Vitreoretinal Degenerations


A420797_2_En_5_Figa_HTML.gif

1. Retinal dialysis

2. Peripheral cystoid degeneration

3. Retinal detachment

4. Retinal drusen

5. Full-thickness tear

6. Paving-stone degeneration

7. Lattice degeneration

8. Bullous retinoschisis

9. Flat retinoschisis

10. White-without-pressure

11. Retinal tuft

12. Snail-track degeneration

13. Pearl degeneration

14. Flap tear

15. Grouped congenital hypertrophy of the retinal pigment epithelium (“bear tracks”)

16. Snowflake degeneration

17. Unifocal hypertrophy of the retinal pigment epithelium

18. Atrophic retinal hole

19. Haemorrhage

20. Preretinal fibrosis

21. Honeycomb degeneration

22. Operculated retinal tear

23. Dark-without-pressure

24. Unifocal atrophy of the retinal pigment epithelium


Snail-track degeneration in sector 12 is highlighted in yellow



Snail-track degeneration, as well as lattice degeneration, is characterized by retinal thinning with vitreous liquefaction (lacuna) right above the lesion, and vitreoretinal tractions [1]. According to published data, retinal tears commonly appear in the inferotemporal quadrant – 54 %, less frequently in the superotemporal – 18 %, superonasal – 16 %, and inferonasal quadrants −12 % [4].

Some experts believe that snail-track degeneration is a variation or an early stage of classic lattice degeneration [69]. Others classify it as a separate group [1, 3, 4, 10] given that the ultrastructural studies proved it to be an independent entity [11, 12].

Snail-track degeneration is often complicated by retinal holes, less frequently by flap tears with traction, and secondary retinal detachment [3, 13]. The indications for prophylactic laser coagulation are the same as those for lattice degeneration.

Kothari et al. (2012) were the first to publish in vivo OCT scans of snail-track degeneration as an irregular and wrinkled retinal surface without vitreous traction [10].

Shaimova et al. (2015) described the characteristic OCT features of this degeneration: irregular and jagged retinal surface, vitreous destruction, and vitreoretinal adhesions with tractions at the lesion margins [14].

In this chapter, we demonstrate different variants of OCT scans of the snail-track degeneration.

Case 18. Snail-Track Degeneration (Classic)

A 24-year-old male patient with moderate myopia and partial posterior vitreous detachment presented with floaters and flashes of light affecting his left eye.


Ophthalmoscopic Findings (Fig. 5.18a, b)


A bright white elongated lesion with multiple small atrophic holes is observed in the far periphery of superotemporal quadrant of the left eye. The surrounding retina is whitish, with retinal vessels poorly visualized in the area of degeneration. There are vitreous adhesions and tractions at the edges of the lesion.

A420797_2_En_5_Fig18_HTML.gif


Fig. 5.18
(a) Snail-track degeneration. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.18c)



Scan 1

Vitreous over the retina is considerably consolidated. The surface of the neurosensory retina is smooth. There is a locally dense area of retinal pigment epithelium.


Scan 2

The retinal surface is irregular. There are vitreoretinal adhesions with traction at the edges of the lesion. The neurosensory retina is dense and slightly elevated at the adhesion site. There is a marked density (increased reflectivity) of the inner retinal layers in the center of the image causing a “shadow” effect (decreased reflectivity) in the underlying tissues.


Scan 3

The retinal surface is irregular and jagged because of multiple areas of retinal thinning (atrophic holes). The retina is dense along the entire lesion. The photoreceptor layer is partially damaged. Retinal pigment epithelium is intact.


OCT Scan Details (Fig. 5.18c)






  • A420797_2_En_5_Figb_HTML.gif Layers of medium reflectivity (increased density) in the vitreous; vitreoretinal adhesions and tractions


  • A420797_2_En_5_Figc_HTML.gif Areas of retinal thinning within the lesion


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the inner neurosensory layers in the center of the lesion


  • A420797_2_En_5_Fige_HTML.gif Areas of redistribution and increased density of the pigment epithelium


  • A420797_2_En_5_Figf_HTML.gif Decreased reflectivity of the outer neurosensory layers, pigment epithelium, and choroid at the level of dense retina

Case 19. Snail-Track Degeneration (Double-Row)

An asymptomatic 17-year-old male patient with moderate myopia and partial posterior vitreous detachment.


