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Vitreoretinal Precursors of Retinal Breaks
Lattice Degeneration
- 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.
Byer's natural history study of lattice retinal degeneration (423 eyes)
- 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 a 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
Cystic Retinal tufts
- May be responsible for 10% of clinical retinal detachments
- associated with small horseshoe-shaped tears in absence of PVD
- Chance of RD is 1/357
- Prophylactic therapy is not recommended if present but otherwise normal
Degenerative Retinoschesis
- 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.