Transcript distinct borders

William D. Townsend, OD, FAAO
Advanced Eye Care, Canyon, TX
Adjunct Professor, UHCO
 During clinic, I initially note a few small
floaters that I had never noticed before
 No flashes of light
 No vision changes
 I mentioned this to my extern, Juan
Menjivar, who wants to dilate me and
examine my peripheral retinas
 I decline; it was a busy week
 My mother was in the hospital- almost died
 We had a bank stockholders meeting
 I had to get ready to speak in Canada
 I knew there wasn’t a problem: I am bullet proof
 I am speaking to the New Brunswick
Association of Optometrists
 Lectures are going great
 The audience is very interactive
 It is a perfect spring day in a beautiful,
historic Canadian city
 I get to hang out with my friend, Dr. Diana
Shechtman who is speaking on retina
 Things could not be better!
 I start off the day in the gym with a 7 am
workout
 Next, I work on today’s lecture to finalize
the content and add new information
 As I work, I notice a small dark spot in my
OD lower temporal field
 What the heck, I plunge on
 Hit in the right eye with a tennis ball
 Within a year, I noted my vision in that eye
was not as quite as bright
 Over the years, the trend continued
 Why? A progressive traumatic NS cataract
 10 May 2007, successful cataract surgery
with implantation of Alcon Toric IOL
 BVA without correction = 20/15
 I tell Diana about my “spot” and express
concern; she calls me a hypochondriac
 1:00 pm- I start my lecture, “Pain
Management”
 As I speak, I note that the grey spot is
rapidly expanding upward reducing my
field in the inferior field. I run into things as I
deliver the lecture
 Otherwise normal eyes- 5 in 100,000 per
year
 Middle age & elderly eyes-20 in 100,000
per year
 Highly myopic eyes- 5,000 in 100,000
 Highly myopic eyes after cataract
surgery- 7%
 The majority of retinal detachments are
rhegmatogenous (tear-induced).
 Virtually all retinal tears are caused by
interaction between vitreous and retina.
 Anatomical variations in the vitreous-retinal
relationship often lead to retinal tears
1.
2.
3.
4.
5.
Macula
Optic nerve
Ora serrata
Vitreous base
General vitreous-retina interface
 Vitreous base
strongest
 Optic nerve
 Macula
 Blood vessels
 Vitreous-retinal interface
weakest
 Peripheral senile pigment degeneration
 Cystoid retinal degeneration
 Oral pearls
 Cobblestone (pavingstone)
degeneration
 Non-cystic retinal tufts
 Congenital RPE hyperplasia
 Retinal white without pressure
 Appearance- Peripheral areas of "'salt &
pepper" hyper-hypo pigmentation;
reticular form has net-like appearance
 Histology- RPE degeneration w/
migration of pigment
 Occurrence- 20% of population over 40
years of age
 Risk- None
 Differential- Retinitis pigmentosa
 Management- None
 Occurrence- 27% of adult autopsy
eyes, bilateral 38% of cases,
increases w/ age, inferior location
most common, high myopes
 Risk- In retinal detachment, retina
may tear at border of lesion
 Differential- Chorioretinal scars
 Mgt- None
 Degenerated glial tissue
 Vitreous traction invariably present
 Risk for tear depends on
Location
Size
Degree of traction present
 Cystic: occur posterior to vitreous base
 Non-cystic: occur within vitreous base
 Appearance- small, thin projections of tissue
that appear as grey-white dots close to ora
 Histology- composed of altered retinal tissue,
degenerated glial tissue; base diameter
usually less than .1 mm
 Occurrence- 72% of adults and bilateral in
50% of cases; vast majority are intrabasal
 Risk- low to none - small size and intrabasal
location
 Differential- none
 Management- none; rarely, small benign
holes are noted at their base
 Appearance- flat, round pigmented lesions,
usually black or dark grey, distinct borders
 Size- varies from small to several disc diameters.
May have a surrounding area of decreased
pigmentation (halo).
 Histology- congenital hypertrophy of RPE; cells
have larger than normal melanin granules;.