Ophthalmoscopic Findings (Fig. 5.19a, b)


Two degenerative lesions are observed in the mid and far periphery of the inferotemporal quadrant of the right eye. The first lesion is at the equator with a full-thickness retinal tear in its center, shallow (subclinical) retinal detachment, and minor hyperpigmentation. The second lesion is closer to the ora serrata with hyperpigmentation and atrophic retinal holes. Vitreous traction at the edges is identified in both lesions.

A420797_2_En_5_Fig19_HTML.gif


Fig. 5.19
(a) Snail-track degeneration (double-row). (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.19c)



Scan 1

Full-thickness tear of the neurosensory retina is seen in the center of the scan and has markedly thin and dense retina at its edge, with clear evidence of vitreoretinal adhesions and tractions. Retinal pigment epithelium is intact.


Scan 2

Multiple areas of marked retinal thinning (atrophic retinal holes) are separated by areas of increased retinal density. There are isolated vitreoretinal adhesions within the lesion and at its edges. Retinal pigment epithelium is intact.


OCT Scan Details (Fig. 5.19c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesions and tractions


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figc_HTML.gif Marked thinning of the neurosensory retina (atrophic holes)


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (density) of the neurosensory retina along the edge of the full-thickness tear


  • A420797_2_En_5_Figh_HTML.gif Destruction of the photoreceptor layer at the level of the thinned retina and a full-thickness tear


  • A420797_2_En_5_Figi_HTML.gif Increased reflectivity of the choroid at the level of the dense neurosensory retina

Case 20. Snail-Track Degeneration with Atrophic Retinal Holes

An asymptomatic 17-year-old male patient with low myopia.


Ophthalmoscopic Findings (Fig. 5.20a, b)


A silver-white lesion with irregular surface and multiple atrophic holes is seen in the mid-periphery of the left eye at 5 o’clock position. The retinal vessel passing through the lesion is partly blurred.

A420797_2_En_5_Fig20_HTML.gif


Fig. 5.20
(a) Snail-track degeneration with atrophic retinal holes. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.20c)



Scans 1 and 2

The retinal surface is irregular and jagged. There are multiple shallow atrophic holes of different sizes in the neurosensory retina. The retina within the lesion is dense. Photoreceptor layer is partially destroyed. Retinal pigment epithelium is intact. The cross-sectional image (Scan 2) shows the area of vitreoretinal adhesion and traction.


OCT Scan Details (Fig. 5.20c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction at the edges of the lesion


  • A420797_2_En_5_Figc_HTML.gif Marked thinning of the neurosensory retina (atrophic retinal holes)


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the neurosensory retina between the atrophic holes

Case 21. Snail-Track Degeneration with Vitreoretinal Adhesion and Retinal Tears

A 25-year-old male patient with severe myopia and partial posterior vitreous detachment presented with complaints of floaters and recurrent flashes of light affecting his right eye.


Ophthalmoscopic Findings (Fig. 5.21a, b)


A local degenerative lesion with blurred borders is observed in the mid-peripheral retina of the temporal quadrant of the left eye. The lesion is bright white, with multiple atrophic holes and full-thickness retinal tears. The vitreous is grayish, with areas of fibrosis and signs of traction. The retinal vessels passing through the lesion are hard to see.

A420797_2_En_5_Fig21_HTML.gif


Fig. 5.21
(a) Snail-track degeneration with fibrosis and retinal tears. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.21c)



Scan 1

There is an elevated area of the neurosensory retina with signs of increased density (increase in layers’ reflectivity) caused by vitreoretinal adhesion and traction.


Scan 2

The area of vitreoretinal adhesion and traction enlarges. There is a hyporeflective band of the consolidated vitreous (preretinal fibrosis) laterally over the retina. The neuroepithelium is thick and dense in the center.


Scan 3

The scan demonstrates a marked vitreoretinal adhesion with a hyperreflective elevated band and a full-thickness tear with shallow detachment of the neurosensory retina. There is an operculum (area of medium reflectivity) detached from the retina over the tear, causing a “shadow” effect in the underlying tissues.


Scan 4

There are severe vitreoretinal adhesions and tractions, intraretinal cavities at the site of adhesion, and a shallow detachment of the neurosensory retina. The elevated part of the retina is dense. A part of the operculum is seen in the vitreous.


