Peripheral Retina Peripheral Retina Abnormalities: with Emphasis Abnormalities: with Emphasis on Retinal Detachment on Retinal Detachment Mukesh B. Mukesh B. Suthar Suthar , MD , MD Assistant Professor Assistant Professor Vitreo Vitreo ‐ ‐ Retinal Specialist Retinal Specialist Optometry Symposium Optometry Symposium Loma Linda University Loma Linda University November 2, 2008 November 2, 2008
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Peripheral Retina Peripheral Retina Abnormalities: with Emphasis Abnormalities: with Emphasis
Optometry SymposiumOptometry SymposiumLoma Linda UniversityLoma Linda University
November 2, 2008November 2, 2008
Retinal AnatomyRetinal Anatomy
The Peripheral RetinaThe Peripheral Retina
Long Ciliary artery Long Ciliary artery and nerveand nerveVortex veinsVortex veinsOra SerrataOra SerrataPars PlanaPars PlanaPars PlicataPars Plicata
The Peripheral RetinaThe Peripheral Retina
Long Ciliary artery and Long Ciliary artery and nervenerveVortex veinsVortex veins
Divides Fundus into Divides Fundus into Posterior and Peripheral Posterior and Peripheral RetinaRetinaAnatomical equator is Anatomical equator is 3mm anterior to 3mm anterior to entranceentrance
Ora SerrataOra SerrataPars PlanaPars PlanaPars PlicataPars Plicata
The Peripheral RetinaThe Peripheral Retina
Long Ciliary artery Long Ciliary artery and nerveand nerveVortex veinsVortex veinsOra SerrataOra SerrataPars PlanaPars PlanaPars PlicataPars Plicata
Ora SerrataOra Serrata
Ora Serrata RegionOra Serrata Region–– More pronounced More pronounced
Extends 1.5 mm Extends 1.5 mm anteriorlyanteriorlyExtends 1.8 temporally, and Extends 1.8 temporally, and 3 mm nasally 3 mm nasally posteriorlyposteriorly to to ora serrataora serrataFirm attachment of:Firm attachment of:–– Sensory retinaSensory retina–– RPERPE–– Vitreous BaseVitreous Base
Consists of 99% water, Consists of 99% water, ++hyaluronichyaluronic acid, salts, acid, salts, collagen fibrils, proteinscollagen fibrils, proteins
•• SteropsisSteropsis•• Less distortionLess distortion•• Better visualization Better visualization
in eyes with hazy in eyes with hazy viewview
•• Wide field of viewWide field of view•• Readily perform Readily perform
scleral depressionscleral depression
Three Mirror Contact LensThree Mirror Contact Lens
•• Excellent Excellent visualizationvisualization
•• Readily view ora Readily view ora serrata and pars serrata and pars planaplana
•• Good visualization of Good visualization of overlying vitreousoverlying vitreous
•• Limited field of viewLimited field of view
Wide Angle Contact LensWide Angle Contact Lens
Excellent field of Excellent field of viewviewDistortion in Distortion in peripheryperipheryPoor depth Poor depth perceptionperceptionLow resolutionLow resolution
SeperationSeperation between between sensory retina and sensory retina and retinal pigment retinal pigment epitheliumepitheliumFour types:Four types:–– RhegmatogenousRhegmatogenous–– ExudativeExudative–– TractionalTractional–– ComplexComplex
SeperationSeperation between between sensory retina and sensory retina and retinal pigment retinal pigment epitheliumepitheliumFour types:Four types:–– RhegmatogenousRhegmatogenous–– ExudativeExudative–– TractionalTractional–– ComplexComplex
SeperationSeperation between between sensory retina and sensory retina and retinal pigment retinal pigment epitheliumepitheliumFour types:Four types:–– RhegmatogenousRhegmatogenous–– ExudativeExudative–– TractionalTractional–– ComplexComplex
SeperationSeperation between between sensory retina and sensory retina and retinal pigment retinal pigment epitheliumepitheliumFour types:Four types:–– RhegmatogenousRhegmatogenous–– ExudativeExudative–– TractionalTractional–– ComplexComplex
Rate approximately 1 in 10,000 / yearRate approximately 1 in 10,000 / yearLifetime estimated, at 0.06 %Lifetime estimated, at 0.06 %Incidence of Retinal Breaks is 3.3 % Incidence of Retinal Breaks is 3.3 % /year/year–– => so, risk of RD is 1:330=> so, risk of RD is 1:330
Common age range 40Common age range 40--70 years old70 years old