 Occurrence- unknown; unilateral in 85% of
cases
 Risk- none
 Differential- nevus, melanoma
 Management- rule out traction as in cystic tufts,
otherwise none
 Appearance- flat, round pigmented
lesions, usually black or dark grey,
distinct borders
 Size- varies from small to several disc
diameters.
 Histology- acquired (hyperplasia)
increased number of RPE cells
 May occur at site of vitreoretinal traction
 Unknown- unilateral in 85% of cases
 Risk- none
 Differential- nevus, melanoma, assess for
vitreoretinal traction
 Enclosed ora bays
 Meridional folds
 Cystic retinal tufts
 Zonular traction tufts
 Acquired peripheral retinoschisis
Typical
Reticular
 Atrophic retinal holes
 Operculated retinal breaks
 Lattice retinal degeneration
 Appearance- grey nodules of varying size,
usually extrabasal
 Histology- degenerated, proliferated cystic
tissue with some degree of vitreous traction
0.1 to 1 mm diam.
 Occurrence- 6% of patients
 Risk- varies depending on source
 Byer: 10% of all retinal detachment caused by
CRT
 Foos: CRT cause 82% of opercula, 97% of tears
 Management: scleral indentation, patient
education, yearly DFE
 Do not underestimate the potential damage!
 Appearance- Usually round,
occasionally elongated red areas
in peripheral retina,
Often w/ cuff of subretinal fluid and
subclinical detachment (30%)
Opercula are almost universally seen
in adjacent vitreous
Pigment surround common
 Histology- Full thickness break in
retina.
 Caused by traction on CRT, or area
of abnormal vitreoretinal traction
 Occurrence- 13.4% of retinal breaks, increased
in frequency w/ age, most common
extrabasal; 80% associated w/ PVD.
 Large operculated breaks associated w/ lattice
degeneration & PVD are rare.
 Reportedly associated w/ WWP & WWOP
 Risk- Slight, increases w/ size
 Differential- Atrophic hole, retinal hemorrhage,
flap tear
 Management- If old, asymptomatic, patient
education, yearly DFE
 If fresh, or symptomatic, patient education, 6 week
DFE.
 If subclinical detachment > 2 dd, refer.
 Occurs in two forms, typical and
reticular
 Caused by splitting of sensory retina
 Found in 4% of general population & 7%
of population over 40 years of age
 Round or ovoid in shape,
 Always associated w/ cystoid
degeneration; advanced stage of same
process
 Bullous lesions more prone to progression
or detachment
 Causes absolute scotoma
 Appearance- Round or ovoid
shape w/ inner & outer layers
separated by fluid.
Details of choroidal vasculature are
obscured
White dots on inner surface (70%) of
lesions.
Inner layer smooth, has white dots on
inner surface (70% of lesions)
Outer layer has moth-eaten,
pockmarked appearance. Inner or
outer layer holes occasionally seen.
 Histology- Splitting of neurosensory retina
in region of outer plexiform layer
 Inner layer is relatively thick & smooth in
appearance. Supporting elements or pillars
between layers at margins of lesions.
 Occurrence- found in .69% of eyes,
 Bilateral in 33%-64% of cases, most common
inferior temporal quadrant (70%-82%),
 some studies indicate more prevalent in
hyperopes.
 Always associated w/ cystoid degeneration;
increases w/ age
 Appearance- Round or ovoid
shape w/ inner & outer layers
separated by fluid.
Details of choroidal vasculature are
obscured; inner layer thinner than in
typical form.
White dots and an arborizing pattern
of white lines in inner layer; outer layer
has moth-eaten, pockmarked
appearance.
Inner or outer layer hole more
common.
 Histology- Splitting of neurosensory retina
in region of internal limiting membrane;
inner layer is relatively thin & smooth in
appearance. Supporting elements or
pillars between layers at margins of
lesions.
 Occurrence- 0.95% of eyes, bilateral in
15.8% of cases: found in 1.62% of
patients.
 Most common in inferior temporal quadrant;
vast majority of lesions in temporal
quadrants.