OCT Scan Details (Fig. 5.21c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesions and tractions


  • A420797_2_En_5_Figc_HTML.gif Area of moderate reflectivity in the vitreous (operculum) over the full-thickness tear


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the inner neurosensory layers within the degeneration


  • A420797_2_En_5_Figj_HTML.gif Shallow retinal detachment at the edges of the full-thickness tear


  • A420797_2_En_5_Fige_HTML.gif Dense pigment epithelium within the neurosensory detachment


  • A420797_2_En_5_Figf_HTML.gif Hyporeflective choroid at the level of dense areas of pigment epithelium and neurosensory retina


  • A420797_2_En_5_Figh_HTML.gif Intraretinal hyporeflective cavity at the site of vitreoretinal adhesion

Case 22. Snail-Track Degeneration with Multiple Tears and Shallow Retinal Detachment

An asymptomatic 30-year-old male patient with moderate myopia. Degeneration was diagnosed during routine fundus examination.


Ophthalmoscopic Findings (Fig. 5.22a, b)


A whitish degenerative lesion with blurred borders is observed in the far peripheral retina of the inferior quadrant of the left eye. There are multiple irregular retinal holes in the center of the lesion; and there is a single bright red full-thickness tear of the neuroepithelium surrounded by a shallow retinal detachment on the left edge of the lesion.

A420797_2_En_5_Fig22_HTML.gif


Fig. 5.22
(a) Snail-track degeneration with multiple tears. (b) Line indicates OCT-scanning direction. (c, d) OCT-scanning results according to the position of the line in Fig. (b)


OCT Scan Description (Fig. 5.22c, d)


The retinal surface is jagged and irregular because of an area of vitreoretinal adhesion with traction. There are multiple atrophic holes in the neuroepithelium in the center, a full-thickness tear of the neurosensory retina with a shallow neuroepithelium detachment on the left side. Small intraretinal hyporeflective cavities are visible in the neuroepithelium. There are areas of hyperplasia of retinal pigment epithelium. Choroid is thinned.


OCT Scan Details (Fig. 5.22c, d)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figc_HTML.gif Marked thinning of the neurosensory retina (atrophic holes)


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the neurosensory retina within the lesion


  • A420797_2_En_5_Figj_HTML.gif Shallow retinal detachment at the edges of the full-thickness tear


  • A420797_2_En_5_Fige_HTML.gif Dense areas of pigment epithelium at the sides of retinal detachment


  • A420797_2_En_5_Figf_HTML.gif Decreased reflectivity of the choroid at the level of dense pigment epithelium

Case 23. Snail-Track Degeneration with Retinal Detachment and Vitreous Fibrosis with Traction

A 45-year-old female patient with moderate myopia and partial posterior vitreous detachment presented with a 10-day history of floaters affecting her right eye.


Ophthalmoscopic Findings (Fig. 5.23a, b)


Two degenerative lesions are observed. The first lesion is located in the mid-periphery of the right eye at 7 o’clock position and has a spongy appearance, grayish cast, blurred borders (shallow retinal detachment), and red full-thickness tears. The vitreous is gray and dense with marked retinal adhesions producing tractions. The second lesion with atrophic holes and vitreoretinal adhesion is located at 8 o’clock position.

A420797_2_En_5_Fig23_HTML.gif


Fig. 5.23
(a) Snail-track degeneration with shallow neuroepithelium detachment and vitreous fibrosis. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.23c)



Scan 1

There is a marked vitreoretinal adhesion with dense (increasingly reflective) neurosensory retina. The vitreous has multiple layers of high and moderate reflectivity and multiple fibrotic bands. A shallow retinal detachment of the neurosensory retina is observed along the whole area of degeneration.


Scan 2

Layers of fibrosis in the vitreous are connected with vitreoretinal adhesions at the borders of the lesion. There is a single large intraretinal cavity at the adhesion site. The shallow retinal detachment is irregular and more elevated in the adhesion area.


Scan 3

Vitreoretinal adhesions become larger and occupy half of the lesion. Multiple intraretinal cavities of different forms and sizes are observed at the level of these adhesions and the shallow neurosensory retinal detachment there looks irregular and more elevated.


Scan 4

At the sites of adhesions, the retina appears dense and elevated, with isolated intraretinal cavities. The intraretinal reflectivity increases casting a “shadow” (reflectivity decrease) over the choroid. The neurosensory retinal detachment in this scan is large, and it enlarges even more in the area of adhesions. Medially, there is a full-thickness tear of the neuroepithelium.


