Findings posing NO IMMEDIATE THREAT TO VISION (Clinically insignificant)Normal variationsName Visible Characteristics/location Probability MxMeridional folds & Complexes - Folds = glial cell proliferation, breaks at posterior border are possible, but rarely develop RD

Elevated, grey-white retinal tissue redundancies

most often superior nasal

Radial orientation

25% of the population, 50% bilaterally

Routine annual examsEducate as to signs (SN) and symptoms (SX) or RDConsider retinal consult if tears develop but usually on if symptomatic

Enclosed Oral Bays

-congenital developmental variation

Brownish (Reddish brown) island of non-pigmented pars plana epithelium isolated from the rest of the pars plana

DDX retinal breaks: gradually sloping orderly border with sclera indentation vs. SHARPLY demarcated edge of a break

6% of pop.

15-20% chance of associated retinal break (rare detachment)

Annual exams, sclera indentation (to help find).

ED: SN/SX of RD

Developmental abnormalitiesVitreoretinal Tufts (3 types: Non-cystic, zonular) – greyish white tufts of tissue at the VR interface, usually located between the equator and ora. Tractional will/may see RPE hyperplasia near or within the tuff. Retinal breaks may occur associated with vitreous liquefaction, syneresis, or vitreous detachment.NON-CYSTIC

- Glial cells proliferation, no attachment to vitreous

- Base of tuff <0.1 mm diameter- Intrabasal location, usually inferonasal- No associated retinal breaks within vitreous base- Indistinguishable from cystic degeneration (bad!)- Usually in clusters, may degenerate- Decapitation of tufts by avulsion produce tiny floating

spherical fragments

72% of population with 50% bilaterally

Routine annual examsED: SN/SX of RD

ZONULAR- Developmental

abnormality

- Posterior displacement of zonual attachments to the peripheral retina

- Larger size, anterior angulation and closeness to ora- LONG with Anterior Bulbous or pointed tip

15% population (small number)

- Base of tufts associated with tropic changes of adjacent retinal cystoid spaces, retinal thinning, and occasionally full thickness holes

- High incidence of associated retinal breaks but low incidence of RD since they are located in vitreous base

Peripheral Degenerations Oral Pearls

- Histopathologic correlated to posterior pole drusen

- Glistening or opalescent white nodule within a retinal dentate process extending over the pars plana.

- Bright white or dark- Usually superior temporal

20% of population

Self-limiting and benignAnnual examNo association with diseasesNever treatedUseful as a landmark for localization.

Cystoid degeneration- cystic spaces

within retina cause appearance of thick retina about ½ DD from ora.

- Bigger cysts when joins together, they’ll separate the retina.

- Hazy grey with enclosed hazy red dots- Two types (but clinically indistinguishable): Typical

(middle) and Reticular (superficial layers) - Often associated with vitreal strands- Usually temporal and/or superior- Inner layer holes can develop

100% of the population by age 8

Beign/routineWatch for retinoschisisRoutine exams – usually benign and self-limitingWatch for development of holes and degenerative retinoschisis

Primary chorioretinal atrophy (pavingstone or cobblestone)

- Choriocpillaris occlusion with subsequent RPE and retinal tissue loss

- Non-pigmented areas between equator and ora- Usually inferior 5 to 7 o’clock. - Often RPE hyperplasia- Deep layers missing, no breaks in inner retina

27% >20 years old

33% bilateral, m:f = 3:1

Routine examinations

Pars plana cysts- Separation of non-

and pigmented ciliary epithelial.

- Histopathologic

- Smooth convex cyst of variable size immediately anterior to ora

- Conform to the individual oral bays, often consecutive- Seen best with scleral indentation- Mostly temporal

3-8% of the population

Monitor annually, retinology if tear present.

equivalent to a sensory RD

- Looks like blisters 1/3 to 3 DD in size- Often associated with traumatic RD or posterior

uveitisWhite-without-pressure

- Disorganization of the nerve fibre layer resulting from an abnormal VR relationship

- Translucent grey area bounded posterior by a reddish brown line; migratory

- Associated with lattice degeneration, posterior staphylomas and local RD.