RRD: FindingsRRD: Findings
Tear found in 97% of Tear found in 97% of the casesthe cases10% from asymptomatic 10% from asymptomatic retinal breakretinal break50% have floaters or 50% have floaters or photopsiaphotopsia+ Shafer+ Shafer’’s sign (tobacco s sign (tobacco dust)dust)Lowered IOPLowered IOPCorrugated retinal Corrugated retinal foldingfolding
RRD: Common Risk FactorsRRD: Common Risk Factors
MyopiaMyopiaAphakiaAphakiaTraumaTraumaRD in fellow eye (15%)RD in fellow eye (15%)Family history of RDFamily history of RDPeripheral LesionsPeripheral LesionsSystemic (GoldmannSystemic (Goldmann--Favre, SticklerFavre, Stickler’’s)s)
AphakiaAphakiaTraumaTraumaRD in fellow eyeRD in fellow eyeFamily history of RDFamily history of RDPeripheral LesionsPeripheral LesionsSystemic (GoldmannSystemic (Goldmann--Favre, SticklerFavre, Stickler’’s)s)
RD: after Cataract ExtractionRD: after Cataract Extraction
–– Firm attachment Firm attachment at vitreous base, at vitreous base, optic nerve, optic nerve, paravascularparavascular
Vitreous Vitreous -- PVDPVD
Posterior vitreous Posterior vitreous detachment (PVD)detachment (PVD)–– SeperationSeperation from from
Optic Nerve.Optic Nerve.–– If other locations, If other locations,
consider another consider another mechanism (mechanism (egeg. . Inflammatory)Inflammatory)
PVD SymptomsPVD Symptoms
FlashesFlashes–– Caused by vitreous Caused by vitreous
tractiontraction–– Not location specificNot location specific
FloatersFloaters–– Single spotSingle spot–– StrandsStrands–– CobwebCobweb–– Sand stormSand stormVisual Field Loss = Visual Field Loss = RDRD
PVDPVD
Prevalence associated with:Prevalence associated with:–– Age (63% at 70 Age (63% at 70 yoyo))–– Axial length / MyopiaAxial length / Myopia–– AphakiaAphakia–– PseudophakiaPseudophakia / Vitreous Loss/ Vitreous Loss–– Inflammatory DiseaseInflammatory Disease–– TraumaTrauma
PVD PVD -- importanceimportance
PVD + Retinal BreakPVD + Retinal Break
1010--15% with 15% with acute symptomsacute symptomshave retinal have retinal break(sbreak(s))–– New retinal break found New retinal break found
in 2%, in 2%, espesp if hemorrhage, if hemorrhage, or, new symptomsor, new symptoms
–– Development of RD Development of RD unlikely if no retinal tears unlikely if no retinal tears found in 4found in 4--6 weeks6 weeks
5050--70% with acute symptoms 70% with acute symptoms and vitreous hemorrhage and vitreous hemorrhage have retinal breakshave retinal breaks–– Avulsion of overlying Avulsion of overlying
1010--15% with acute symptoms 15% with acute symptoms have retinal have retinal break(sbreak(s))–– New retinal break found New retinal break found
in 2%, in 2%, espesp if hemorrhage, if hemorrhage, or, new symptomsor, new symptoms
–– Development of RD Development of RD unlikely if no retinal tears unlikely if no retinal tears found in 4found in 4--6 weeks6 weeks
5050--70% with 70% with acute symptoms acute symptoms and vitreous hemorrhageand vitreous hemorrhagehave retinal breakshave retinal breaks–– Avulsion of overlying Avulsion of overlying
* Modified AAO, Preferred Practice Pattern, 2003* Modified AAO, Preferred Practice Pattern, 2003
Lesions not predisposing to Lesions not predisposing to RDRD
Cobblestone Cobblestone degenerationdegenerationPeripheral Peripheral cystoidcystoiddegenerationdegenerationWhite with/without White with/without pressurepressureRPE HyperplasiaRPE HyperplasiaRPE RPE HypertophyHypertophyPars plana cystsPars plana cysts
• From Dr. H. Riley / Indiana University
Lesions not predisposing to Lesions not predisposing to RDRD
Cobblestone Cobblestone degenerationdegeneration–– Multiple, round, area of Multiple, round, area of
choroidal, retinal atrophychoroidal, retinal atrophy–– Often bilateralOften bilateral
Peripheral Peripheral cystoidcystoiddegenerationdegenerationWhite with/without White with/without pressurepressureRPE HyperplasiaRPE HyperplasiaRPE RPE HypertophyHypertophyPars plana cystsPars plana cysts
White Without PressureWhite Without Pressure
Lesions predisposing to RDLesions predisposing to RD
