The Peripheral Retina What you don t see can hurt you! James W. Walters, PhD, OD 2017

Size: px

Start display at page:

Download "The Peripheral Retina What you don t see can hurt you! James W. Walters, PhD, OD 2017"

Dora Lawrence
5 years ago
Views:

1 The Peripheral Retina What you don t see can hurt you! James W. Walters, PhD, OD 2017

2 The 2 things I don t want to miss! And the 2 reasons why Occult retinal detachments Occult malignancies You can not prove the null hypothesis WNL (means we never looked)

3 Goals for this hour Illustrate a variety of peripheral retinal anomalies with photographs and drawings with emphases on those that predispose the retina to detachment. Provide a searchable set of photos and drawings as a clinical reference for peripheral anomalies. Provide a review of best practice BIO techniques. (It s all about position)

4 The Gambler lyrics by Donald Alan "Don" Schlitz, Jr You got to know when to hold 'em, know when to fold 'em Know when to walk away and know when to run You never count your money when you're sittin' at the table There'll be time enough for countin' when the dealing's done

5 Drawings By T. Tarrant

6 Retinal Detachment The most serious consequence of the peripheral retinal degenerations is rhegmatogenous retinal detachment. Three factors predispose the retina to a retinal detachment.

7 All three of these factors are related to the vitreous and age related vitreous changes. The vitreous is more or less attached to the retina throughout. The vitreous liquefies with age. The vitreous shrinks with age.

8 Regarding the etiology of rhegmatogenous retinal detachment, it can be stated unequivocally that, the vitreous is the villain

9 The drawings and case reports that follow are intended to provide an overview of the degenerative conditions that occur in the peripheral retina with particular attention given to those factors that predispose the retina to a rhegmatogenous retinal detachment (RD).

10 Benign Retinal Degenerations Snowflakes Pavingstone Reticular Pigmentary Degeneration Equatorial Drusen Oral Chorioretinal Degeneration Peripheral Cystoid Degeneration

11 Snowflakes

12 Pavingstone Focal chorioretinal atrophy present in approximately 25 % of normal eyes

13 Reticular Pigmentary Degeneration Honeycomb Degeneration frequently seen in the elderly.

14 Equatorial Drusen Also more commonly seen in the elderly

15 Oral Chorioretinal Degeneration Also more commonly seen in the elderly

16 Peripheral Cystoid Degeneration Present is all adult eyes, increase with age

17 Predisposing Retinal Degenerations Lattice degeneration RPE hyperplasia associated with lattice Radially oriented lesions posterior to equator Trophic and tractional breaks Snailtrack degeneration

18 Predisposing Retinal Degenerations (cont.) Acquired retinoschisis White without pressure Pigment clumping Diffuses chorioretinal atrophy Paravesicular vitreoretinal detachment

19 Lattice Degeneration Sharply demarcated, circumferentially oriented areas of retinal thinning. The term lattice derives from the fact that the area of degeneration is often crisscrossed by sclerotic vessels. This condition exists in approximately 10% of the population. The next 5 drawings represent lattice and associated conditions.

20 Classic Lattice Note the atrophic holes in the thinned area of retina. The holes at the edge of the lattice represent a greater risk than those in the middle.

21 RPE hyperplasia Pigmentary changes in the RPE are often associated with lattice degeneration

22 Radially Oriented Sclerotic Vessels Posterior to Equator (note the similarity to the last slide)

23 Trophic and Tractional Breaks The round holes are tropic breaks, the longer linier and horseshoe like brakes are tractional.

24 Snailtrack Degeneration Very similar to classic lattice degeneration and may be a variation of that condition

25 Acquired Retinoschisis Present in 5% of the population over 20 years of age. A schisis is a splitting of the neural retina. In this drawing there is an accompanying inner retinal detachment as well.

26 White Without Pressure More easily seen in dark eyes. More significant if associated with a break.

27 Pigment Clumping Clumping left, horseshoe tear without traction right

28 Diffuses Chorioretinal Atrophy Seen more in myopic eyes

29 Paravesicular Vitreoretinal Detachment The traction seen into the vitreous put this retina at risk for an RD during an acute posterior vitreous detachment.

