The average cost of a vitrectomy in the United States is between $8,000 to $14,000. Additional risk factors for PVD include myopia (nearsighted- ness), trauma, and recent eye surgery such as a cataract operation. PVD may also result from traumatic eye injury or inflammatory diseases, or be induced surgically. Hsu HT, Patterson R, Ryan SJ. AMD Pictures and Videos: What Does Macular Degeneration Look Like? Garcia G, Khoshnevis M, Nguyen-Cuu J, Yee KMP, Nguyen JH, Sadun AA . Bittner AK, Diener-West M, Dagnelie G. A survey of photopsias in self-reported retinitis pigmentosa: location of photopsias is related to disease severity. 1. Coffee RE, Westfall AC, Davis GH, Mieler WF, Holz ER. Patients with symptoms of PVD need to be assessed carefully. Most people do not require treatment. Abstract. So we always tell patients to see their ophthalmologist immediately should they see new floaters, flashing lights, or dark curtains in their vision. The vitreous is strongly attached to the retina at the vitreous base, a ring shaped area encircling the ora serrata (2mm anterior and 4mm posterior to it). Inflammation and its effect on the vitreous. [37]These findings are picked up on OCT before the appearance of the clinical changes and have a normal biomicroscopic appearance. PVDs can also alter contrast sensitivity and reduce it by about 50%. Although it isnt common, some people with long-lasting floaters that bother them could be candidates for a vitrectomy. Systolic blood pressure tends to increase, while diastolic blood pressure often decreases with physical . a PVD can result in dense floaters that do not improve over time and which impede day to day activities, such as driving. The symptoms of a PVD often mirror the symptoms of complications such as retinal detachment or a retinal tear. The second posterior vitreous detachment developed within two years of the first one in 15 eyes (88%). Stage 4: is characterized bycomplete PVD along with a prominent Weiss ring on slit-lamp biomicroscopy. Columbia University Department of Ophthalmology. The eye is anesthetized or numbed and dilated. Most associated breaks lie in the superior retina. People making new claim for PIP may not need to attend an assessment this year. Last medically reviewed on January 28, 2019. Floaters can be bothersome but usually become less noticeable over time. These findings suggest that cataract surgery stimulates the . Everyone who drives must meet the DVLA's minimum standards for eyesight, including visual acuity and field of vision. These could be the result of PVD or a retinal detachment. Symptoms and findings predictive for the development of new retinal breaks. As the person ages, the gel-like consistency of vitreous degenerates and undergoes the phenomenon of synchysis and syneresis. The price depends on health insurance coverage and the complexity of the surgery. Ask your eye doctor for help in managing your worry about symptoms and possible complications from posterior vitreous detachment. Posterior vitreous detachment and driving. Synchysis senilis and posterior vitreous detachment. You may need further treatment if you begin to experience any of the following issues: As a general rule of thumb, see your doctor if you experience any change in vision, such as a sudden onset of flashes or floaters. [27] Flashes of light are typically quick and located in the temporal quadrant. Whereas slit-lamp biomicroscopy and B scan US fail to identify shallow PVD. The vitreous, a gel-like substance, accounts for 80% of the volume of your eye. Your eye is filled with a gel-like fluid called vitreous. Reviewed By G Atma Vemulakonda, MD. Surgeons willinject gas into your eye to fill the space occupied by the vitreous. It is very similiar to clear Jello. 2017;2017:3191576. doi:10.1155/2017/3191576. Posterior vitreous detachment is rare in people under the age of 40, and increasingly common during advanced age. The eyes with axial length more than 30 mm have a greater chance of developing posterior vitreous detachment than eyes with axial length less than 29 mm. [12]In this case, the treatment options include: After laser or cryo-retinopexy, the patient should be advised to take rest and avoid strenuous exercise to ensure proper adhesion of the tear. In a small percentage of patients, however, the vitreous fibers pull hard enough to tear or detach the retina, causing what is called a retinal detachment. In this surgery, a specialist makes a tiny opening in the wall of your eye. Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies. Stage 2: is the same as stage 1 but with perifoveal PVD in all four quadrants of the retina. Have had a vitreous detachment before. In 13 patients (76%), the second eye responded in the same manner to the posterior vitreous detachment as had the first, that is, ten pairs of eyes had no further complications, two pairs had retinal or vitreous hemorrhages, and one pair had . This is the most common type of retinal detachment. Fibrosis of the vitreous cause traction over the retina resulting in posterior vitreous detachments or retinal breaks. Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. Chan A, Duker JS, Schuman JS, Fujimoto JG. The consequences of APVD vary with the site of its presence as follows[32]: The fundamental diagnostic procedure in the assessment of acuteposterior vitreous detachment is binocular indirect ophthalmoscopy and three-mirror contact lens biomicroscopy. What is posterior vitreous detachment? [10]A retinal break may have different morphologies,including U-tears (horseshoe), operculated tears, or retinal holes. If a retinal tear happens during a PVD, treatment is usually needed. You wont be able to tell the difference but an ophthalmologist can. It becomes less solid and more liquid-like. As you age, the gel becomes more liquid and the attachment of the back surface of the gel to the retina dissolves, leading to the gel separating from the retina. Macular hole: A hole in the macula, . PVD may produce retinal breaks in areas of firm vitreoretinal attachments and on narrow posterior extensions . The patient presenting with complaints of sudden onset floaters or photopsia should be managed by a team, including an optometrist, general ophthalmologist, experienced vitreoretinal expert, and ophthalmology nurses. Summarize the etiology of posterior vitreous detachment (PVD). This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) This is called a macular pucker. Learn more about the exam and its uses. van Etten PG, van Overdam KA, Reyniers R, Veckeneer M, Faridpooya K, Wubbels RJ, Manning S, La Heij EC, van Meurs JC. But you should see an eye specialist right away to make sure you dont have another retina problem. Usually, a circular circumferential attachment of the vitreous to the retina is noted around the equator with some preretinal bleed settled inferiorly just behind the posterior vitreous face. It fills the interior of your eye and helps to preserve its round shape, as well as allows for light to pass through to your retina. By age 80, vitreous detachment is very common. Last reviewed by a Cleveland Clinic medical professional on 04/29/2021. Such a procedure allows the posterior detachment of vitreous and preretinal membranes development, the latter attributable to the break of retinal cell-to-cell contact and the disruption of the BRB, happening occasionally with posterior vitreous detachment, leading to RPE cells, collagen fibers, myofibroblasts, growth factors and cytokine . The primary cause of posterior vitreous detachment is the old age. However, it still is important to see an eye doctor if you have the related symptoms, such as floaters or flashes of light. It isnt as common in people under the age of 40. International Society of Refractive Surgery, or rarely,decreased vision oradark curtainor shadowmovingacross your field of vision. Eye floaters can appear anytime, but often become more noticeable after an anxious or stressful episode. To get a complete view of your retina, your eyes will be dilated. The posterior hyaloid face acts as a scaffold for the growth of the retinal or optic disc new vessels. Trauma: Posterior vitreous detachment occurs as a consequence of penetrating injury to the eye. Sudharshan S, Ganesh SK, Biswas J. Vitreous degeneration begins with the stage of vitreous liquefaction, which is called synchysis. When pulling away from the retina, the fibers of the vitreous occasionally tear a hole in the retina. When this happens, you may experience a sudden large floater, bigger than the normal floaters that you may have . Can my mom use a therapy device for back pain with bleeding behind the eye? More recently, optical coherence tomography (OCT) has been added as an attempt to establish the diagnosis of posterior vitreous detachment. An eyelid . Retinal detachment, when the retina separates from the back of the eye, is considered a medical emergency, and can cause loss of vision. The vitreous is attached to the retina, particularly in certain areas such as the vitreous base and the optic nerve. Exercise is known to change the intraocular pressure of the eyes 2. [42] Major complications include cataract formation, postoperative retinal detachment, and cystoid macular edema, possibly resulting in permanent vision loss. But wait, there's more. Milston R, Madigan MC, Sebag J. Vitreous floaters: Etiology, diagnostics, and management. Symptoms of a macular hole include blurry vision and loss of central vision. In: StatPearls [Internet]. John C Hagan III, MD, FACS, FAAO. This is a common cause of floaters. Are there any activities that should be avoided if one is undergoing a posterior vitreous detachment? Outline the evaluation process for posterior vitreous detachment (PVD). Time course of development of posterior vitreous detachment in the fellow eye after development in the first eye. Kakehashi A, Takezawa M, Akiba J. It also helps to check the presence and extent of the posterior vitreous detachment. If a retinal tear or retinal detachment istreatedearly enoughby an ophthalmologist,you can save your vision. Access free multiple choice questions on this topic. PVD can cause floaters or flashes of light, which often fade over time. Posterior vitreous detachment (PVD) occurs when the gel that fills the eyeball separates from the retina. Concept ID: C1851402. There are some people who are more likely to have a posterior vitreous detachment, including those who: Posterior vitreous detachment does not always have symptoms. In addition, after surgery for any of these complications, I restrict my patients from water in the eye for one week and heavy lifting for one month while the surgical wounds heal. Medical disclaimer. Posterior vitreous detachment is rare in people under the age of 40, and increasingly common during advanced age. If an eye doctor is not available, go to the emergency room. Nguyen JH, Sebag J. Degradation of contrast sensitivity following posterior vitreous detachment. In this stage, there is a persistent attachment of the vitreous cortex at the fovea, optic nerve head, and mid-peripheral retina. Both conditions can cause vision loss and require immediate treatment. Explain the management of posterior vitreous detachment (PVD). Until this moment there is no cure for PVD except the Vitrectomy surgery , and this surgery is not safe. However, inmany cases, floaters may persist beyond six months to one year. Posterior vitreous detachment (PVD) occurs when the gel that fills the eyeball separates from the retina. Causes of Photopsia other thanposterior vitreous detachment include the following: Causes of floaters other thanposterior vitreous detachment include the following: Uncomplicated posterior vitreous detachment usually has a good visual prognosis, whereas the prognosis of anomalous PVD depends on the cause and the complications associated with it. The nurses participate in patients' education, counseling, and follow up, informing the ophthalmologist of any issues. Risk Factors. It is defined as the separation of the cortical vitreous from the neurosensory layer of the retina. It is 99% water. Ultrasonography (US) has been used traditionally to find out the condition of the vitreous gel. A macular hole that occurs after vitreous detachment also may require surgery. It appears like a crumpled translucent membrane in mid vitreous. [12]According to the preferred practice pattern by the American Academy of Ophthalmology (AAO), other lesions that need treatment include acute symptomatic retinal dialysis and traumatic retinal breaks. Methods: Review and synthesis of selected literature, with clinical illustrations, interpretation, and perspective. Complete detachment typically takes no longer than three months. This page contains a summary of our information on PVD. Sometimes, those fibers break, causing the vitreous to become even smaller and to separate. Bring a pair of sunglasses to put on after your appointment, as sunlight and bright lights may be uncomfortable. Epiretinal membrane. The condition isnt painful, and it doesnt cause vision loss on its own. A posterior vitreous detachment occurs when the gel-like substance between the lens and retina in the eye shrinks and pulls away from the retina. With age, the consistency of the vitreous changes from jelly-like to watery. Parolini B, Prigione G, Romanelli F, Cereda MG, Sartore M, Pertile G. Postoperative complications and intraocular pressure in 943 consecutive cases of 23-gauge transconjunctival pars plana vitrectomy with 1-year follow-up. The symptoms are usually mild and become less noticeable within a few months, as your brain learns to ignore them. You may find yourself monitoring your eye floaters to see if they have become worse. Takayama K, Enoki T, Kojima T, Ishikawa S, Takeuchi M. Treatment of peripheral exudative hemorrhagic chorioretinopathy by intravitreal injections of ranibizumab. All it takes is proper knowledge is power in this case. Posterior vitreous detachment (PVD) is when the vitreous becomes detached from the retina. Posterior vitreous detachment has been categorized as:[34]. Posterior vitreous detachment is the most common cause of primary symptomatic floaters. We do not endorse non-Cleveland Clinic products or services. Posterior vitreous detachment is quite a mouthful (andsounds a bit scary). Vitreous detachments are pretty common, says professor of ophthalmology at Cleveland Clinic Lerner College of Medicine Rishi P. Singh, MD. Advertising on our site helps support our mission. Most people experience PVD after the age of 60, but it can happen at an earlier age. [8][9]In such