Retinal breaks

Retinal breaks- any full- thickness defect in the neurosensory retina

Can cause RD 6% of population have break 1/10,000-15,000 per year- RD 0.07% chance of developing RD in a

lifetime

Direct retinal perforation, contusion, vitreous tractionCoupContrecoup

Usually multiple Inferotemporal and superonasal

quadrants Most common- dialyses + avulsion

of vitreous base= ocular contusion Others: horseshoe-shaped tears,

operculated holes

Young patients- higher incidence of eye injury

Rarely develop acute rhegmatogenous RD

Vitreous acts as tamponade 12%- immediately 30%- 1 month 50%- 8 months 80%- 24 mos

Vitreous base- 2 mm anterior and 4 mm posterior to the ora serrata

Optic disc, macula, along major vessels, margins of lattice degeneration, sites of chorioretinal scars

Increasing age- 63% in > 70 y/o axial lengthAphakia – 66-100% Inflammatory diseaseTraumamyopia

ICCE- 84%ECCE w/ open capsule-

76%ECCE w/ intact capsule-

40%

Photopsias Multiple floaters Curtain or cloud Vitreous hemorrhage

Retinal tear present in 15% w/ acute PVD 50-70% w/ acute PVD + vitreous hge

IO w/ scleral depression Slit lamp biomocroscopy w/ 3-

mirror lens Hemorrhage or pigment? Reexamine in 3- 4 weeks patching, bed rest, head elevation

for 45⁰ B- scan vitrectomy

6-10% of general population 1/3-1/2- bilateral Myopia, familial predilection

1. Atrophy of the inner layers2. Overlying pocket of liquefied

vitreous, 3. condensation and adherence of

vitreous at the margin of lesion Progresses to RD- tractional tear or

atrophic hole

Areas of elevated glial hyperplasia Noncystic retinal tufts Cystic retinal tufts may

predispose Zonular traction tufts to RD

folds of redundant retina Superonasally Associated w/ dentate processes Tears occur at the most posterior

limit of the folds

Oval islands ofpars plana epithelium located immediately posterior to the ora

Almost/completely circumscribed by the peripheral retina

Tears can occur at or near the posterrior margins of enclosed ora bays

Paving-stone or Cobblestone Degeneration

RPE hyperplasia RPE hypertrophy Peripheral Cystoid Degeneration

•22% over 20 y/o•Atrophy of the outer retina1.Atrophy of the RPE and outer retinal layers2.Attenuation or absence of the choriocapillaries3.Adhesions b/n the remaining neuroepithelial layers amd bruch’s membrane•Inferior quadrant, anterior to the equator•NEVER the site of PRIMARY retinal break

•Proliferation of RPE cells•Old areas of inflammation and trauma, RD, retinal tear •Benign, but may cause field loss•Appears as black

•Enlargement of RPE cells•Congenital or acquired•Aging and degenerative change•Large cells and large, spherical melanin granules, •very dark, well demarcated•BENIGN

•Present in approximately 100% of > 20 y/o•Temporal•1. TYPICAL•Cysts in the outer plexiform layer

•2. RETICULAR•Nerve fiber layer•Posterior to typical cystoid•May develop into full-retinal break

Reduce the risk of RD Risk outweigh the benefit May not eliminate the risk of new

tears or detachment GOAL: create a chorioretinal scar

around the break Acute symptomatic break are more

dangerous than the old ones

Acute symptomatic flap tear Acute operculated holes

+ persistent vitreous tractionLarge holeSuperior locationVit hem

Atrophic holes+ traction

Flap tearsEmmetropic, phakic eyesLattice degenerationMyopiaSubclinical detachmentAphakia w/ detachment in the other

eye Operculated holes Atrophic holes

Treat the entire lesion Posterior and lateral margins 6-10% of eyes 20-30% of eyes w RD 1%- RD in untreated lattice

degeneration

•High myopia •RD in the fellow eye•flap tears•aphakia

1-3 % incidence of RD Asymptomatic breaks –

prophylaxis? Flap tears Subclinical detachments

Asymptomatic retinal detachment Detachment in w/c subretinal fluid

extends more than 1 DD from the break but not more than 2DD posterior to the equator.

Traction on the break

TYPE OF LESION TREATMENT

Horseshoe tears Almost always

Dialysis Almost always

Operculated tear sometimes

Atrophic hole Rarely

Lattice degeneration w/o horseshoe tears

Rarely

Zorab et.al., American academy of Ophthalmology Section 12 p. 290 2008-2009

Type of lesion

phakic Highly myopic

Fellow eye Aphakic or pseudopha

kic

Retinal dialysis

Almost always

Almost always

Almost always

Almost always

Horseshoe tears

sometimes sometimes sometimes sometimes

Operculated tears

no rarely rarely rarely

Atrophic holes

rarely rarely rarely rarely

Lattice deg’n w/ or w/o holes

no no sometimes rarely

Zorab et.al., American academy of Ophthalmology Section 12 p. 291, 2008-2009

http://one.aao.org/CE/Practice Guidelines