30% of population (5% <20 yo, 66% >70 Yo, 10X more in AA)

Annual exam (6mo f/u if WWOP: near lattice, scalloped borders, elevated tractional membrane, progressive vitreous degeneration)

White-with-pressure - Optical phenomenon of the retinal similar to WWOP- Patches of retinal appear translucent grey or

whitened upon sclearal depressionCongenial hypertrophy of the RPE (CHRPE)

- Enlarged RPE cells and choriocapillaris atrophy

- Used to be known as “halo nevus”- 2DD- Dark gray to black areas of variable size- Typically flat with surrounding hypopigmented area- Scotomata occur in the affected areas that become

more dense with age- Associated with familial adenomatous polyposis

(FAP)

Annual exam

Pigmented Ocular Fundus Lesions (POFLs)

- “Bear Track”- Punch out lesions

- Various types of POFLs in FAP (Autosomal Dominance)- Small dark lesions in peripheral fundus near vortices- Larger more characteristic ovoid, tear-shaped, or

coffee bean shaped lesions are closer to the posterior pole.

- Some POFLS have dephm. Halo/ post depigm. Tail- Depigm. Lacunae also possible.- Use 3 mirror exam to not miss lesions.

Multiple POFLs is specific (>90%) sensitive (70% - 80%) marker for adenomatou polyposis (through lack of POFLs does not preclude diagnosis)

FAP (Familila adenomatous polyposis)/gardner syndrome: hundreds of adenomatous colonic polyps, adenocarcinoma of colon inevitably develops unless the colon is resected prophylactically

NO ASSOCIATION WITH SOLITARY PATCHES OF CHRPE

Examine other family members**

Peripheral (Senile) Pigmentary degenerationAka Reticular

- Granular pigment between the ora and equator

- Often accompanied by peripheral degenerative drusen

- Pigment may cuff venules or be bone spicule-like (not RP)

- Caused by degenerating RPE with pigment scattered in sensory retina with loss of photoreceptors and sclerosis of the choriocapillaris

20% >40 yo, usually bilateral

Routine exams –self-limiting and benign

Findings which MAY pose a THREAT to visionLattice Degeneration

- Well demarcated localised inner retinal thinning with vitreous condensation and exaggerated VR attachments at the borders

- A space of absent vitreous (lacuna) overlies the thinning (possibly some glial tissue)

- Sclerotic vessels (a or v) appear as white lines following vessels

- 1-4 DD in length and ½-2 DD in width- Posterior lesions are wider- WWOP is frequently found along the borders of

lattice, as are overlying vitreous lacunae- Lattice with holes are common inferiorly and lattice

with sclerosed vessels more common superiorly- Often confused with scisis when lattice has led to

subclinical RD, and also with tufts

Prevalence 6-10 % reached by age 10Bilateral in 33-48%80% show RPE

Atropic Holes in Lattice - Never any symptoms, never any VR traction- Gradual decrease in the thickness of the retina- Usually very small <1/4DD- 2:1 inferior retina- Maybe the first noticed feature of the lattice lesion- Atrophic holes in lattice may slowly collect SR fluid

beneath them (subclinical detachment)- Majority when first diagnosed already are surrounded

with a very narrow rim of SR fluid- SUBCLINICAL DETACMENT: extending more than 1 DD

beyond the retinal break, but no more than 2 DD posterior to the equator

29-43% of lattice lesions have atrophic holes (increases with age)Symptoms: Aphakia or pseudophakia, significant VR traction, Miotic use

Educate all patients with lattice on SN/SX of RD.Asymptomaic F/U yearlyFlashes or floater – 6 moAtrophic holes (Asymptomatic) and no risk factors – 6 mo.Marginal breaks – retinal consult (28-35% chance of RD)NO prophylactic treatment unless: Fellow eye RD, symptomatic tears, strong family history of RD, eye with lattice is aphakic or soon to Linear Tears alongside - Linear or horseshoe shaped 20-40% of

Lattice- Tears at posterior

margin of lattice

- Risk is greatest for juxtabasal or extrabasal lattice surgical RD had lattice; but only 1-5% of lattice get an RD (7yrs)

become aphakic or highly myopicExamine symptomatic px q 6 mo.Most flap tears with lattice are treated, although may have more post-treatment problems

Acquired Retinoschisis- Separation of the

sensory retina

- Most located inferotemporal with 70% progressing post. To equator

- Absolute scotoma- 60% have vitreous liquefaction, 25% have a break in at

least one of the layers of the schisis, 40% have breaks in both layers

- <10% degenerative - Progression of the RS will terminate if a PVD occurs

since the vitreous traction is relieved- Chance of RD 0.024%- Best seen with sclera indentation- Layers are separate but move together because of

viscous substance in schisis cavity-

<10% show progression, expansion, or retinal break