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Anatomy
- Long posterior ciliary nerve and vein at 3:00 and 9:00 from equator
to ora
- Pars plana
- Short posterior nerve
- Vitreous base
- Vortex veins at equator
Photopsia Causes
- Acute PVD 14%
- Horseshoe tear 10%
- Lattice 41%
- Round holes 14%
- Snail Track 10%
- WWOP or WWP 14%
Peripheral changes that are not a problem
Retinal pigmentation's
Benign choroidal melanoma (Nevus)
- 30% incidence
- Flat slate gray lesion with indistinct margins
- 80% have overlying drusen
Size
.5-2 DD Benign
2-5 DD Elevated and drusen do fluroscein
5 DD+ Feeder vessels malignant
Congenital hypertrophy of the RPE
- Bear tracks
- Flat, black area with surround of depigmentation,
- Scotomas
Halo nevus
Dark without pressure
- Flat brown areas in Blacks at posterior pole
- Potential sickle cell?
Post-inflammatory chorioretinal scar
- White - yellow area of fibrosis and RPE scattering of pigment
- Often overlying vitreous condensation and strand attachments
- Lesion may reactivate (Toxoplasmosis)
- Look for tears if PVD
RPE hyperplasia
- Jet black irregular areas of RPE growth in response to injury
Senile pigmentary degeneration
- Tapetochoroidal degeneration
- 20% of 40+, Bilateral degeneration of RPE
- Granular pigment between ora and equator near veins
- Degeneration of RPE
Retinal depigmentations
Primary chorioretinal atrophy
- Cobblestone degeneration
- 20% of 40+
- 33% bilateral
- Small pale yellow or depigmented areas of periphery
- Choriocapillaris breakdown
- Can see underlying choroidal vessels through the depigmented
area
Retinal pigment epithelial window defect
- Yellow - white, round, well circumscribed area
- Absence of melanin in RPE
Enclosed oral bay
- 6% Incidence
- Brownish depression at ora surrounded by sensory retina
- Develop breaks
Oral pearls
- 20% incidence
- Solitary white spheres at ora
- Equivalent to drusen
Pars plana cysts
- Oval, smooth, transparent at ora
- Equivalent to retinal detachment
- Associated with traumatic retinal detachment and Uveitis
Peripheral cystoid degeneration
Typical
- Bilateral in everyone age 8+
- Hazy gray with red dots
- Usually superior temporal
- May be a precursor to retinoschisis
Reticular
- Usually inferior temporal
- 18% of adults
- 41% bilateral
- Reticular, appears as "fishbone" looking sclerotic
vessels
- More often in myopes and 10x in Blacks
- Translucent gray area between equator and ora
- Posterior bounded by reddish line
- Anterior fades to ora
- Associated with PVD
- Vitreoretinal traction may lead to tears
- Follow close if near lattice, has scalloped borders, is elevated
or if marked vitreous degeneration
White with pressure
- Retina appears grayish on scleral indentation only
Serious peripheral changes
Retinal folds, holes and splits
Acquired retinoschisis
- Splitting of sensory retina
- 70% bilateral
- Both sexes
- 4% of population
- 7% overage 40
- Usually inferior - temporal
- 70% go to equator
- 11% progress to a retinal detachment
- 60% have vitreous liquefaction
Flat - typical
- Advanced cystoid anterior to equator
- Inner layer is flat with beaten metal look
Bullous
- Thin transparent ballooning forward of retinal tissue
- Usually inferior temporal
- 70% have whitish snowflakes on the surface
- Taut and does not move
- Space filled with fluid
- Rhegmatous retinal detachment "flaps in the breeze"
Atrophic retinal holes
- 3% Incidence
- Round, full thickness hole
- Red spot surrounded by cuff of whitish edema or RPE hyperplasia
- If pigmented probably more than 3 months old
Choirodal rupture
- White arcuate parrallel to disc
Meridial fold or complex
- Gray - white tissue redundancies perpendicular to ora
- 25% incidence
- 50% bilateral
- More often males
- Most often superior - nasal
Operculated retinal hole
- Round red holes, with an overlying free floating plug of
retina attached to the vitreous
Commotio retinae
Malignant choroidal melanoma
- Mottled, white to gray - green elevated lesion with orange
overlay
- Usually 10 DD + when discovered
- RPE hyperplasia ("Melanoma bodies") on surface
indicates malignant
- Starts in choroid but may grow into vitreous
- Metastases to brain, liver, lungs
- Irradiate best treatment
Vitreal degeneration's
Lattice
- "Snail track"
- "Scheckenspuren"
- White margin of vitreous condensation around a sealed lacuna
of liquefied vitreous overlying thinned retina
- Usually found 11:00 - 1:00 and 5:00 - 7:00
- Peak incidence by age 20
- 6-10% Incidence, 50% Bilateral
- 25% chance of tear
- Stage 1 - Grayish retinal thinning usually along a vessel
