Peripheral Retinal Disorders

7/27/2019 Peripheral Retinal Disorders

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intrabasal

extrabasal

oral zone

juxtabasal

Rhegmatogenous Retinal

Detachment

Most common, more common in high myopes,

fellow eye shows 25% chance of development.

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

-


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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 s ee u to 5D of induced m o ia

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

een most common y:

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 trainedM.D. or D.O.

Surrounding detachment >1DD

Flap has visible attachment

Prior to YAG or cataract surgery

Prior to retinal detachment in fellow eye

Retinal Tear ??

Retinal tear

Retinal Tear with Photocoagulation


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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



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Mild retinal elevation


Linear appearance


Increased risk factors based on location:

Juxtabasal

uper or

Proximity to liquefied vitreous


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Atrophic Retinal Hole


Management

Consultation if:

Symptomatic

urroun ng ret na etac ment

Follow if:

Asymptomatic

Surrounding retinal detachment < 1DD


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Operculated Retinal Holes

Operculum = free floating necrotic retinaltissue

Better prognosis since vitreoretinal adhesion is

relieved


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Operculated Retinal Hole



operculum


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operculum

Management

Consultation if:

Symptomatic

urroun ng ret na etac ment

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 -


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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


Chorioretinal atrophy and fishboning may be

seen

Liquefied vitreous typically overlies lesion

Assessment through scleral indentation


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with an atrophic hole


atrophic hole withscleral depression



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Management

Consultation or referral if: Symptomatic with atrophic holes

arg na ret na rea s

Follow if:

Asymptomatic

Symptomatic without atrophic holes

Lattice Degeneration ??

Snail-Track Degeneration

Lattice degeneration without fishbone

appearance


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Management

Consultation or referral if:

Symptomatic with atrophic holes

arg na ret na rea s

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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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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Elevated

schisis cavity


Elevated

schisis cavity


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Differentiating Retinal

Detachment from Retinoschisis

Characteristic RD SchisisTransparency Little Common

Surface Folds Smooth

Fluid Shift Often Absent

Tear Common Rare

Field Defect Relative Absolute

Management

No inner or outer layer breaks annually

Location anterior to equator annually

Inner la er breaks onl 6 months

Location posterior to equator 3 months

Outer layer breaks refer

Inner and outer layer breaks refer

Scheduled intraocular surgery refer

Diagnosis Requiring Non-Urgent

Treatment/Management


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Focal Chorioretinal Atrophy

Known as pavingstone or cobblestonedegeneration

Atrophy of RPE and outer retina

Appears yellow with distinct borders, slightly

posterior to ora serrata




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Management

Monitor annually

Congenital Hypertrophy

of the RPE

Known by the acronym CHRPE or chirp.

RPE hypertrophy refers to the RPE cell that

melanin pigment along with choriocapillaris

atrophy.

Another variant of CHRPE known as beartracks.


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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

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 h ertro h of RPE

RPE attenuates red-free light

Therefore, nevus will disappear with red-freelight 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) Associated Findings Classification

0.5 2 None Benign

2 5 Elevated lesion,

overlying drusen,

SRF

Suspicious,

ultrasound, FA,

photodocument,

RV 6 months

5 or larger Elevation, drusen,

photopsia, orange

pigment

Malignant until

proven otherwise


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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


Observed surrounding:

RD

att ce egenerat on

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 ??

Management

Monitor annually

Scalloped border ~> q 6 months

Symptomatic ~> scleral indentation along

posterior border to locate tear

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Peripheral Retinal Disorders