OCT Scan Details (Fig. 5.23c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesions and tractions with layers of moderate and high reflectivity (fibrosis) in the vitreous


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the neurosensory inner retinal layers at the site of vitreoretinal adhesions


  • A420797_2_En_5_Figh_HTML.gif Intraretinal hyporeflective cavities within marked vitreoretinal adhesions


  • A420797_2_En_5_Figj_HTML.gif Neurosensory retinal detachment within the lesion


  • A420797_2_En_5_Figf_HTML.gif Hyporeflective inner retinal layers, pigment epithelium, and choroid at the dense retina level

Case 24. Snail-Track Degeneration with Multiple Tears

A 35-year-old highly myopic female patient with partial posterior vitreous detachment presented with complaints of floaters affecting her left eye.


Ophthalmoscopic Findings (Fig. 5.24a, b)


A dark gray lesion with three round, full-thickness tears of different sizes is observed in the mid-periphery of the inferior quadrant of the left eye. The retina is elevated and looks spongy (shallow detachment).

A420797_2_En_5_Fig24_HTML.gif


Fig. 5.24
(a) Snail-track degeneration with multiple tears. (b) Line indicates OCT-scanning direction. (c, d) OCT-scanning results according to the position of the line in (b)


OCT Scan Description (Fig. 5.24c, d)


The retinal surface is irregular because of vitreoretinal adhesion with traction. There are three full-thickness tears of the neuroepithelium with shallow retinal detachment and several small hyperreflective deposits in the neuroepithelium. The photoreceptor layer is partially destroyed. Destructive changes are seen in retinal pigment epithelium.


OCT Scan Details (Fig. 5.24c, d)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tears of the neurosensory retina


  • A420797_2_En_5_Figc_HTML.gif Areas of marked thinning of the neurosensory retina


  • A420797_2_En_5_Figd_HTML.gif Increased reflectivity (increased density) of the neurosensory retina within the area of degeneration


  • A420797_2_En_5_Figj_HTML.gif Shallow retinal detachment at the edges of full-thickness tears


  • A420797_2_En_5_Figh_HTML.gif Pigment epithelium destruction


  • A420797_2_En_5_Figi_HTML.gif Hyperreflective choroid in the area of pigment epithelium destruction

Case 25. Snail-Track Degeneration with Retinal Tear and Pigment Epithelium Atrophy

A 19-year-old male patient with partial posterior vitreous detachment and no symptomatic complaints.


Ophthalmoscopic Findings (Fig. 5.25a, b)


A degenerative lesion with multiple whitish deposits, retinal thinning, and atrophic retinal holes is observed in the far-peripheral retina of the inferior quadrant of the right eye. Two well-defined oval lesions at the borders of degeneration correspond to a retinal tear (red lesion on the left) and pigment epithelium atrophy (white lesion on the right).

A420797_2_En_5_Fig25_HTML.gif


Fig. 5.25
(a) Snail-track degeneration with retinal tear and pigment epithelium atrophy. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.25c)



Scan 1

The retinal surface is smooth. Layers of neuroepithelium are well visualized. Retinal pigment epithelium is intact. The hyperreflective (consolidated) layer of the vitreous forms an adhesion with the retinal surface. Overlying vitreous layers are hyporeflective.


Scan 2

The retinal surface is irregular and slightly elevated by the site of vitreoretinal adhesion with traction at its borders. In the middle of adhesion, there are multiple hyperreflective deposits in the neuroepithelium.


Scan 3

The retinal surface is irregular because of the site of vitreoretinal adhesion with traction at its borders. Laterally, there is an atrophic hole in the neuroepithelium and medially – an area of the pigment epithelium atrophy with a hyperreflective “shadow” in the choroid (comet-tail). The neuroepithelium in the center of the scan is thinned and hyperreflective with no distinguishable layers.


Scan 4

Transverse scan through the area of degeneration. The center of the scan shows an atrophic hole in the neuroepithelium with a hyperreflective “shadow” in the underlying tissues. The neuroepithelium is thinned and consolidated. There are vitreoretinal adhesions with marked traction at the edges of the lesion.


OCT Scan Details (Fig. 5.25c)






  • A420797_2_En_5_Figk_HTML.gif Layers of moderate reflectivity in the vitreous (consolidation)


  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction at the edges of degeneration


  • A420797_2_En_5_Figh_HTML.gif Hyperreflective (dense) neurosensory retina at the edges of degeneration, at the sites of vitreoretinal adhesions


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figd_HTML.gif Dense and thin neurosensory retina in the center of degeneration


  • A420797_2_En_5_Figc_HTML.gif Pigment epithelium destruction


  • A420797_2_En_5_Figi_HTML.gif Increased reflectivity of the choroid in the areas of pigment epithelium destruction.

Case 26. Snail-Track Degeneration with Retinal Tear and Pigment Epithelium Destruction

A 21-year-old male patient with low myopia presented with no complaints. Retinal degeneration was diagnosed during routine examination.


Ophthalmoscopic Findings (Fig. 5.26a, b)


A white oval degenerative lesion with blurred borders is observed in the mid-periphery of the superotemporal quadrant of the right eye. Retina in the center of the lesion is lighter and has whitish deposits. There is a wide band of hyperpigmentation in the far retinal periphery.

A420797_2_En_5_Fig26_HTML.gif


Fig. 5.26
(a) Snail-track degeneration with retinal tear and pigment epithelium destruction. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.26c)



Scan 1

The retinal surface is irregular and jagged because of multiple atrophic lesions in the neuroepithelium. There is an atrophic area of retinal pigment epithelium with destructed photoreceptor layer in the center of the scan. This atrophic area casts a “shadow” over the choroid making it look hyperreflective. The vitreous at the edges of the lesion is consolidated, it attaches to the retinal surface and causes tractions. There is a hyporeflective cavity over the lesion – lacuna (optically void area). Choroid in the area of degeneration is thinned.


Scan 2

There are multiple atrophic lesions in the neuroepithelium and a full-thickness tear in the center of the scan. Neuroepithelium at the tear margins is dense. There are signs of vitreoretinal adhesion and traction over the lesion surface.


OCT Scan Details (Fig. 5.26c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesions


  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figc_HTML.gif Marked thinning of the neurosensory retina (atrophic hole)


  • A420797_2_En_5_Figd_HTML.gif Hyperreflective (dense) neurosensory retina at the tear margins


  • A420797_2_En_5_Figh_HTML.gif Destructed photoreceptor layer in the area of retinal thinning and the full-thickness tear


  • A420797_2_En_5_Figi_HTML.gif Hyperreflective choroid in the area of dense neurosensory retina



Lattice Degeneration


Lattice degeneration (Table 5.3) appears as retinal thinning with the loss of neurosensory layer and marked vitreoretinal adhesion at the margins of the lesion [15]. Lattice degeneration is found in 6–8 % of eyes in general population [7, 16, 17]. This condition affects both retina and vitreous, and is considered a severe peripheral vitreochoreoretinal degeneration with risk of retinal tears and rhegmatogenous retinal detachment caused by vitreous traction [15, 18, 19]. The degenerative changes comprise retinal thinning with subsequent fibrosis and vitreous liquefaction over the lesion (lacuna). Vitreoretinal adhesions at the margins of the lesion are a common finding [13, 20, 21]. This degeneration can have an oval or linear pattern of lesions with either single or grouped distribution [19]. Lesions may be isolated or multiple, with radial or circumferential crisscrossing lines, and in some cases have tiny white or yellowish deposits, pigment clumps, atrophic holes, or retinal tears [17, 19, 2224].

Two types of lattice degeneration are distinguished: typical and atypical. Typical lattice degeneration appears as well-outlined, spindle-like areas of retinal thinning, with white crisscrossing lines between the equator and the posterior margin of the vitreous base. Atypical lesions usually have radial perivascular distribution. Lattice degeneration can cause tractional retinal tears along its posterior edge because of tight vitreoretinal adhesions with resulting rhegmatogenous retinal detachment [13].

The frequency of lattice degeneration in eyes with retinal detachment is reported to be 13.9–35 % [25, 26]. Furthermore, this degeneration is found in 14.5–26.18 % of fellow eyes [8, 27]. In eyes with acute posterior vitreous detachment associated with lattice degeneration, flap tears are found in 1.5–2 %, and operculated tears in 16–24 % of cases [3, 21, 28]. However, lattice degeneration itself seldom causes retinal detachment, accounting for 1 % [23], 2–4 % of patients [7].

To date, no universally accepted indications for the prophylactic laser coagulation of lattice degeneration have been proposed. Some experts believe that prophylactic treatment is indicated for clinically significant symptoms, flap tears, retinal detachment in the fellow eye, aphakia, or family history [29]. Other authors recommend laser treatment only in case of retinal detachment in the fellow eye associated with lattice degeneration [15, 17]. Laser surgery does not always prevent the retinal detachment because new retinal tears can occur in seemingly healthy retina. It is thought that one should not always seek medical care in case of lattice degeneration with atrophic holes [17]. Alternatively, prophylactic laser photocoagulation is advocated in any type of lattice degeneration by some researchers [3].

Some authors emphasize that lattice degeneration without retinal tears or with retinal holes should be treated individually according to the guidelines of the American Academy of Ophthalmology (see Table 7.​1 in Chap. 7). Prophylactic laser treatment is indicated in flap tears with persistent vitreous traction. According to Brinton and Wilkinson (Table 5.2), laser photocoagulation should be performed around the lesion and at the base of the vitreous body to decrease the risk of post-operative retinal detachment due to insufficient scarring around the tear [6].


Table 5.2
Guidelines for prophylactic laser photocoagulation in lattice degeneration with or without retinal holes



























Type of break

With symptoms

Asymptomatic

No risk factors

High myopia

Fellow eyea

Pseudophakiab

Lattice degeneration with/without retinal holes

Sometimes

No

Rarely

Sometimes

Rarely


Adapted version of table from [6]. Reproduced with the permission of Oxford University Press. Taken from original version in Precursors of Rhegmatogenous Retinal Detachment in Adults. San Francisco, CA: American Academy of Ophthalmology; 2008, by Permission of American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern®Guidelines. Available at: www.aao.org/ppp

aApplies to patients who have had a retinal detachment in the other eye

bApplies to pseudophakes, aphakes, and patients prior to cataract surgery



Table 5.3
Diagram of peripheral retinal degenerations























































A420797_2_En_5_Figl_HTML.jpg

1. Retinal dialysis

2. Peripheral cystoid degeneration

3. Retinal detachment

4. Retinal drusen

5. Full-thickness tear

6. Paving-stone degeneration

7. Lattice degeneration

8. Bullous retinoschisis

9. Flat retinoschisis

10. White-without-pressure

11. Retinal tuft

12. Snail-track degeneration

13. Pearl degeneration

14. Flap tear

15. Grouped congenital hypertrophy of the retinal pigment epithelium (“bear tracks”)

16. Snowflake degeneration

17. Unifocal hypertrophy of the retinal pigment epithelium

18. Atrophic retinal hole

19. Haemorrhage

20. Preretinal fibrosis

21. Honeycomb degeneration

22. Operculated retinal tear

23. Dark-without-pressure

24. Unifocal atrophy of the retinal pigment epithelium


Lattice degeneration in sector 7 is highlighted in yellow

The review by Wilkinson (2014) found no randomized controlled trials showing clinical benefits of prophylactic laser surgery for asymptomatic tears and lattice degeneration. The author concluded that prophylactic treatment is only justified in managing vitreous traction and retinal tears associated with symptoms of flashes and floaters [30].

Case 27. Lattice Degeneration (Classic)

A 59-year old female patient with moderate myopia and partial posterior vitreous detachment presented with complaints of floaters affecting her left eye.


Ophthalmoscopic Findings (Fig. 5.27a, b)


A hyperpigmented degenerative lesion with blurred borders and a white retinal vessel in the center is observed in the mid-periphery of the inferotemporal quadrant of the left eye. Vitreoretinal adhesions with traction are seen at the border of the lesion. Retinal structure in the center of the lesion is changed and atrophic.

A420797_2_En_5_Fig27_HTML.gif


Fig. 5.27
(a) Classic lattice degeneration. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.27c)



Scan 1

The retinal surface is smooth. Inner and outer layers of the neuroepithelium can be distinguished. The retinal pigment epithelium is intact. The posterior hyaloid membrane is thickened, hyperreflective, and detached from the retina.


Scan 2

The retinal surface is irregular. A hyporeflective cavity in the vitreous (lacuna) is observed over the area of degeneration. Vitreoretinal adhesions are present at the edge of degeneration. Marked thinning and hyperreflective deposits within the retina and pigment epithelium are seen in the center of the scan.


Scan 3

The retinal surface is irregular because of vitreoretinal adhesions and traction at the borders of the lesion. A hyperreflective sclerosed blood vessel is observed within the neuroepithelium. Hyperplasia of the pigment epithelium is seen at the sides.


Scan 4

The retinal surface is irregular because of three areas of neuroepithelium thinning. Vitreous traction is moderate.


OCT Scan Details






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction; layers of moderate reflectivity in the vitreous


  • A420797_2_En_5_Figc_HTML.gif Thin and dense neurosensory retina within the lesion. Marked retinal thinning closer to the center of the lesion


  • A420797_2_En_5_Fige_HTML.gif Dense pigment epithelium in the center of the lesion and at the level of the vitreoretinal tractions


  • A420797_2_En_5_Figf_HTML.gif Decreased choroid reflectivity at the level of the dense pigment epithelium


  • A420797_2_En_5_Figh_HTML.gif Cross-section image of the sclerosed retinal vessel with tough walls


  • A420797_2_En_5_Figk_HTML.gif Photoreceptor layer destruction at the border of the lesion

Case 28. Lattice Degeneration with Retinal Tears and Sclerosed Retinal Vessels

A 64-year old male patient with pseudophakia of his right eye presented with floaters affecting his right eye and incidental flashes of light during eye movements.


Ophthalmoscopic Findings (Fig. 5.28a, b)


A large lesion with multiple full-thickness tears of various forms and sizes is observed in the mid-periphery of the superior quadrant of the right eye. Multiple sclerosed retinal vessels (branching white lines) and atrophic areas of the retinal pigment epithelium with various pigmented deposits are seen within the area of degeneration.

A420797_2_En_5_Fig28_HTML.gif


Fig. 5.28
(a) Lattice degeneration with retinal tears, hyperpigmentation, and sclerosed vessels. (b) Line indicates OCT-scanning direction. (c, d) OCT-scanning results according to the position of the line in (b)


OCT Scan Description (Fig. 5.28c, d)


The retinal surface is irregular because of three full-thickness tears with shallow retinal detachment at the edges. The intact neuroepithelium has small hyporeflective cavities and areas of increased density in the pigment epithelium.


OCT Scan Details (Fig. 5.28c, d)






  • A420797_2_En_5_Figg_HTML.gif Full-thickness tears of the neurosensory retina


  • A420797_2_En_5_Figc_HTML.gif Areas of marked thinning and consolidation of the neurosensory retina between the tears


  • A420797_2_En_5_Figd_HTML.gif Isolated intraretinal hyporeflective cavities in the margin of the full-thickness tear


  • A420797_2_En_5_Fige_HTML.gif Increased density of the pigment epithelium


  • A420797_2_En_5_Figf_HTML.gif Decreased reflectivity of the choroid at the level of the dense pigment epithelium


  • A420797_2_En_5_Figh_HTML.gif Destroyed pigment epithelium


  • A420797_2_En_5_Figi_HTML.gif Increased choroid reflectivity at the level of the pigment epithelium destruction

Case 29. Lattice Degeneration with Hyperpigmentation and Pigment Epithelium Atrophy

An asymptomatic 27-year old male patient with moderate myopia and lattice degeneration in his left eye presented with complaints of decreased vision in his left eye.


Ophthalmoscopic Findings (Fig. 5.29a, b)


An elongated irregular lesion with blurred borders is observed in the mid-periphery of the inferior quadrant of the left eye. All through the lesion, there are whitish areas of pigment epithelium atrophy with choroid showing through. In the center and at the sides of the lesion there are dark pigment clumps. The gray line along the border of the lesion indicates vitreous traction.

A420797_2_En_5_Fig29_HTML.gif


Fig. 5.29
(a) Lattice degeneration with hyperpigmentation and areas of pigment epithelium atrophy. (b) Lines indicate OCT-scanning direction. (c) OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.29c)



Scan 1

The retinal surface is irregular and wavy because of vitreous adhesion and two areas of pigment epithelium atrophy. The neurosensory retina in the center of the atrophic region is thinned. The comet-tail effect is observed in the choroid.


Scan 2

Vitreoretinal adhesions with traction at the borders enlarge. Atrophic lesions and pigment epithelium hyperplasia are seen in the center.


Scan 3

Vitreoretinal adhesion enlarges sharply. Neuroepithelium is thinned at the edges, thickened and hyperreflective in the center.


Scan 4

Vitreous traction at the edges of the degenerative lesion persists. Thin areas of neuroepithelium at the edges of the area of degeneration interchange with thick areas in the center. Hyperplasia of the pigment epithelium is observed in the center of the scan.


OCT Scan Details (Fig. 5.29c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction


  • A420797_2_En_5_Figc_HTML.gif Marked thinning of the neurosensory retina at the edge of the lesion


  • A420797_2_En_5_Figd_HTML.gif Increased density of the neurosensory retina, more pronounced in the center of the lesion


  • A420797_2_En_5_Figh_HTML.gif Pigment epithelium destruction


  • A420797_2_En_5_Fige_HTML.gif Increased density of the pigment epithelium


  • A420797_2_En_5_Figi_HTML.gif Increased reflectivity of the choroid in the area of pigment epithelium destruction


  • A420797_2_En_5_Figf_HTML.gif Decreased reflectivity of the choroid in the area of dense pigment epithelium

Case 30. Lattice Degeneration with Linear Hyperpigmentation

A 77-year old male patient with low hyperopia and early stage cortical cataract presented with the main complaint of decreased vision.


Ophthalmoscopic Findings (Fig. 5.30a, b)


Multiple pigment deposits are observed along the retinal vessel in the mid-periphery of the superotemporal quadrant of the right eye. Pigment deposits are arranged in parallel lines. The retina in the affected region is dark and grayish.

A420797_2_En_5_Fig30_HTML.gif


Fig. 5.30
(a) Lattice degeneration with linear hyperpigmentation along the retinal vessel. (b) Lines indicate OCT-scanning direction c OCT-scanning results according to the position of the lines in (b)


OCT Scan Description (Fig. 5.30c)



Scans 1 and 2

The retinal surface is irregular. There are multiple hyperreflective deposits of various shapes in the area of thinned neuroepithelium, shadowing the underlying tissues. A vitreoretinal adhesion with traction is seen at the edge of the area of degeneration.


OCT Scan Details (Fig. 5.30c)






  • A420797_2_En_5_Figb_HTML.gif Vitreoretinal adhesion and traction


  • A420797_2_En_5_Figc_HTML.gif Thinned and dense neurosensory retina within the lesion, with more prominent thinning in the central part


  • A420797_2_En_5_Fige_HTML.gif Increased density of the pigment epithelium


  • A420797_2_En_5_Figd_HTML.gif Intraretinal hyperreflective deposits within the whole area of degeneration


  • A420797_2_En_5_Figf_HTML.gif Decreased reflectivity of the choroid at the level of the intraretinal deposits


  • A420797_2_En_5_Figh_HTML.gif Destructed pigment epithelium between the intraretinal deposits


  • A420797_2_En_5_Figi_HTML.gif Increased reflectivity of the choroid in the area of pigment epithelium destruction

Case 31. Lattice Degeneration with Flap Tear and Shallow Retinal Detachment

A 50-year-old female patient presented with a 3-day history of flashes of light, sparkles, and floaters affecting her right eye after physical exercises. Her ophthalmic history included preventive retinal laser photocoagulation of her right eye 4 years ago.


Ophthalmoscopic Findings (Fig. 5.31a, b)


An area of vaguely delineated lattice degeneration with a horseshoe tear and shallow retinal detachment is observed in the mid-periphery of the superotemporal quadrant of the right eye. White sclerosed vessels, hyperpigmented zones, light silvery lines, and a dark-brown haemorrhage along the edge of the retinal tear are observed in the area of degeneration. There are several laser burns under the shallow retinal detachment along the border of degeneration.

A420797_2_En_5_Fig31_HTML.jpg


Fig. 5.31
(a) Full-thickness retinal tear with shallow retinal detachment associated with lattice degeneration. (b) Line indicates OCT-scanning direction. (c, d) OCT-scanning results according to the line direction in (b)


OCT Scan Description (Fig. 5.31c, d)


There is a full-thickness retinal tear in the left part of the scan. The neurosensory retina is detached around the tear. There are marked vitreoretinal adhesions with traction and multiple intraretinal cavities with optically transparent content. There is a section of dense pigment epithelium in the area of degeneration and the neurosensory retina stays attached to it. There are multiple hyperreflective (consolidated) layers in the vitreous.


OCT Scan Details






  • A420797_2_En_5_Figg_HTML.gif Full-thickness tear of the neurosensory retina


  • A420797_2_En_5_Figj_HTML.gif Neurosensory retinal detachment cavity


  • A420797_2_En_5_Figd_HTML.gif Multiple intraretinal cavities in the detached retina


  • A420797_2_En_5_Figc_HTML.gif An elevated dense flap of the detached neurosensory retina


  • A420797_2_En_5_Fige_HTML.gif A section of dense pigment epithelium the retina stays attached to

Case 32. “Silvery” Lattice Degeneration

A 29-year-old male patient presented with the main complaint of flashes of light after physical exercises.


Ophthalmoscopic Findings


A large area of degeneration along the retinal vessel is observed in the mid-periphery of the superior quadrant of the right eye. The lesion has clear borders, silvery luster, multiple pigment clumps of various sizes and multiple sclerosed vessels (Fig. 5.32a, b).
Jun 27, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Vitreoretinal Degenerations
Premium Wordpress Themes by UFO Themes