Lattice Lattice degenerationdegenerationCystic retinal tuftCystic retinal tuftMeridonal foldsMeridonal foldsEnclosed ora baysEnclosed ora baysDegenerative Degenerative RetinoschisisRetinoschisis
Lesions predisposing to RDLesions predisposing to RD
Lattice Lattice degenerationdegenerationCystic retinal tuftCystic retinal tuftMeridonal foldsMeridonal foldsEnclosed ora baysEnclosed ora baysDegenerative Degenerative RetinoschisisRetinoschisis
Lattice DegenerationLattice Degeneration
Found in 8% of the Found in 8% of the population, bilateral population, bilateral in 45%in 45%Risk to RD in 5% ; Risk to RD in 5% ; with Myopia ~ 25%with Myopia ~ 25%Often in myopia, Often in myopia, familial patternfamilial pattern30% of patients with 30% of patients with RD have latticeRD have lattice
Lattice DegenerationLattice Degeneration
Often found midway Often found midway between ora serrata between ora serrata and the equatorand the equatorCircumferential area Circumferential area with with crisscriss--crossing crossing white lattice lines white lattice lines ((hyalinizedhyalinized blood blood vessels)vessels)–– Perivascular and Perivascular and
radial (radial (egeg. Stickler. Stickler’’s s syndrome)syndrome)
Lattice DegenerationLattice Degeneration
No ILM (#1); No ILM (#1); retinal thinning ; retinal thinning ; overlying vitreous overlying vitreous liquefaction (#3); liquefaction (#3); adherence at adherence at borders (#4)borders (#4)
Lesions predisposing to RDLesions predisposing to RD
Lattice degenerationLattice degeneration–– Risk to RD ~ <1%Risk to RD ~ <1%
Horseshoe tearHorseshoe tearOperculated HoleOperculated HoleAtrophic HoleAtrophic HoleGiant Retinal TearGiant Retinal TearMacular holeMacular holeDialysesDialyses–– Full thickness Full thickness
disinsertiondisinsertion at the ora at the ora serrataserrata
–– Often associated with Often associated with blunt traumablunt trauma
Treatment of Retinal Treatment of Retinal BreaksBreaks
3030--50% of symptomatic horseshoe 50% of symptomatic horseshoe tears result in RD, tears result in RD, –– => => vsvs those treated to 5%those treated to 5%
Follow up closely, since new retinal Follow up closely, since new retinal breaks occur in 8%breaks occur in 8%
Applied either Applied either with Indirect with Indirect Ophthalmoscope, Ophthalmoscope, or Contact Lensor Contact Lens55--7 days for 7 days for adhesionadhesion
nu4
Slide 60
nu4 scar forms in 5-7 daysnew user, 10/26/2008
Differential Diagnosis of Retinal Differential Diagnosis of Retinal DetachmentDetachment
Repair of Retinal Repair of Retinal DetachmentDetachment
Basically five options:Basically five options:–– RetinopexyRetinopexy (Laser or (Laser or CryotherapyCryotherapy))–– Pneumatic Pneumatic RetinopexyRetinopexy–– BalloonBalloon–– Scleral BuckleScleral Buckle–– Pars Plana VitrectomyPars Plana Vitrectomy
Repair of Retinal Repair of Retinal DetachmentDetachment
Basically five options:Basically five options:–– RetinopexyRetinopexy (Laser or (Laser or CryotherapyCryotherapy))–– Pneumatic Pneumatic RetinopexyRetinopexy–– BalloonBalloon–– Scleral BuckleScleral Buckle–– Pars Plana VitrectomyPars Plana Vitrectomy
Limited to Limited to Superior Superior detachmentsdetachmentsPositioning Positioning requirementrequirement
Scleral BuckleScleral Buckle
Indents eye from Indents eye from outside to outside to reapposereappose retinaretinaNeed to be able to Need to be able to visualize all breaksvisualize all breaksVariations:Variations:–– +/+/-- DrainageDrainage–– Encircling vs. Encircling vs.
Radial BandRadial Band
Pars Plana VitrectomyPars Plana Vitrectomy
VersatileVersatileVarious gauges: Various gauges: 20g, 23g, and 25g20g, 23g, and 25g
Pars Plana VitrectomyPars Plana Vitrectomy
VersatileVersatileVarious gauges: 20g, Various gauges: 20g, 23g, and 25g23g, and 25g
Giant Retinal tearGiant Retinal tear
Defined as greater Defined as greater than 3clock hoursthan 3clock hoursBilateral GRT Bilateral GRT especially in high especially in high myopesmyopes, Stickler, Stickler’’s s syndromesyndrome