30 Retinal Breaks Large retinal brakes, especially those with vitreous traction, put the patient at the highest risk for retinal detachment. Within this category of risk factors for RD, however, there are conditions that range from nearly benign to very risky.

31 Horseshoe Tears The white area surrounding this tear is represents a sub clinical retinal detachment and puts the patient at a very high risk for progression to RD.

32 Horseshoe Tear with traction The traction shown here puts this patient at a very high risk for retinal detachment.

33 An Operculated Round Tear The retinal vessel bridging this tear puts this patient at a high risk for a retinal bleed and detachment.

34 Round Tear With Free-floating Opurculum The fact that there is no longer any vitreous traction when the opurculun is free floating lowers the risk for retinal detachment considerable.

are long standing and therefore safer because there

35 Retinal Tears and Detachments With Pigmented Edges The presents of pigment suggests these conditions are long standing and therefore safer because there has been no progression to a detachment for some time.

36 Acquired Retinoschisis With Inner Layer Holes The lighter color of these holes suggests that they are inner layer only and not full thickness, confirming that this is a schisis and not a retinal detachment.

37 Acquired Retinoschisis With Inner and Outer Layer Breaks The retina in the area of the schisis provides no place for the vitreous to attach hence no traction can occur making these breaks much safer.

38 CASE: 416 A-C TITLE: Pavingstone Degeneration of the Retina AGE: 40 RACE: White SEX: Female

39 Exam Results This 40 year old white female's principle complaints were intermittent dimming in patches of her vision when reading (alleviated upon rest), occasional dizziness, double vision, a "banging" sensation in her ears, and an occasional metallic taste sensation. Presently she is being treated with prism for a vertical heterophoria. As a child, this patient suffered rheumatic fever and has been diagnosed as having minor mitral valve prolapse.

40 Exam Results The patient had hysterectomy surgery eight years previously and is currently taking Estrogen and Tagamet. In her most recent physical examination, her general health appeared satisfactory. Her symptoms of loss in her visual fields while reading has been diagnosed as ocular migraine. BVA s are 20/15 OD & OS. Ophthalmoscopy revels regions of hypopigmented retinal degeneration in both eyes, located inferiorly. These regions have scalloped borders, appearing like cobblestones.

44 CASE: 637 A-J TITLE: Drusen/pavingstone degeneration AGE:46 RACE: White SEX: Male

45 Exam Results This 46-year-old white male was seen for further evaluation of bilateral peripheral chorioretinal atrophy noted on previous examinations. The patient presented with no visual complaints. Medical, ocular and familial histories were unremarkable. BVA s are 20/15 in each eye. The patient is an 8.00 diopter OU. Ophthalmoscopy reveals pavingstone degeneration in the peripheral retina of both eyes.

48 CASE: 235 A-B TITLE: Lattice Degeneration AGE: 37 RACE: White SEX: Female

49 Exam Results This 37-year-old white female was referred for a further evaluation of peripheral retinal pigmentary disturbances. Visual and medical histories were unremarkable. The BVA s are 20/20 in both eyes. Goldmann bowl perimetry with the II-4 isopter reveals a slight constriction of the temporal fields OS, with OD being normal. The central field is normal in both eyes. Ophthalmoscopy reveals lattice degeneration in both eyes.

52 CASE: 504 A-E TITLE: Lattice Degeneration AGE: 55 RACE: Hispanic SEX: Male

53 Exam Results This 55-year-old Hispanic male presented with a chief complaint of "foggy" vision in his left eye. He was diagnosed as having diabetes seventeen years ago, for which he is presently taking no medication. Best visual acuities are 20/20+ for each eye through a diopter correction. Pressures are 25mmHg OD and 23mmHg OS. Ophthalmoscopy reveals a C/D ratio of.2/.2 OD and.3/.4 OS. Lattice degeneration with pigment clumping is noted in the superior quadrant of the right eye.

