9

Peripheral Retinal Diseases

RETINAL TEARS

Elisabeth Maureen Sledz, MD and John D. Pitcher III, MD

• Most common after posterior vitreous detachment (PVD); up to 20% of symptomatic PVD may have tear(s)
  
• Risk factors: post-trauma, myopia, lattice degeneration, previous cataract surgery, following YAG laser capsulotomy

Categories

• Horseshoe: retinal break caused by vitreous traction; located at sites of strong vitreoretinal adhesion (vitreous base); usually occurs at time of PVD (Figure 9-1A)
  
• Operculated: round defect with overlying operculum of retinal tissue

• Atrophic hole: caused by chronic thinning of sensory retina rather than traction; associated with myopia and lattice degeneration; may remain stable or cause insidious onset retinal detachment (RD; Figure 9-1B)
  
• Giant tear: spontaneous or traumatic, > 90 degrees or > 3 clock hours (Figure 9-1C)

Signs and Symptoms

“Floaters” (spider webs, lines/strings, tiny dots); peripheral “flashes” (photopsias) most prominent at night or in dark room and worsens with eye movement; blurred vision if concomitant vitreous hemorrhage or debris

• Anterior segment: pigmented cells in anterior vitreous on slit lamp exam (tobacco dust, Shafer’s sign); high suspicion for retinal tear if present
  
• Posterior segment: Weiss ring (circular vitreous condensation); vitreous hemorrhage may be present; retinal tears (most common in superotemporal quadrant, may occur adjacent to lattice degeneration; Figure 9-2)

Testing

Optical coherence tomography (OCT) may show small hyperreflective dots in vitreous (“falling ash sign”) related to pigmented cells or red blood cells

Differential Diagnosis

Vitreous hemorrhage from other etiology, vitritis, pavingstone degeneration, lattice degeneration, meridional fold, retinal tuft

Management

• Emergent laser retinopexy or cryotherapy for acute symptomatic tears to prevent RD
  
• Asymptomatic operculated and atrophic holes may be observed with education about RD warnings (flashes, floaters, curtain over vision), however treatment may be recommended if history of RD in contralateral eye or strong family history of RD

LATTICE DEGENERATION

Priya Sharma Vakharia, MD and Chirag P. Shah, MD, MPH

• Common peripheral retinal finding (~8% to 10% of the population) with increased prevalence in myopic eyes
  
• Increases risk of retinal tears and detachment, though lifetime risk of RD < 1%

Signs and Symptoms

Typically asymptomatic

Often located at vitreous base or peripheral retinal vessels and may be focal or diffuse in distribution; variable appearance including crisscrossing fine white reticular lines, snail-track appearance, peripheral perivascular thinning, and condensed areas of vitreoretinal traction overlying retinal thinning; may be associated with pigmentation from retinal pigment epithelial hyperplasia; may be associated with atrophic holes, tears (Figure 9-3A), or RDs

Differential Diagnosis

Cobblestone/pavingstone degeneration, white without pressure, congenital hypertrophy of the retinal pigment epithelium (RPE), RD, retinoschisis, chorioretinal scar, snowflake degeneration, reticular degeneration, normal pigmentation of ora serrata

Management

• Observation in asymptomatic cases: patients should be instructed to return promptly if any symptoms of flashes, floaters, curtain in peripheral vision, or vision changes
  
• Laser photocoagulation/cryotherapy (Figure 9-3B): consider as prophylaxis in patients with history of RD in fellow eye or if there is documented increase or progression of subretinal fluid secondary to lattice and atrophic round holes

COBBLESTONE DEGENERATION

Paul S. Baker, MD

• Common, benign peripheral RD also known as pavingstone degeneration that is more common with aging
  
• No associated risk of retinal tears or RD

Signs and Symptoms

Asymptomatic

Exam Findings

Yellow-white round/oval discrete patches of choroidal and retinal atrophy, typically bilateral, often with pigment hyperplasia at edges and large underlying choroidal vessels visible centrally; located in far retinal periphery, between ora serrata and equator, most commonly inferior; usually 1 to several disc diameters in size, and often appear in clusters though may become confluent (Figure 9-4)

Differential Diagnosis

Lattice degeneration, atrophic retinal holes, snail track degeneration, congenital hypertrophy of the retina pigment epithelium (CHRPE)

Management

None

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