retinal breaks

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  • 1. Retinalbreaks- any full- thicknessdefect in the neurosensory retina Can cause RD 6% of population have break 1/10,000-15,000 per year- RD 0.07% chance of developing RD in alifetime

2. Directretinal perforation, contusion, vitreous traction Coup Contrecoup Usually multiple Inferotemporal and superonasal quadrants Most common- dialyses + avulsion ofvitreous base= ocular contusion Others: horseshoe-shaped tears,operculated holes 3. Young patients- higher incidence of eyeinjury Rarely develop acute rhegmatogenous RD Vitreous acts as tamponade 12%- immediately 30%- 1 month 50%- 8 months 80%- 24 mos 4. Vitreous base- 2 mm anterior and 4 mmposterior to the ora serrata Optic disc, macula, along major vessels,margins of lattice degeneration, sites ofchorioretinal scars 5. Increasing age- 63% in > 70 y/o axial lengthAphakia 66-100%ICCE- 84%Inflammatory disease ECCE w/ open capsule- 76%Trauma ECCE w/ intact capsule- 40%myopia 6. Photopsias Multiple floaters Curtain or cloud Vitreous hemorrhage Retinal tear present in 15% w/ acute PVD 50-70% w/ acute PVD + vitreous hge 7. IO w/ scleral depression Slit lamp biomocroscopy w/ 3- mirrorlens Hemorrhage or pigment? Reexamine in 3- 4 weeks patching, bed rest, head elevation for45 B- scan vitrectomy 8. 6-10%of general population 1/3-1/2- bilateral Myopia, familial predilection1. Atrophy of the inner layers2. Overlying pocket of liquefied vitreous,3. condensation and adherence of vitreous at the margin of lesion Progressesto RD- tractional tear or atrophic hole 9. Areasof elevated glial hyperplasia Noncystic retinal tufts Cystic retinal tuftsmay predispose Zonular traction tuftsto RD 10. folds of redundant retina Superonasally Associated w/ dentate processes Tears occur at the most posterior limitof the folds 11. Oval islands ofpars plana epitheliumlocated immediately posterior to the ora Almost/completely circumscribed by theperipheral retina Tears can occur at or near theposterrior margins of enclosed ora bays 12. Paving-stone or Cobblestone 22% over 20 y/o DegenerationProliferation of RPE cellsAtrophy approximatelyretina > 20 RD, RPE areas of inflammation100% trauma,y/o retinal Old hyperplasiaPresent in of the outer and ofEnlargement of RPE cells3.Atrophy of the Temporal RPE hypertrophy RPE and outer retinal layerstearCongenital or acquired4.Attenuation or absence lossthe1. TYPICAL may cause field ofAging and but Cystoid Degeneration Benign,Peripheral the outer plexiform layer Cysts degenerative change in Appears as black choriocapillaries spherical melanin granules,Large cells and large,2. RETICULAR 5.Adhesions b/n the remaining neuroepithelialverydark, well demarcated Nerve fiber layerBENIGN amd bruchs membrane layersPosterior to typical cystoid Inferior quadrant,full-retinalto the equatorMay develop into anterior breakNEVER the site of PRIMARY retinal break 13. Reducethe risk of RD Risk outweigh the benefit May not eliminate the risk of new tearsor detachment GOAL: create a chorioretinal scar aroundthe break Acute symptomatic break are moredangerous than the old ones 14. Acute symptomatic flap tear Acute operculated holes + persistent vitreous traction Large hole Superior location Vit hem Atrophic holes + traction 15. Flap tears Emmetropic, phakic eyes Lattice degeneration Myopia Subclinical detachment Aphakia w/ detachment in the other eye Operculatedholes Atrophic holes 16. Treat the entire lesion Posterior and lateral margins 6-10% of eyes High myopia 20-30% of eyes w RD RD in the fellow eye 1%- RD in untreated lattice degenerationflap tearsaphakia 17. 1-3% incidence of RD Asymptomatic breaks prophylaxis? Flap tears Subclinical detachments 18. Asymptomaticretinal detachment Detachment in w/c subretinal fluidextends more than 1 DD from the breakbut not more than 2DD posterior to theequator. Traction on the break 19. TYPE OF LESIONTREATMENTHorseshoe tearsAlmost alwaysDialysis Almost alwaysOperculated tear sometimesAtrophic holeRarelyLattice degeneration w/o horseshoe Rarelytears Zorab et.al., American academy of Ophthalmology Section 12 p. 290 2008-2009 20. Type of lesionphakic Highly myopicFellow eye Aphakic orpseudophakicRetinalAlmost always Almost always Almost always Almost alwaysdialysisHorseshoesometimes sometimes sometimes sometimestearsOperculatednorarelyrarelyrarelytearsAtrophic holes rarelyrarelyrarelyrarelyLattice degnnonosometimes rarelyw/ or w/oholes Zorab et.al., American academy of Ophthalmology Section 12 p. 291, 2008-2009 21. http://one.aao.org/CE/Practice Guidelines