 Outer layer holes in 22.7% of eyes. ; increases
w/ age
 Risk
 More prone to progress past equator than
typical form
 More prone to cause retinal detachment,
especially when outer layer holes are present
 Greatest risk is when outer and inner layer
holes co-exist in same lesion
 Appearance- small (<.5 dd) round red
areas in peripheral retina, often w/
surrounding cuff of fluid and subclinical
detachment
 Histology- full thickness break in retina.
 Occurrence- 76% of all retinal breaks,
occur in 2.4%of eyes, 4% of cases, 76%
found w/in lattice lesions, associated w/
meridional folds, ZTT, CRT; increased in
myopes, 80% have associated
subclinical detachment
 Risk- minimal; 7% lead to clinical
detachment
 Differential- tractional tear, retinal
hemorrhage; scleral depression
 Management- document, yearly DFE,
refer if clinical detachment > 2 dd
noted
 Appearance- red, U-shaped lesion w/
"horse running toward the posterior pole”
 Cystic retinal tuft may be seen at end of flap;
25% < 1/4 dd in size
 Histology- full thickness retinal break w/
attached flap of retina having traction from
vitreous on apex of the flap
 Occurrence- 10% of all retinal breaks
 Frequently symptomatic due to traction.
 Often found at posterior border of lattice, scars,
CRT, enclosed ora bays, chorioretinal scars
 81% occur in individuals over 40 years of age
50% in superior nasal quadrant.
 Risk - moderate to high because of the continuing
presence of traction.
 Differential- atrophic hole, operculated tear,
hemorrhage
 Management- Small (< 1/4 dd) and asymptomatic:
patient education & 4 week DFE, Larger (> 1/4 dd)
or symptomatic, especially if superior, or Hx
detachment fellow eye: refer
 Appearance
Varies widely; usually parallels the ora
White lines- 12%-15%
Atrophic holes- 18%-43%
Pigment- 83%
White spots- 80%
 Histology- thinned area of peripheral
retina with overlying lacunae of
liquified vitreous, vitreous traction on
margins,especially posterior
 Occurrence: 8%-11% of individuals
Increased in myopic eyes
Most common @ 12 o’clock & 6 o’clock
 Risk
0.5% chance for detachment
30% of all detachments associated with
lattice
Greatest risk is large horseshoe tears
 Differential: pavingstone, retinal dialysis,
scleral indentation is essential
 Management:
 Observe w/ annual DFE
 Educate on signs & symptoms
 Refer if breaks at margin are discovered
 Examine parents, siblings
 My macula is still on, but the detachment is
progressing quickly
 In New Brunswick and neighboring Nova
Scotia - one surgical retinologist
 He is out of the country on vacation
 My options
 Fly home- it will take too long
 Get across the border to US health care
 With Lil and Dwight at the helm, I head fo
the border
 Our local retinal specialist back in Texas,
Dr. Eddie Ysasaga arranges for me to see
a retinal specialist in Portland, Maine the
next morning
 Dr. Lil Linton and her husband Dwight drive
me 300 miles to Portland while I lie face
down in the back seat
 Portland retinal surgeon Dr. Fred Miller has
made reservations for us at the La Quinta
across the street from his office
 Sometimes ignorance is bliss
 Macula on detachments have much better
prognosis- therefore an ocular emergency
 I could tell from my vision that the detachment
was getting close to fixation
 I knew exactly what was happening
 Fear- what will I do if I lose my vision
 Second guessing- I should have let Juan
dilate me
 I am going to go through this without the
physical presence of family or friends
 I pray a lot
 7:00 am- Dr. Fred Miller is waiting at his
office- he has already contacted the
surgery center & has people in place
 He confirms the diagnosis and we
discuss surgical options
 We decide to go with a vitrectomy, cryo,
and air bubble- partly at my insistence
 He personally drives me to the center
and we prep for surgery
 9:00 am- I am ready for surgery and we
head for the OR
 I get and IV and some Versed
 I am awake, but “happy”
 Dr. Miller inserts ports through my pars
plana, and performs a vitrectomy.
