Peripheral Retina Abnormalities: with Emphasis onlomalindahealth.org/media/health-care/pdfs/ophthalmology/retina.pdf · Peripheral Retina Abnormalities: with Emphasis on Retinal Detachment

Peripheral Retina Peripheral Retina Abnormalities: with Emphasis Abnormalities: with Emphasis

on Retinal Detachmenton Retinal Detachment

Mukesh B. Mukesh B. SutharSuthar, MD, MD

Assistant ProfessorAssistant ProfessorVitreoVitreo‐‐Retinal SpecialistRetinal Specialist

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


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


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

dentate processes dentate processes nasallynasally

–– 3DD wide, 1DD 3DD wide, 1DD anteriorlyanteriorly, 2DD , 2DD posteriorlyposteriorly

–– Sensory retina Sensory retina --> > nonpigmentednonpigmented ciliary ciliary epitheliumepithelium

Pars PlanaPars PlanaPars PlicataPars Plicata


Ora Serrata RegionOra Serrata RegionPars PlanaPars Plana–– Asymmetrical (wider Asymmetrical (wider

temporally)temporally)–– Average 4mm width Average 4mm width

(from ora serrata to (from ora serrata to ciliary crest)ciliary crest)

–– Entrance for Entrance for VitrectomyVitrectomy

Pars PlicataPars Plicata


Ora Serrata RegionOra Serrata RegionPars PlanaPars PlanaPars PlicataPars Plicata–– contains 73 ciliary contains 73 ciliary

processesprocesses–– Production of Production of

aqueous aqueous humorhumor–– Ciliary musclesCiliary muscles

VitreousVitreous

Vitreous BaseVitreous Base

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

ExaminationExamination

Indirect Indirect OphthalmoscopyOphthalmoscopyThree mirror Three mirror contact lenscontact lensWide angle Wide angle contact lenscontact lensTransilluminationTransillumination

Indirect OphthalmoscopyIndirect Ophthalmoscopy

•• 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

Peripheral Retina: Retinal Peripheral Retina: Retinal DetachmentDetachment

SeperationSeperation between between sensory retina and sensory retina and retinal pigment retinal pigment epitheliumepitheliumFour types:Four types:–– RhegmatogenousRhegmatogenous–– ExudativeExudative–– TractionalTractional–– ComplexComplex







Rhegmatogenous Retinal Rhegmatogenous Retinal DetachmentDetachment

1.1. Retinal breakRetinal break2.2. Hydrostatic forcesHydrostatic forces3.3. Liquefied vitreousLiquefied vitreous4.4. TractionTraction

* University of Toronto Schema * University of Toronto Schema ((BreakBreak--FluidFluid--FluidFluid--TractionTraction))


1.1. Retinal breakRetinal breakrhegmarhegma = break= breakoften caused by often caused by PVDPVD

2.2. Hydrostatic forcesHydrostatic forces3.3. Liquefied vitreousLiquefied vitreous4.4. TractionTraction))


1.1. Retinal breakRetinal break2.2. Hydrostatic forcesHydrostatic forces

RPE pump, RPE pump, intraocular intraocular pressure, osmotic pressure, osmotic pressure)pressure)

3.3. Liquefied vitreousLiquefied vitreous4.4. TractionTraction


1.1. Retinal breakRetinal break2.2. Hydrostatic forces Hydrostatic forces 3.3. Liquefied vitreousLiquefied vitreous

•• Offers access pointOffers access point•• Enters through Enters through

breakbreak

4.4. TractionTraction


1.1. Retinal breakRetinal break2.2. Hydrostatic forcesHydrostatic forces3.3. Liquefied vitreousLiquefied vitreous4.4. TractionTraction

•• Mechanical forcesMechanical forces•• Ocular saccadesOcular saccades

RRD: IncidenceRRD: Incidence

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)

RRD: Common Risk FactorsRRD: Common Risk Factors

MyopiaMyopia–– 11--3D, risk 4x population3D, risk 4x population–– > 3D, risk 10x population> 3D, risk 10x population

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

Surgical Surgical complications complications increase riskincrease risk

• Norregaard, BJO 1996

RRD: PreventionRRD: Prevention

Recognition of acute PVD signsRecognition of acute PVD signsAssess Risk FactorsAssess Risk FactorsIdentify peripheral pathologyIdentify peripheral pathologyTreatment of Treatment of ““high riskhigh risk”” tearstearsPatient EducationPatient Education









VitreousVitreous

Posterior vitreous Posterior vitreous detachment (PVD)detachment (PVD)–– Vitreous Vitreous

liqufeactionliqufeaction((syneresissyneresis))

–– 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

vesselvessel–– ParipapillaryParipapillary vesselvessel

PVD + Retinal BreakPVD + Retinal Break

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

vesselvessel–– ParipapillaryParipapillary vesselvessel

Which Retinal Breaks to Which Retinal Breaks to Treat?Treat?