59 CASE: 427 A-C TITLE: Lattice degeneration AGE: 28 RACE: White SEX: Female

60 Exam Results This 28-year-old white female was seen for further evaluation of peripheral retinal degeneration in both eyes. The patient has no ocular or visual complaints. The patient's medical history is noncontributory. The BVA s are 20/20+ OD, OS. A fundus examination reveals lattice degeneration 360 degrees in both eyes. Scleral depression reveals many atrophic holes within the lattice and two areas of fluid beneath the retina. The posterior pole shows no degeneration in either eye.

64 CASE: 465 A-D TITLE: Lattice degeneration AGE:37 RACE: White SEX: Female

65 Exam Results This 37-year-old white female presented with complaints of floaters in her right eye. One year previously, the she was diagnosed as having congenital tortuosity, white without pressure, and lattice degeneration with holes in both eyes. BVA s are 20/20 in each eye with diopters OD, OS. Ophthalmoscopy revealed congenital tortuosity, white without pressure and lattice degeneration with holes.

70 CASE:190A-E TITLE:White-without-pressure AGE:15 RACE:Black SEX: Female

71 Exam Results This 15-year-old AA female presented with decreased distance vision and headaches. The patient is a 2-diopter myope with BVA s of 20/20 in both eyes. Visual fields, as determined by tangent screen, are normal in both eyes. Ophthalmoscopy reveals white-without-pressure 360 degrees in the right eye, being more pronounced in the superior nasal quadrant. Similarly, the left eye shows this same condition, with more occurring in the superior temporal quadrant.

77 CASE: 195 A-C White-without-pressure AGE: 37 RACE: Asian SEX: Male

78 Exam Results This 37-year-old Asian male was initially seen with the complaint that his eyes did not focus equally, worse when tired. The ocular and family histories were unremarkable. He is an diopter myope with BVA s of 20/20 for both eyes. Binocular findings at distance and near, and the external examination are unremarkable. Ophthalmoscopy of the right eye is unremarkable. The left eye reveals white-withoutpressure, superior and temporal to the disc. The purple spot a photographic artifact.

82 CASE: 700 A-D TITLE: Retinoschisis AGE: Unknown RACE: Hispanic SEX: Male

83 Exam Results This 53-year-old Hispanic was seen for a routine examination. His family and medical histories were non-contributory. He was a mild myope OD and a compound hyperopic astigmat OS. BVA s are 20/15 in each eye. The B&L automated kinetic perimeter shows an inferior nasal field loss in the right eye. Intraocular pressures are 16mm Hg bilaterally. Ophthalmoscopy reveals normal vasculature with a cup to disc ratio of.3/.3 in each eye.

84 Exam Results Binocular indirect ophthalmoscopy reveals an elevated schisis with an underlying retina detachment in the superior-temporal quadrant of the right eye. No holes or tears were noted in the inner retina layers. Numerous holes and tears were noted in the outer layers. A diagnosis of retinoschisis with a retinal detachment was made.

89 CASE: 650 A-E TITLE: Retinal detachment/ Retinoschisis AGE: 32 RACE: black SEX: female

90 Exam Results This 32-year-old black female patient presented complaining of occasional floaters. She had been seen seven years previously at which time lattice degeneration with retinal holes was noted inferiorly in both eyes. There is no history of ocular trauma. BVA s are 20/15 OD, and 20/20 OS. The patient is a six diopter myope. The anterior segment evaluation reveals snowflake cataracts in both eyes. Ophthalmoscopy reveals inferior lattice degeneration in the right eye with two atrophic retinal holes.

91 Exam Results An evaluation of the left eye reveals what appears to be a retinoschisis, with areas of outer layer detachment extending from a pigmented line at 2 o'clock inferiorly. Kinetic visual fields depict a right visual field that is normal. The left visual field, however, shows a superior nasal field loss corresponding to the schisis.

