Finding The Retinal Hole:Lincoff’s Rules

Vincent Reppucci, MDDirector Retina Service

St. Luke’s-Roosevelt Hospital CenterNYC, NY USA

5th THESSALONIKI INTERNATIONAL VITREO-RETINAL SUMMER SCHOOL

23-27 June 2015Thessaloniki, Greece

Lincoff’s Rules A method of predicting the

location of retinal holes hasbeen formulated.

It is based on the fact that the developmentof subretinal fluid, following the occurrenceof a retinal tear, is governed by a limitednumber of anatomical factors and gravity.

As a result, detachments form ina predictable manner aroundthe tear or hole of their origin,and the shape of thedetachment points to theposition of the retinal hole.

One thousand retinal detachments wereanalyzed, and they confirm this concept.

Lincoff’s Rules

1. In superior nasal or temporal detachments, thehole lies within 1½ clock hours of the highestborder 98% of the time.

2. In total detachment or superiordetachments that cross the midline, theprimary hole is at 12 o'clock or in a triangle,the apex of which is at the ora serrata, and thesides of which intersect the equator one hour toeither side of 12 o'clock. This occurs 93% of thetime.

3. In inferior detachments the higher sideindicates to which side of the disc an inferiorhole lies 95% of the time.

4. When an inferior detachment is bullous, theprimary hole lies above the horizontal

RULE 1:In superior nasal or temporal detachments, the hole lieswithin 1½ clock hours of the highest border 98% of the

time.

• Detachment withprimary hole insuperotemporalquadrant. Fluid hasrevolved arounddisc and risen onnasal side to level ofhole.

• Distribution of retinal breaks in 279superotemporal or nasaldetachments.

RULE 2:In total detachment or superior detachments

that cross the midline, the primary hole is at 12o'clock or in a triangle, the apex of which is at

the ora serrata, and the sides of which intersectthe equator one hour to either side of 12

o'clock. This occurs 93% of the time.

Detachment crosses verticalmeridian above, caused by atear near 12 o'clock. Loweredge corresponds with sideof hole.

Distribution of retinalbreaks in 340detachments thatcrossed 12 o'clockmeridian.

RULE 2:In total detachment or superior detachments

that cross the midline, the primary hole is at 12o'clock or in a triangle, the apex of which is at

the ora serrata, and the sides of which intersectthe equator one hour to either side of 12

o'clock. This occurs 93% of the time.

RULE 3:In inferior detachments the higher side indicatesto which side of the disc an inferior hole lies 95%

of the time.

• lnferior detachment withprimary hole at 6:30o’clock. Higher side ofdetachmentcorresponds with side ofretinal hole.

Distribution of retinal breaksin 153 inferior detachments

RULE 3:In inferior detachments the higher side indicatesto which side of the disc an inferior hole lies 95%

of the time.

lnferior detachmentwith equal fluid levelspointing to a hole atsix o'clock.

lnferior detachment of 14 years'duration. Side of highest borderof detachment still correspondswith side of retinal break.

lnferior detachment in which fluid riseshigher on side opposite hole because oftraction on retina. Note concave contourof detachment on secondary side (left).

Inferior detachment in whichfluid was blocked bychorioretinal adhesions on aprevious scleral buckle.

RULE 3:In inferior detachments the higher side indicatesto which side of the disc an inferior hole lies 95%

of the time.

RULE 4:When an inferior detachment is

bullous, the primary hole lies abovethe horizontal meridian

Inferior bullous detachment caused by a superior hole whichconnects by a shallow peripheral sinus. Rotating headdemonstrates pathway to hole. (center) with hole above and(right) with hole dependent.

• Almost total detachment. Superior wedgeof attached retina discloses true characterand points to presence of primary hole inperiphery near highest border.

Examination technique

• Determine if detachment is inferior orsuperior

• If superior does it cross the midline• If inferior is it bullous• Map the detachment extent nasally and

temporally• You have determined location of

primary tear

Demarcation lines

• Suggest stability of detachment forseveral weeks

• Very useful to assist in localizing thelocation of tear as it provides a timelineof the detachment progression.

54 y.o. Female Pseudophake

75 y.o. Female Pseudophake

72 y.o. Phakic Male asymptomatic

72 y.o.monocularRabbiVitreoushemeeccentricdisciformwithsubretinalhemecataract

58 y.o. Male Pseudophake. 3 months s/psuccessful encircling buckle for RD.

68 yo male, s/p inferior RD encirclingband, failed, Vx failed, Repeat Vx Si Oil,IOL, Macular pucker inferior RD beneathSi oil; Remove oil membrane peel Airtamponade. 2 weeks out.