Retinal DialysisRetinal Dialysis AlwaysAlwaysHorshoeHorshoe tearstears AlwaysAlwaysOperculated HoleOperculated Hole–– SymptomaticSymptomatic SometimesSometimes–– AsymptomaticAsymptomatic RarelyRarely

Atrophic holeAtrophic hole RarelyRarelyLattice degenerationLattice degeneration RarelyRarely

* 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


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


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)


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)


Lattice degenerationLattice degeneration–– Risk to RD ~ <1%Risk to RD ~ <1%

Cystic retinal tuftCystic retinal tuft–– Round elevation, Round elevation, glialglial

tissuetissue–– 5% in autopsy, 5% in autopsy,

bilateral in 20%bilateral in 20%–– Risk to RD ~ 0.28%Risk to RD ~ 0.28%

Meridonal foldsMeridonal foldsEnclosed ora baysEnclosed ora bays


Lattice degenerationLattice degeneration–– Risk to RD ~ <1%Risk to RD ~ <1%

Cystic retinal tuftCystic retinal tuftMeridonal foldsMeridonal folds– Redundant fold of retina

to pars plicata processes– May have associated

posterior break– Superior nasal common

Enclosed ora baysEnclosed ora bays

Retinal BreaksRetinal Breaks

Horseshoe tearHorseshoe tearOperculated HoleOperculated HoleAtrophic HoleAtrophic HoleGiant Retinal TearGiant Retinal TearMacular holeMacular holeDialysesDialyses












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%

Treatment: Laser Treatment: Laser RetinopexyRetinopexy

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

RetinoschisisRetinoschisisVitreous HemorrhageVitreous HemorrhageChoroidal LesionsChoroidal Lesions–– Choroidal DetachmentChoroidal Detachment–– Choroidal MelanomaChoroidal Melanoma

RetinoschisisRetinoschisis

Differential Diagnosis of Retinal Differential Diagnosis of Retinal DetachmentDetachment

RetinoschisisRetinoschisisVitreous HemorrhageVitreous HemorrhageChoroidal LesionsChoroidal Lesions–– Choroidal DetachmentChoroidal Detachment–– Choroidal MelanomaChoroidal Melanoma

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

Success approaches 90Success approaches 90--95%95%

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

Success approaches 90Success approaches 90--95%95%

Retinal Detachment: Retinal Detachment: Macular StatusMacular Status

Visual prognosis good if macula on (87%Visual prognosis good if macula on (87%>>20/50)20/50)

Prognosis guarded if macula off (50%Prognosis guarded if macula off (50%>>20/50)20/50)

Prognosis related to macula off duration (??, age)Prognosis related to macula off duration (??, age)

Retinal Detachment: Retinal Detachment: DurationDuration

PnematicPnematic RetinopexyRetinopexy

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

ReplacementsReplacements

FluidFluidAirAirGas: SF6, C3F8Gas: SF6, C3F8Silicon OilSilicon Oil

Peripheral Retina SummaryPeripheral Retina Summary

AnatomyAnatomyExaminationExaminationRetinal DetachmentRetinal Detachment–– TypesTypes–– VitreousVitreous–– Retinal BreaksRetinal Breaks–– Risk FactorsRisk Factors–– Introduction to RD Introduction to RD

RepairRepair


AnatomyAnatomyExaminationExaminationRetinal DetachmentRetinal Detachment–– TypesTypes–– VitreousVitreous–– Retinal BreaksRetinal Breaks–– Risk LesionsRisk Lesions–– Introduction to RD Introduction to RD

RepairRepair



RepairRepair



RepairRepair



RepairRepair



RepairRepair



RepairRepair

Peripheral RetinaPeripheral Retina

Thank You!Thank You!

Documents

Peripheral Retina Abnormalities: with Emphasis onlomalindahealth.org/media/health-care/pdfs/ophthalmology/retina.pdf · Peripheral Retina Abnormalities: with Emphasis on Retinal Detachment