98 CASE: 236 A-F TITLE: Retinal detachment, retinal holes, lattice degeneration AGE: 26 RACE: White SEX: Male

99 Exam Results This 26-year-old white male presented for a routine contact lens examination. The medical, ocular and family histories were unremarkable. The BVA s for this 3-diopter myope are 20/15 in both eyes. Ophthalmoscopy reveals severe lattice degeneration between the equator and ora serrata 360 degrees in both eyes. There are six full thickness sensory retinal holes in the left eye. The holes are situated temporally and inferiorly between the ora and the equator, separate from the lattice area.

100 Exam Results Two atrophic holes are observed temporally between the ora and equator in the right eye. A retinal detachment between the 2 and 3 o'clock meridian is observed. The patient was referred for cryosurgery to halt progression of the detachment.

101

102

103

104

105

106 CASE: 810 A-D TITLE: Snail track degeneration with hole AGE: 27 RACE: White SEX: Male

107 Exam Results A 27-year-old white male presented complaining of blurry vision at distance for the past year. His ocular and medical history was unremarkable. BVA s are 20/15 OD and OS. Motilities were unrestricted, color vision was normal and no afferent papillary defect was noted. Intraocular pressures were 9 mmhg in both eyes. Biomicroscopy was unremarkable.

108 Exam Results A fundus exam revealed lattice degeneration 360º in both eyes, superior temporal snail tracking in the right eye and a small retinal hole surrounded by lattice inferiorly in the left eye. The patient was educated on the signs and symptoms of retinal detachment and advised to seek yearly-dilated eye exams.

109

110

111

112

113

114

115 CASE: 336 A-D TITLE: Peripheral Retinal Hole AGE: 25 RACE: White SEX: Female

116 Exam Results This 25-year-old white female presented for a routine examination. She is a contact lens wearer with no specific ocular or visual complaints. Her history reveals unilateral kidney removal at 10 years of age. There is a negative history of ocular trauma or inflammation. The family history is unremarkable. An undilated fundus examination two years previously was negative for retinal pathology.

117 Exam Results BVA s are 20/20 both eyes. A dilated fundus examination reveals a retinal hole located in the vortex vein region in the periphery of the left eye. It appears roughly circular with none pigmented borders and surrounded by a subclinical detachment. The hole was considered to be non treating because of the apparent lack of traction and unlikely to progress to a full blown rhegmatogenous retinal detachment

118 Exam Results She was referred to ophthalmologist for a second opinion. Cryopexy was recommended as a preventive measure and was subsequently performed. On the follow up examination chorioretinal scarring is evident over an area approximately twice the size of the hole with its cuff of fluid.

119

120

121

122

123 CASE: 175 A-D TITLE: Retinal Hole AGE: 27 RACE: White SEX: Male

124 Exam Results This 27-year-old white male complained of blurred, hazy vision and numerous floaters in his left eye. The patient's general health and family history is unremarkable. BVA s are 20/15 for both eyes through DS. Ophthalmoscopy of the right eye reveals a yellow streak area of degeneration in the temporal mid periphery with areas of peripheral degenerative breaks. The left eye reveals a three-disc diameter retinal detachment in the inferior temporal quadrant, surrounding a retinal hole.

125 Exam Results The patient underwent Argon laser treatment to seal off the area of the retinal detachment. The fresh scars area shown. A 16-day follow-up reveals excellent chorioretinal adhesion surrounding the area of detachment.

126

127

128

129

130 Rhegmatogenous Retinal Detachment The patient who presents with symptoms of flashes and floaters must be considered to be a candidate for retinal detachment until proven otherwise. In such patients a well documented peripheral fundus examination is essential. (BIO with scleral depression 360 o )

131 CASE: 551 A-P TITLE: Retinal Detachment AGE: 65 RACE: White SEX: Female

132 Exam Results This 65-year-old white female presented with a chief complaint of a blind spot in her right eye on the nasal side. She reported no decrease in visual acuity, flashes, floaters, or distortions in association with this spot. Two years ago, the patient had been diagnosed as having a posterior vitreous detachment in the right eye. She reported no problems with the left. BVA s are 20/20 for each eye. Field-testing reveals a significant inferior nasal deficit in the right eye, but no deficits in the left eye.

