7/18/2010

Peripheral Retinal Disorders

Philip E E. Walling Walling, O.D., O D F.A.A.O. FA A O Professor of Optometry Michigan College of Optometry

No financial relationships to disclose

Course Objectives
Discuss management of:
Retinal emergencies Retinal R ti l urgencies i Retinal non-urgencies

Location of Peripheral Anomalies

*Oral zone *Juxtabasal zone *Intrabasal zone *Extrabasal zone

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oral zone

intrabasal

extrabasal juxtabasal

Rhegmatogenous Retinal Detachment

Most common, more common in high myopes, fellow eye shows 25% chance of development. Separation of neurosensory retina from RPE via liquefied vitreous through retinal break. Stable detachments older than 3 months may show demarcation line.

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Tractional Detachment
Secondary to ocular disease Not typically in peripheral retina Non-bullous; traction causes concave appearance

Exudative Detachment
Subretinal serous or hemorrhagic fluid originates from choroid Smooth appearance (non-bullous) (non bullous)

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Abnormal retina vessel RPE pump (Coats disease)

CSCR or ARM Sick RPE RPE pump

RPE decomposition, loss of tight junctions, RPE pump

Choroidal tumors RPE breakdown, RPE pump

Rhegmatogenous Retinal Detachment

Symptoms
Flashes Floaters

Asymptomatic Signs
Elevation of retina Pigment granules in anterior vitreous

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Management
Immediate referral to fellowship trained M.D. or D.O. Can see up to 5D of induced myopia Post-surgical complications include: CME Preretinal fibrosis

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Retinal Tear
Associated with vitreoretinal traction Occurs during vitreous collapse Apex of tears points to posterior pole Seen S most t commonly: l
Myopia Over 40 Secondary to trauma Lattice degeneration

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Retinal Tear

Vitreal adhesion

Retina Tear from Acute PVD

2 tears with 1 common flap

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Retina Tear from Acute PVD

Retinal Tear

Retinal Tear

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Retinal Tear

Retinal Tear

Retinal Tear

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Management
Consultation or referral to fellowship trained M.D. or D.O. Treatment indicated if:
Surrounding detachment >1DD Flap has visible attachment Prior to YAG or cataract surgery Prior to retinal detachment in fellow eye

Retinal Tear ??

Retinal Tear with Photocoagulation

Retinal tear

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Diagnosis Requiring Urgent Treatment/ Management

Atrophic Retinal Holes

Most common retinal break 3% of population Etiology thought secondary to vascular insufficiency, not vitreoretinal traction Red and darkens with scleral indentation White surrounding cuff indicates some vitreoretinal adhesion

Atrophic Retinal Holes

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Atrophic Retinal Holes

Atrophic Retinal Holes

Mild retinal elevation

Linear appearance

Atrophic Retinal Holes

Increased risk factors based on location:
Juxtabasal Superior S i Proximity to liquefied vitreous

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Atrophic Retinal Hole

Atrophic Retinal Holes

Management
Consultation if:
Symptomatic Surrounding S di retinal ti l detachment d t h t > 1DD

Follow if:
Asymptomatic Surrounding retinal detachment < 1DD

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Operculated Retinal Holes

Operculum = free floating necrotic retinal tissue Shows same characteristics as atrophic holes Better prognosis since vitreoretinal adhesion is relieved

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Operculated Retinal Hole

Operculated Retinal Hole

Operculated Retinal Hole

operculum

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Operculated Retinal Hole

operculum

Management
Consultation if:
Symptomatic Surrounding S di retinal ti l detachment d t h t > 1DD

Follow if:
Asymptomatic Surrounding retinal detachment < 1DD

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Vitreoretinal Traction Tufts

Located between ora serrata and equator Gray-white tissue RPE hyperplasia Association with retinal tears Tend to occur nasally

Vitreoretinal Traction Tuft

tuft

tuft

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Vitreoretinal Traction Tuft

tuft

Management
Education of retinal detachment symptoms Retinal break associated with traction tuft refer immediately

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Lattice Degeneration
Maximum incidence in third decade 10% of population, bilateral 50% of time Severity increases with time Predisposition to retinal breaks and subsequent retinal detachment Associated tears located at border of lesion

Lattice Degeneration
Chorioretinal atrophy and fishboning may be seen Vitreal adhesions at border of lesion Liquefied vitreous typically overlies lesion Assessment through scleral indentation

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Lattice Degeneration

Lattice Degeneration

Lattice Degeneration

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Lattice Degeneration

Lattice Degeneration

Lattice Degeneration with an atrophic hole

Lattice Degeneration atrophic hole with scleral depression

Lattice Degeneration

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Management
Consultation or referral if:
Symptomatic with atrophic holes Marginal M i l retinal ti l breaks b k

Follow if:
Asymptomatic Symptomatic without atrophic holes

Lattice Degeneration ??

