Anatomy of Peripheral Retina

&
Peripheral Retinal Degenerations
Presented by:- Dr. Neelam Khatwani
DNB Resident
Sant Parmanand Hospital, Delhi

Moderator:- Dr. Sandhya Gupta

Sr. Consultant
Sant Parmanand Hospital, Delhi
ANATOMY Retina

Posterior Peripheral
pole retina

Optic Near
Macula
disc periphery

Foveola Mid
periphery

Fovea Far periphery

Parafovea Ora serrata

Perifovea
PERIPHERAL RETINA
PARS PLANA

• Ciliary body starts 1mm away from limbus and extends 6mm posteriorly.

Anterior Pars
Ciliary 2mm plicata
body Posterior Pars
4mm plana

Clinical implications:-
Ideal location for PPV Incision/Intra vitreal injections is: i.e in mid Pars plana ; to
• 4mm posterior to limbus --- Phakic eyes prevent damage to lens
• 3.5 mm posterior to limbus --- Pseudophakic eyes
• 3mm posterior to limbus --- Aphakic eyes
 Dentate processes
ORA SERRATA • Extensions of retina into pars plana

Oral bays
• Scalloped edges of pars plana epithelium between
• Junction between dentate processes.
retina & ciliary body.
Meridonal folds
• Small radial folds of thickened retinal tissue in line
• Nasal ora (11’O clock to with dentate process.
5’O clock) is more
Supero-nasal quadrant.
folded as compared to
temporal ora. If associated with a small retinal hole at apex–
Meridonal complex.
• Found in approx. 20% normal individuals
• Ora extensions: Enclosed oral bays
• Small islands of pars plana surrounded by retina between
meeting of 2 adjacent dentate process.
 Meridonal
folds Enclosed
Oral bays

Dentate Meridonal
process complex

Oral bays
 VITREOUS BASE

• 3-4 mm wide zone above ora serrata where cortical vitreous is strongly
attached.

• Applied anatomy:-
• After PVD, posterior hyaloid face remains attached at vitreous base, so less
risk of retinal holes converting into retinal detachment.
• In vitreous base avulsion in blunt trauma cases, tear occurs between non-
pigmented epithelium of pars plana and ora serrata.
SITES OF VITREOUS ADHESION

Physiological Pathological
Vitreous base (strongest adhesion) Lattice degeneration

WWP & WWOP

OD margins
Cystic retinal tuft

Perifoveal VMT

Pre retinal new vessels in PDR

Peripheral blood vessels
Retinal pigmentary clumps
Loosely attached to ILM of sensory
retina. Zonular traction tufts
 PERIPHERAL RETINAL DEGENERATIONS

INNOCUOUS PRE-DISPOSING TO RD

• Micro cystoid degeneration • Lattice degeneration

• Paving-stone degeneration
• Reticular/Honey comb
degeneration
• Peripheral drusen
• Pars plana cyst
• Snail-track degeneration
• Cystic retinal degeneration
• Degenerative retinoschisis
• Zonular tractional tuft
• WWP & WWOP
• Myopic choroidal atrophy
Micro cystoid degeneration
•Tiny vesicles with indistinct margins in greyish white background.
•Seen in adults & incidence increase with age.
•Can lead to Typical Degenerative Retinoschisis.

Paving-stone degeneration
•Focal areas of chorio-retinal atrophy with pigmented margins.
•Found in 25% of normal individuals.

Reticular/honey comb degeneration

•Age related change.
•Perivascular pigmentation.

Peripheral drusen
• Scattered, small pale discrete lesions with hyperpigmented borders.
• Seen in old age; similar to drusen at posterior pole.

Pars plana cyst

• Intra-retinal clear-walled cyst arising from non-pigmentary ciliary epithelium.
• Mostly seen temporally, in 5-10% of normal eyes.
 LATTICE DEGENERATION

Prevalence
• Normally present in 8% of normal population.
• Mostly seen in Moderate myopes in 2nd to 3rd decade. RD with lattice on flap of tear
• Most important degeneration directly related to Retinal
detachment.
• 40% of eyes with retinal detachment have associated lattice
degeneration

Pathology
• Internal limiting membrane discontinuity & atrophy of
underlying neurosensory retina.
• Due to abnormal strong vitreous adhesion with synchtic
vitreous overlying lattice & creating traction. Vitreous synchysis
Signs
• Mostly bilateral ; Supero-temporal
• Spindle shaped areas of retinal thinning between equator Multiple lattice with small holes
& ora.
• Sclerosed vessels- network of white lines- characteristic
• Snowflakes- remnants of degenerated muller cells.
• Associated with RPE hyperplasia – Pigmented lattice.
• Can be associated with small retinal holes.

