Proliferative vitreoretinopathy: An integrative, multi-pathway perspective on pathogenesis and therapy

Proliferative vitreoretinopathy (PVR) remains the principal biological cause of failed retinal detachment repair. Classical pathogenic models centred on retinal pigment epithelium (RPE) dispersion, retinal injury responses or compartment-restricted mechanisms do not fully explain the heterogeneity, biomechanical behaviour and clinical variability of PVR. We propose an integrative framework in which PVR is conceptualised as a biological process arising from the interaction of three interdependent pathways: vitreous scaffolding (residual vitreous cortex and embedded hyalocyte populations); inflammatory conditioning (RPE dispersion with blood-retinal barrier disruption and a profibrotic intraocular milieu); and retinal remodelling (retinal injury responses with glial remodelling and altered biomechanical properties). Within this framework, inflammatory conditioning establishes a permissive profibrotic milieu, retinal remodelling alters tissue compliance and force propagation and vitreous remnant scaffolds at the vitreoretinal interface facilitate spatial organisation of fibrocontractile activity. Although mechanistic evidence supports the contribution of each of the three pathways to PVR pathogenesis, direct prospective validation of their threshold-dependent convergence as a unified construct requires further research. The proposed model, therefore, distinguishes biological plausibility from proven causality and aims to generate testable hypotheses rather than prescriptive conclusions. By integrating inflammatory, retinal and vitreoretinal interface perspectives within a unified conceptual structure, this framework provides a biologically coherent explanation for the spatial distribution, contractility, recurrence patterns and clinical heterogeneity of PVR.