- Stage 2 - Vessel sheathed and looks "fish-bone" and
RPE hyperplasia
- Stage 3 - Reddish retinal holes and tears
Snowflake vitreoretinal degeneration
- <15 yrs old White without pressure
- 15-25 Elevated
yellow dots in WWOP
- 25-50 Sheathing,
cataract, retinal degeneration
Vitreoretinal tufts
- 72% Incidence
- 50% Bilateral
- Cystic tufts 5% Incidence and unilateral
- Zonular tufts 15%
- Accumulation of glial cells, causing retinal degeneration vitreous
detachment
- Grayish - white tissue between retina and vitreous
- Localized phosphene may signal impending retinal tear
- Photocoagulate at first sign of tear
- Most often nasal between equator and ora
Pars planitis
- Chronic inflammation of peripheral retina, probable autoimmune
- 75% bilateral
- Primary problem in 8% of uveitis
- Dirty, yellowish, exudates next to small sheathed vessel's
in periphery ("Snowbanks")
- Hazy vision, or floaters
- Possible cystoid macular degeneration
Very serious peripheral changes
Giant retinal tears
- 4x males > -8.00
- 90 degrees +
- 70% idiopathic
- Fellow eye at risk
13% Giant retinal tears
12% Retinal tears
10% Retinal holes
16% Retinal detachment
Linear retinal tear
- Red surrounded by gray atrophic tissue
- 30% chance of retinal detachment
Retinal detachment signs
- Weak bond between sensory retina and RPE
- Strong bond between RPE and bruch's
- Most retinal detachments between RPE and sensory retina
- Immediate cause of rhegmatous retinal detachmentis vitroretinal
traction
- "Tobacco dust"
- Shaffers sign
- Pigment or red blood cells in anterior vitreous
- Sudden onset or increase in number of floaters
- Key in detection is inability to see choroidal structures
- Sudden shower of small gnat-like floaters
- Sudden change in vision
- Loss of field
R.D. Risks
- Vitreous liquefaction
- -3.00 myopia
- Other eye retinal detachment
- Famial history of retinal detachment
- Aphakia
- Retinal thinning
- Vitroretinal traction in elderly
Rhegmatous retinal detachment
Hereditary chorio-retinal diseases
Tests
EOG
Measure of potential from RPE
ERG
Measure of response to stimulation
VER
Measure at cortex when eye is stimulated
Heriditary retinal diseases
Central
Albinism
Central areolar choroidal dystrophy
- Onset age 40+, variable inheritance
- Macular stippling leading to RPE and choroid atrophy
- Poor visual acuity
Dominate drusen (Doynes honeycomb)
- Onset of drusen between 1-3 decade and decreased visual
acuity by 5-6 decade
- Autosomal dominate
Gyrate dystrophy of choroid and retina
- Autosomal recessive
- Progressive RPE and choroidal atrophy
- Bare sclera showing through
- Alter Diet
Lebers congenital amaurosis
- Congenital pigment dystrophy
- Blindness in first year
Patterned anomalies of RPE
- Autosomal dominate
- Onset 1-3 decade
- Bilateral
- Visual acuity often not as bad as expected from appearance
Sjogrens reticular pigment epithelial dystrophy
- Pigmented lines form fishnet that radiates from macula
Macreticular pattern dystrophy
Butterfly dystrophy
- Butterfly or iron cross
- Macular RPE
Progressive cone dystrophy's
- Onset in 1-2 decade
- Bulls eye atrophic macula
Stargardts (Fundus flavimaculatous)
- Yellow - white flecks appear in 1-2 decade and progress
towards macula
- Loss of foveal reflex
- Grayish yellow depigmentation and pigment stippling around
normal looking fovea
- Macula slimes with fish tail yellow flecks
- Eventually 2 DD beaten bronze and poor visual acuity
- Autosomal recessive
Vitelliform dystrophy (Bests disease)
- Egg yolk between age 4-10
- Autosomal dominate
Peripheral
Choroideremia
- Night blindness in first - second decades
- RPE stippling, choroidal atrophy and eventual gyrate atrophy
- X Linked Recessive
Congenital stationary night blindness CSNB
- Night blindness, mild acuity reduction, normal retina
- Oguchi's disease
Variation of CSNB where when light adapted retina has a yellow
- gray tint
Retinitis pigmentosa
Standard retinitis pigmentosa
- Attenuation of vessel's
- Spicule pigmentation in mid periphery (Ring Scotoma)
- Optic pallor
- Cystoid macular degeneration
Inverse retinitis pigmentosa
Retinitis pigmentosa san pigmento
Retinitis punctata albescens
- Progressive type
Discrete white dots that do not confluence, especially in posterior
pole
May have disc pallor and vessel attenuation
Autosomal recessive?
- Stationary type
Dots mainly mid - periphery and peri - macular
Disc and vessels normal
Non - progressive night blindness with daytime good
Autosomal recessive
Rod monochromatism
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