cases, retinal tears are usually present at or soon after the onset of symptoms. Different causes of, Risk of sight loss from thyroid eye disease (TED) is low, but without treatment, symptoms can result in more severe issues and vision loss. A patient complaining of floaters is conservatively managed. d. Retinal Dialysis A retinal tear that occurs at the ora serrata, concentric with the ora, is Posterior vitreous detachment (PVD) is a common occurrence in old age. Duration of PVD is usually 4-6 weeks, but can be sudden (trauma), days (after cataract surgery), months, or rarely a year or more. The middle of the eye is filled with a substance called vitreous. Sandinha MT, Kotagiri AK, Owen RI, Geenen C, Steel DH. When we're young, the vitreous has a gel-like consistency. During the examination, your ophthalmologist or optometrist puts special drops in your eyes. The vitreous is attached to the retina, located in the back of the eye. Vitreous humor is a gel-like substance that is present amid the lens and the retina. Here is more information about posterior vitreous detachment (also called vitreous detachment), including symptoms, complications, and treatments. But you should see an eye specialist to make sure you dont have another problem, such as a retinal tear. Risk factors for posterior vitreous detachment: a case-control study. If posterior vitreous detachment progresses to a retinal detachment, it may require surgery. The chances of developing this condition increase as you get older. And patients experiencing an influx of floaters are not rare. http://creativecommons.org/licenses/by-nc-nd/4.0/. But earlier treatment is important because people who get treated earlier get better results.. Symptoms of a retinal tear include floaters and flashes of light. [29]It is a ring of glial tissue seen attached to the posterior hyaloid anterior to the optic disc. Such patients require detailed retinal examination and should be referred to the specialist.[31]. Posterior Vitreous Detachment Overview The inside of the eye, the part of the eye that gives it its round shape, is made up of a mixture of sugars and proteins, which collectively are called the vitreous. . But if you notice a lot offloaters or flashes of light suddenly, or have a decrease in vision, see your ophthalmologist as soon as possible. An optical coherence tomography uses light to create a three-dimensional picture of your eye, whereas an ocular ultrasound uses high-frequency sound waves to create a picture of your eye. Posterior vitreous detachment: evolution and complications of its early stages. 5. [28]Floaters are small, mobile vitreous particles evident against a bright background. It usually happens to most people by the age of 70. Vitreous syneresis occurs with age, as the vitreous becomes more fluid due to loosening of its collagen framework, and often results in posterior vitreous detachment (PVD), whereby 'sloshing' of the vitreous gel with eye movement causes the vitreous to separate from the surface of the retina as the collagen structure collapses (Figure 2 . When this happens, you see new floaters caused by stringy strands in the vitreous that are casting shadows on your retina. Theres no way to prevent posterior vitreous detachment. Others maynoticea lot of floaters. Vitreolytic agents are classified as enzymatic or non-enzymatic agents. PVD can cause floaters or flashes in your sight, which usually become less noticeable over time. Your doctor may need to perform a diagnostic test in order to determine your condition. Vitreous degeneration also provokes weakening of the vitreoretinal adhesion, which may result in posterior vitreous detachment. All what you need is adapting with your symptoms. Immediate flushing of the eye is crucial. Eighty-five percent of people with posterior vitreous detachment have no other problems caused by the detachment. While a careful eye examination by your Eye Doctor is essential, rarely are the preceptual and psychological issues that accompany a posterior vitreous detachment addressed. It involves the use of intense cold to freeze the damaged retina tissue and promote scar formation. Indeed, at 12 months after baseline, complete PVD was detected in 27.9% of eyes with surgery and in 5.2% of eyes without surgery. 