 He fills my eye with air and cryos the area
around the flap tear
 He then performs a retinotomy to allow
fluid under my retina to escape
 They close. I can see nothing with my right
eye
 Now the waiting begins- I go back to the
La Quinta and sleep
 After a night of sleeping with my head
elevated, I awake, walk across the street to
Dr. Miller’s office
 The initial findings; CF @ 2 feet, BUT if I hold a
near card close to my eye I can see 20/30
 I celebrate with pizza!
 My daughter Erin flies in- she will drive me
2300 miles back to Canyon, Texas
 The pressure inside a commercial aircraft is
roughly equivalent to an altitude of 6000
feet
 Rapid decline in air pressure causes the air
bubble to expand causing high IOP, pain,
vision loss
 Even going over a mountain has the same
effects only more gradual
 The air bubble usually lasts @ 1 week
 Final check up with Dr. Miller looks good.
My retina is flat, no infection.
 We hit the road
 Along the way, I begin to watch the
bubble recede- I can read signs in my
upper field.
 1 May 2008 we arrive in Canyon
 The local retinal surgeon examines me the
following day and is concerned
 He tells me to be still and limit activity
 I am back at work on a limited schedule
 2:00 pm- as I examine my patient, I note a
grey spot in my superior field and it makes
me nervous It is déjà vu from the opposite direction
 2:30 pm- Dr. Janet Townsend informs me
that now my right inferior retina is
beginning to detach
 The retinal specialist confirms her findings
and we schedule surgery for the next day
 Pavingstone degeneration is common in
high myopes
 It is innocuous unless the individual has a
retinal detachment
 Pavingstone then becomes a potential site
for multiple tears to occur
 I had seven tears
 This time the bottom half of my retina is
detached
 7:00 am- this time the procedure will be
much more invasive
 Dr. Antonio Aragon inserts ports through
the pars plana
 He fills my eye with air 83% air and 17%
C3F8, (octafluoropropane) the longest
residing gas used in retinal surgery.
 Other options include air and SF6
Air- Cheap, only good in certain cases
 Short residence time (@ 1 week)
 May not be adequate for some cases
Require longer tamponade
 SF 6 (sulfur hexafluoride)
 Medium residence time (@ 2-3 weeks)
 C3 F8 (octafluoropropane)
 Long residence time (@ 6-8 weeks)
 Longer duration reduces likelihood of
failure, redetachment
 Dr. Aragon positions a silicone band
around my peripheral retina and tightens
it to bring it in contact with RPE
 He then lasers the areas around the tears
and closes; we are finished!
 I am now to lie face down for the next ten
days
 This is no way to spend your birthday!
 The initial post op report is good- I can see
some print if I hold it close
 I wear a shield at all times, only removing it
to instill Vigamox, Omnipred, and Nevanac
 Ten days later, I can only see hand motion
and my eye hurts, but I can discontinue
positioning face down
 I am back at work, but can only see with one
eye.
 Any procedure that requires binocular vision
goes to my associates
 The bubble is regressing and I can see in my
superior field
 Dr. Aragon is concerned; my eye is very
inflamed
 The drops continue
 The gas bubble is gone
 I am now myopic, but with correction I am
20/20
 But
 My eye is still inflamed, with significant cells and
flare
 My pressures are going up because I use
steroids every other hour.
 I now know what it is like to need steroids,
but to be a steroid responder
 My inflammation still persists, but is
beginning to decrease
 I am on three meds for IOP, but my
pressure spikes as high as 51 mm Hg
 I see halos around lights
 I get discouraged
 We increase the Nevanac and taper the
steroid
 I am finally off all steroids
 There is no flare, shaking my head results in
an amazing display of cells
 Leukocytes still reside in my anterior
chamber blocking outflow.
 I take my meds; the IOP is < 30 mm Hg
 OCT of my nerve looks good
 I continue Combigan Q 12 hours & Azopt Q
8 hours
 Moderate NS OS
 Pseudophakia OD with 20/20+ vision
 No inflammation
 No medications
 I am blessed!
 I appreciate vision more than ever before
 I appreciate what we as optometrists do
more than ever
 Know the risk factors for retinal tears &
detachment
 Know how to recognize and manage
peripheral retinal conditions that pose a risk
of retinal tears, detachment
 Take good care of your own eyes
THANK YOU