Snail-Track Degeneration
Lattice degeneration without fishbone appearance Appears to be left by snail or slug

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Snail-Track Degeneration

Snail-Track Degeneration

Management
Consultation or referral if:
Symptomatic with atrophic holes Marginal M i l retinal ti l breaks b k

Follow if:
Asymptomatic Symptomatic without atrophic holes

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Acquired Retinoschisis
Splitting of the retina Split filled with vitreous Found in up to 25% of population Most common location inferotemporal Acquired retinoschisis divided into:
Typical Reticular

Acquired Retinoschisis

Typical Retinoschisis
Advanced form of cystoid degeneration Not typically associated with retinal holes Inner layer smooth, may show beaten metal appearance Most common

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Typical Retinoschisis

Typical Retinoschisis

Schisis cavity

Reticular Retinoschisis
Thin, transparent retina ballooning forward Surface usually taut unless inner leaf hole Whitish flecks occasionally seen on surface Posterior edge does not show pigmented demarcation line Rarely progresses toward posterior pole More likely to progress to a retinal detachment

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Reticular Retinoschisis

Reticular Retinoschisis

Elevated schisis cavity

Reticular Retinoschisis

Elevated schisis cavity

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Reticular Retinoschisis

Posterior borders of schisis cavity

Reticular Retinoschisis

Reticular Retinoschisis

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Reticular Retinoschisis

Reticular Retinoschisis

Reticular Retinoschisis

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Differentiating Retinal Detachment from Retinoschisis

Characteristic
Transparency Mobility Surface Fluid Shift Tear Field Defect

RD
Little Mobile Folds Often Common Relative

Schisis
Common Immobile Smooth Absent Rare Absolute

Management
No inner or outer layer breaks Location anterior to equator y breaks only y Inner layer Location posterior to equator Outer layer breaks Inner and outer layer breaks Scheduled intraocular surgery annually annually 6 months 3 months refer refer refer

Diagnosis Requiring Non-Urgent Treatment/Management

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Focal Chorioretinal Atrophy

Known as pavingstone or cobblestone degeneration 25% of general population Atrophy of RPE and outer retina Appears yellow with distinct borders, slightly posterior to ora serrata

Focal Chorioretinal Atrophy

Focal Chorioretinal Atrophy

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Focal Chorioretinal Atrophy

Management
Monitor annually

Congenital Hypertrophy of the RPE

Known by the acronym CHRPE or chirp. RPE hypertrophy refers to the RPE cell that
are enlarged with the same amount of melanin pigment along with choriocapillaris atrophy. Another variant of CHRPE known as bear tracks.

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CHRPE

CHRPE

Familial Adenomatous Polyposis

Diagnosis made when more than 100 adenomatous polyps found in the colon and rectum Malignancy is unavoidable without prophylactic total colectomy

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CHRPE

CHRPE

Note double-ring sign

CHRPE

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CHRPE

CHRPE

Management
Familial tendency of familial adenomatous polyposis (FAP) refer for sigmoidoscopy Children carrying gene for FAP may present with 4 or more bilateral CHRPEs Otherwise monitor annually

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RPE Hyperplasia
Jet black irregularly shaped area RPE cells replicate for retinal repair Found in:
Atrophic retinal holes Demarcation lines of RD Choroidal neovascular net Any area of retinal damage

RPE Hyperplasia

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RPE Hyperplasia

RPE Hyperplasia

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Management
Rule out process of hyperplastic proliferation Without inflammatory process annually

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Choroidal Nevus
30% of population Flat, slate gray lesion Accumulation of choroidal melanocytes Disappears with red free light

Choroidal Nevus
Overlying drusen may be seen with time May increase in size without malignancy Pregnancy can result in malignancy May show overlying serous detachment Approximately 1-3% chance of malignancy

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Choroidal Nevus

Amelanotic Choroidal Nevus

Nevus vs. CHRPE

Facts:

Choroidal nevus located under RPE CHRPE is a hypertrophy of RPE RPE attenuates red-free light Therefore, nevus will disappear with red-free light and CHRPE will be unaffected

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Choroidal Nevus
Nevus Nevus Red Free

CHRPE
CHRPE CHPRE Red Free

Choroidal Nevus or CHRPE??

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Choroidal Nevus

Management
Varies with presentation Record size (L & W) or photodocument Photocoagulation with serous detachment

Differential Diagnosis:
Nevus vs. Melanoma
Size (DD)
0.5 2 25

Associated Findings
None Elevated lesion, overlying drusen, SRF Elevation, drusen, photopsia, orange pigment

Classification
Benign Suspicious, ultrasound, FA, photodocument, RV 6 months Malignant until proven otherwise

5 or larger

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White Without Pressure

Abnormal vitreoretinal traction 3% of population Usually bilateral Can appear raised Pseudo-hole = area within WWOP without traction

White Without Pressure

Observed surrounding:
RD Lattice L tti degeneration d ti Staphylomatous areas of retina

May show linear tears along posterior border Scalloped borders may indicate strong vitreoretinal traction

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White Without Pressure

White Without Pressure

White Without Pressure

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White Without Pressure ??

Management
Monitor annually Scalloped border ~> q 6 months Symptomatic ~> scleral indentation along posterior border to locate tear

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