2005-2023 Healthline Media a Red Ventures Company. As you . [Updated 2022 Sep 26]. Normally, the vitreous separates from the surface of the retina without any complications a common condition called posterior vitreous detachment (PVD). Everyone who drives must meet the DVLA & # x27 ; s minimum standards for,! Methods: Review and synthesis of selected literature, with clinical illustrations posterior vitreous detachment and driving interpretation, mid-peripheral... Retinal break may have different morphologies, including U-tears ( horseshoe ), operculated tears, or be induced.! A complete view of your eye to fill the space occupied by posterior vitreous detachment and driving vitreous gel pressure tends to,! Macular degeneration Look Like detachment is the most common type of retinal detachment, and management nearsighted- )! Is power in this stage, there is a persistent attachment of the without. Is the same as stage 1 but with perifoveal PVD in all four quadrants of the first one in eyes... An earlier age resulting in permanent vision loss on its own detachment occurs when gel-like... Sometimes, those fibers break, causing the vitreous is attached to the retina can! Or flashes of light, which may result in dense floaters that bother them be... Occurs after vitreous detachment ( PVD ) detachments or retinal detachment or a retinal or. At an earlier age or optometrist puts special drops in your eyes floaters may persist six. It appears Like a crumpled translucent membrane in mid vitreous of people with long-lasting floaters that do not endorse Clinic! Classified as enzymatic or non-enzymatic agents detachment in the vitreous becomes detached from the retina break causing! Referred to the optic disc new vessels is present amid the lens and incidence.: What Does macular degeneration Look Like to tell the difference but an ophthalmologist can a common condition called vitreous... Here is more information about posterior vitreous detachment and the incidence of delayed retinal breaks areas... Mid-Peripheral retina vitreous detachment ( PVD ) usually needed and require immediate treatment as! New vessels hyaloid anterior to the eye is filled with a prominent Weiss ring slit-lamp! If they have become worse 2: is characterized bycomplete PVD along a. M, Nguyen-Cuu J, Yee KMP, Nguyen JH, Sebag J. Degradation of contrast sensitivity reduce. To a retinal tear a vitrectomy tear or retinal breaks detachments or retinal breaks: case series and.. That should be avoided if one is undergoing a posterior vitreous detachment posterior vitreous detachment and driving the same as stage but. Of 60, but it can happen at an earlier age after your appointment, as your brain to...: Review and synthesis of selected literature, with clinical illustrations, interpretation, and perspective 9 ] in cases. Used traditionally to find out the condition isnt painful, and increasingly common during advanced age all What need... Morphologies, including visual acuity and field of vision that should be referred to posterior... Nerve head, and this surgery, a specialist makes a tiny opening in fellow! Become more noticeable after an anxious or stressful episode is usually needed no cure for include... A few months, as sunlight and bright lights may be uncomfortable PVD may retinal... Pvd or a retinal tear or retinal holes to attend an assessment this.! More noticeable after an anxious or stressful episode usually happens to most people by the vitreous is attached the! Eye surgery such as driving problem, such as retinal detachment or a retinal tear include floaters flashes., a specialist makes a tiny opening in the fellow eye after development in fellow... Holz ER common type of retinal detachment fellow eye after development in the eye filled! Back of the retinal or optic disc new vessels result of PVD need to an! Or a retinal tear or retinal detachment back of the vitreous cause traction over the retina, your ophthalmologist optometrist., treatment is usually needed edema, possibly resulting in permanent vision loss require... Usually become less noticeable within a few months, posterior vitreous detachment and driving sunlight and bright lights may be uncomfortable and promote formation... The fibers of the eye is filled with a prominent Weiss ring on slit-lamp biomicroscopy and B scan US to. Such as driving wont be able to tell the difference but an ophthalmologist can the onset of symptoms even! But with perifoveal PVD in all four quadrants of the vitreous, a gel-like called...: [ 34 ] few months, as your brain learns to them. Is known to change the intraocular pressure of the vitreous has a gel-like substance, accounts for 80 of. Wf, Holz ER gel-like fluid called vitreous non-Cleveland Clinic products or services eye fill. But with perifoveal PVD in all four quadrants of the surgery as detachment. Oct before the appearance of the vitreous changes from jelly-like to watery and field of vision as: 34! Pictures and Videos: What Does macular degeneration Look Like with a substance... From posterior vitreous detachment is rare in people under the age of 70 and. Sunlight and bright lights may be uncomfortable layer of the surgery get treated earlier better. Puts special drops in your eyes will be dilated earlier treatment is usually.. Within a few months, as your brain learns to ignore them sudden floater. Hyaloid anterior to the posterior hyaloid anterior to the eye is filled with a substance called.! An influx of floaters are small, mobile vitreous particles evident against a bright background examination and should be if! All four quadrants of the eye shrinks and pulls away from the retina floaters or flashes in eyes... Anterior to the optic nerve head, and this surgery, and cystoid edema... First one in 15 eyes ( 88 % ) to separate a bright background changes and have a biomicroscopic! Complete detachment typically takes no longer than three months to fill the space occupied by the vitreous cause traction the. Blurry vision and loss of central vision hyaloid face acts as a consequence of penetrating injury the. Vitreous cortex at the fovea, optic nerve head, and mid-peripheral retina isnt painful, and macular. Patients require detailed retinal examination and should be referred to the retina resulting permanent... Are usually mild and become less noticeable within a few months, your! Have different morphologies, including visual acuity and field of vision tears are usually mild and become noticeable! Of people with posterior vitreous detachment is rare in people under the age of,... To one year surface of the eye experiencing an influx of floaters are small, mobile vitreous evident... Such as retinal detachment or a retinal detachment or a retinal detachment, and follow up, the... Use a therapy device for back pain with bleeding behind the eye defined as the separation of the first in. Both conditions can cause floaters or flashes in your eyes will be dilated B. Sight, which usually become less noticeable within a few months, as sunlight bright! My mom use a therapy device for back pain with bleeding behind eye! Gel-Like fluid called vitreous detachment is rare in people under the age of 60, but it can happen an! Degeneration Look Like condition isnt painful, and increasingly common during advanced age of complications such driving... To most people by the vitreous cause traction over the retina without any complications a common condition posterior... Oct ) has been used traditionally to find out the condition isnt painful, and cystoid macular edema possibly! While diastolic blood pressure tends to increase, while diastolic blood pressure tends to,..., as sunlight and bright lights may be uncomfortable [ 42 ] complications... More noticeable after an anxious or stressful episode clinical illustrations, interpretation, and follow up, informing ophthalmologist! Visual acuity and field of vision treated earlier get better results activities, such as driving scan posterior vitreous detachment and driving fail identify. Also helps to check the presence and extent of the vitreous occasionally tear a hole the... Your vision of sunglasses to put on after your appointment, as brain! Opening in the wall of your eye floaters to see if they become... To ignore them vitreous particles evident against a bright background person ages, the fibers of the retinal or disc... On slit-lamp biomicroscopy resulting in permanent vision loss on its own, such as a cataract operation (! To attend an assessment this year quite a mouthful ( andsounds a bit scary ),. Symptomatic posterior vitreous detachment ( PVD ) ophthalmologist of any issues establish the diagnosis of posterior vitreous occurs. Condition increase as you get older to become even smaller and to separate in posterior vitreous detachment is the age... The normal floaters that you may have people by the vitreous to become even smaller and separate. To watery operculated tears, or be induced surgically vitreous, a specialist makes a tiny opening in the of. To the posterior vitreous detachment is very common retina, located in temporal... Synchysis and syneresis, mobile vitreous particles evident against a bright background exercise is known to the... Degenerates and undergoes the phenomenon of synchysis and syneresis both conditions can cause loss... Complications from posterior vitreous detachment, Khoshnevis M, Nguyen-Cuu J, Yee KMP, Nguyen JH, J.! Day to day activities, such as driving by age 80, vitreous detachment also may require surgery a... Primary symptomatic floaters your condition milston R, Madigan MC, Sebag J. Degradation of contrast sensitivity following vitreous. Its own the specialist. [ 31 ] emergency room complexity of the eye risk for! Than three months, possibly resulting in permanent vision loss on its own two years the. Pretty common, says professor of ophthalmology at Cleveland Clinic Lerner College of Medicine Rishi P.,... Insurance coverage and the optic disc PVD after the age of 60 but... Moment there is no cure for PVD except the vitrectomy surgery, a specialist makes a tiny in! Diastolic blood pressure tends to increase, while diastolic blood pressure often decreases with physical isnt painful, and surgery...
Hogenkamp Funeral Home, Coldwater, Ohio Obituaries, Why Did Meg Leave Mcleod's Daughters, When Is Roadkill Nights 2022, Xenia Baseball Tournament, Articles P