133 Exam Results Ophthalmoscopy reveals a retinal detachment three to four disc diameters temporal to the macula in the right eye corresponding exactly to the field loss. Both eyes show scattered drusen and signs of retinal stretching in the periphery. The temporal detachment of the retina in the right eye is associated with a retinal hole within a nonpigmented lattice degeneration region.

134 Exam Results Three days later, the patient had a scleral buckling procedure performed on the right eye. Six weeks after the surgery, she returned for a follow-up visit. Field-testing reveals a residual nasal deficit in the periphery of the right eye. Ophthalmoscopy of the right eye shows that the retinal detachment had settled satisfactorily on the scleral buckle. The attachment has a secure appearance with pigment coagulation of the retina in the area of the scleral buckle.

135

136

137

138

139

140

141

142

143

144

145

146 Post Surgery

147 Post surgery

148

149 CASE: 678 A-E TITLE: Retinal detachment AGE: 57 RACE: White SEX: Female

150 Exam Results This 57-year-old white female presented with complaints of flashes and floaters of recent, sudden onset. She also reported rapidly deteriorating peripheral vision. She denied any history of ocular trauma. The BVA s are 20/40 OD and 20/25 OS through a 6.00 D myopic correction. Examination of the pupils reveals Grade 2 relative afferent pupillary defect in the right eye with normal pupillary responses in the left.

151 Exam Results Ophthalmoscopy reveals a large retinal detachment in the superior field of the right eye with no macular involvement. Ophthalmoscopic examination of the left eye shows no defects. Kinetic perimetry shows an inferior temporal field defect in the right eye and normal fields in the left. B-scan of the right eye confirms the detached area.

152

153

154

155

156

157 A Case of a Shallow Retinal Detachment in a 15 y/o AA Male

158 HPI A 14 years old AA male presented with a complaint of something wrong with his vision for months. He had been seen by an optometrist who could not improve the habitual acuity in his right eye to better than 20/400. He was referred to an ophthalmologist and told that he may have a retinal detachment. The mother elected to come to the UEI for a second opinion because that Dr did not except Medicaid. A fundus examination showed the following.

159 Examination Results Habitual Rx : OD: = X 018 OS: = X 152 OD: An opaque edematous neural retina in the posterior pole secondary to a retinal detachment. OS: White without pressure 360 degrees

160

161

162

163

164

165 Epilog The patient under went a scleral Buckle procedure 4 days later with prophylactic laser treatment. Subsequent repair and reattachment with laser was required 19 months later. His present acuity is OD: 20/50, OS: 20/20

166 Retinal Detachment vs Retinoschisis 23 year old middle eastern Myopic contact lens wearer. HPI: Referred for retinal evaluation with Dx of White without pressure seen at his last contact lens exam 14 days prior.

167 Examination findings Confrontation Visual Fields: Full to finger counting VA: 20/20 OD, OS, OU Anterior Segment: Unremarkable OD & OS Ophthalmoscopy: Poster pole unremarkable OD & OS Right Eye White without pressure 12 to 8 O'clock. Well defined demarcated atrophic area of retina approximately 5DD in size seen at 11:00 O'clock

168 Examination findings (cont.) OCT: OD 5 line raster at 11:00 O'clock showed an operculum but no underlying retinal hole Diagnosis: Bullous retinoschisis or non rhegmatogenous retinal detachment Patient was educated on the symptoms of a retinal detachment and referred to retinal a specialist for further treatment and follow up.

169 OD Posterior Pole

170 Superior Temporal Retina

171

172 Is this a retinal hole?

173 Is this a retinal hole?

Recurrent intraocular hemorrhage secondary to cataract wound neovascularization (Swan Syndrome)

Recurrent intraocular hemorrhage secondary to cataract wound neovascularization (Swan Syndrome) John J. Chen MD, PhD; Young H. Kwon MD, PhD August 6, 2012 Chief complaint: Recurrent vitreous hemorrhage,