediately.