Vitreoretinal Precursors of Retinal Breaks

Occurs in 8% (6-10%) slightly more than half are unilateral
0.5-1% will get a retinal detachment
20-30% of those with rhegmatogenous retinal detachments have lattice
Clinical appearance varies widely
- most common is circumferential round, linear or ovoid areas of retinal thinning, often crossed by whitish lines that represent hyalinized retinal vessels
- may also have superficial white/yellow flecks, patches of pigmentation, round or linear white patches or craters, small atrophic holes
Histologic appearance usually has one of the three:
- localized thinning of inner retinal layers
- vitreous liquefaction overlying thinned retina
- vitreous condensation with exaggerated vitreoretinal attachments at the margins of the lesion
Associated with retinal tears, detachments, tractions which may be symptomatic or asymptomatic
Monitoring recommended if asymptomatic with a consideration for prophylactic treatment in a fellow eye of those with retinal detachment.

276 consecutive patients with average 10.8 years follow-up (1-25 years)
Subclinical retinal detachments 2.3% (10/423) eyes
- 1 disc diameter of subretinal fluid on all sides of the break
- no extension posterior to the equator.
- treatment needed in 1
Atrophic retinal holes 35%
Tractional retinal tears, asymptomatic 0.7% (3/423 eyes)
- none treated and none progressed
Tractional retinal tears, symptomatic 1.2% (5/423 eyes)
- all treated
Retinal detachment 0.7% (3/423 eyes)
- two due to round retinal holes in lattice lesions
- 1 from a symptomatic retinal tear
Recommendations from this study
- Phakic eyes if asymptomatic should not have prophylactic treatment
- Retinal detachment in the setting of vitreoretinal traction on lattice lesions containing round retinal holes is relatively common in the setting of significant myopia

acquired splitting of the retina layers
Most are over 50 years
1-4% of the population over age 50
Bilateral in 85% and equal male:female
associated with hyperopia
associated with cystoid generation of the peripheral retina
- cyst-like spaces within the retinal layers
- extent 3 mm posterior to ora
- occur in nearly all adults
- typical type- occurs in outer plexiform layer immediately adjacent to the ora
- reticular type- occurs in the nerve fiber layer immediately posterior to typical cystoid degeration
retinal breaks can occur within the inner layer, outer layer or both but do not necessarily cause retinal detachment
Inner breaks by themselves don't cause retinal detachment
Retinal detachments divided into two types
- Outer layer hole without inner layer holes with fluid in the subretinal space
- Breaks in the inner and outer layer with fluid in the subretinal space
Clinical appearance:
- thin and smooth elevation of peripheral retina
- inferior temporal quadrant in 70%, superior temporal in 30%
- during scleral depression, the entire enclosed structure can be displaced inward
- small white dots “snowflakes” may be present (thought to be muller cell footplates or neurons that once bridged the cavity)
- sclerotic retinal vessels can occur in the area
- laser will whiten the outer layer

Feature	Retinoschisis	Retinal Detachment
Age	Middle Age to Elderly	Middle Age
Refractive association	Hyperopia	Myopia
Symptoms	Usually absent	Acute present, Chronic Absent
Scotoma	Absolute	Relative
Vitreous Hemorrhage or Pigment	Absent	Common
Location	Inferior or Superior Temporal	Acute: usually superior, Chronic: usually inferior
Texture	Smooth	Acute: Corrugated, Chronic: smooth
Muller footplates	Common	Absent
Mobility	Relatively immobile	Acute: often very mobile, Chronic: May be relatively immobile
Movement with scleral depression	Moves as a single unit	Height decreases
Color with scleral depression	“White with pressure” may be seen in outer layer	No “White with pressure”
Breaks	May be present	Present
Lattice in elevated area	Unlikely	Suggestive
Retinal pigment epithelium	Normal unless retinal detachment present or regressed	Acute: Normal, Chronic: Atrophy and demarcation lines may be present
OCT	Splitting of retinal layers	Subretinal fluid
Effect of laser through retinal break	Uptake through inner layer break	No uptake through full-thickness break
Natural history	Progression rare or slow	Acute: progressive, Chronic: may be non-progressive or slowly progressive

Adapted from Table 98.1, Ryan's Retina 7th ed, 2023.