sclerosed vessels forming a characteristic white

network; a vortex vein is seen superonasally
 Management of lattice degeneration

• Asymptomatic lattice +_ small Retinal Breaks - No Rx

• Asymptomatic lattice +_small breaks + RD in fellow eye – Rx Prophylactically

• Extensive lattice > 6’oclock + High myope + High risk of RD – Rx prophylactically

• Associated asymptomatic ‘U’ tear – Rx

 (A) U-tear in lattice prior to
laser

Treatment options:

• Laser retinopexy
• Using slit lamp delivery under topical anaesthesia. (B) immediately following laser
• Settings –
• duration of 0.1 second,
• A spot size of 200–300 μm with a three-mirror contact
lens or 100–200 μm with a wide-field lens,
• Starting power of 200 mW; moderate blanching. (C) 2 months after laser
• The lesion is surrounded with two to three rows of
confluent burns.
• Lasers used – Argon blue – green (488-514nm);
Nd:YAG (1064nm); Diode (810nm)
Cryoretinopexy
• Preferred for multiple contiguous tears or extensive lesions, and in
eyes with hazy media or small pupils.

• Subconjunctival or regional anaesthesia is commonly required.

• The cryotherapy probe tip is exposed beyond its rubber sleeve. The
instrument should initially be purged (e.g. 10 seconds at −25 °C,
repeating after a minute). The treatment temperature is set
(typically −85 °C).

• Check the effectiveness of the instrument by activating it in sterile

water for 10 seconds, when a 5 mm ice ball should form.

• Under BIO visualization, the lesion is indented and the foot pedal
depressed until visible whitening (up to 2mm) of the retina is seen.

• It is critical not to remove the tip from the treated area until thawing
is allowed (2–3 seconds).

• The lesion is surrounded by a single row of applications.

 SNAIL TRACK DEGENERATION
• Bands of ‘snow flakes’ at peripheral retina –
‘white frost like appearance’.

• Precursor to lattice degeneration.

• Marked vitreous traction rarely seen;

therefore rarely associated with ‘U-tears’ ,
but retinal holes are common.

• Prophylactic Rx rarely required.

• 1-2 yearly follow up.

 CYSTIC RETINAL TUFT
• ‘Granular patch’ or ‘Retinal rosette’.
• Congenital abnormality consisting of a small,
round or oval, discrete elevated whitish lesion,
more commonly temporally.
• Comprised principally of glial tissue;
• Strong vitreoretinal adhesion present. Associated
with retinal holes and horseshoe tear.
• Under-recognized lesion, present in up to 5% of
the population.
• Risk of RD is under 1%.
 DEGENERATIVE RETINOSCHISIS
Prevalence
Intraretinal cavities
• Normally present in 5% population.
• Hypermetropes; Age>20 yrs

Pathology
Gradual coalescence of cavities of micro cystoid
degeneration
Retinoschisis
Splitting of Neurosensory retina into outer & inner layers

severing of neurons & complete loss of vision in affected

areas

Retinoschisis Retinal detachment

 More common
Typical Splitting at level of OPL.
Seen anterior to equator.
Degenerative
Retinoschisis

Reticular Less common

Splitting at level of NFL; inner layer thinner & more elevated
Seen posterior to equator
A/w with complications- microaneurysms, telangiectasia
RETINOSCHISIS VS RETINAL DETACHMENT
 Large outer layer break.
Retinal vessels in the inner
layer can be seen traversing
the rolled edge undiverted
Retinoschisis & micro cystoid
degeneration

Retinoschisis with inner & outer

layer breaks
 Small peripheral retinoschisis, no breaks, no symptoms ----
Review once in 1 / 2 years.

Large Retinoschisis extending posterior to equator + breaks

present in both layers: Do OCT to check whether it is
RD/Retinoschisis

MANAGEMENT OF If small RD with outer layer breaks – Scleral buckling

RETINOSCHISIS

Complex RD- PPV

If Large Retinoschisis approaching to fovea- Prophylactic

Retinopexy
Zonular traction tuft

• Prevalence - 15%
• Aberrant zonular fibre extending posteriorly, attached at retina
near ora serrata, and exerts traction.
• Typically located nasally.
• Risk of retinal tear formation is around 2%.
 WWP & WWOP
WWP
• ‘White with pressure’ (WWP) - retinal areas in which a
translucent white–grey appearance can be induced by
scleral indentation.
• Each area has a fixed configuration that does not change
when indentation is moved to an adjacent area.
• Associated with abnormally strong attachment of the
vitreous gel.
• May not indicate a higher risk of retinal break formation.

• ‘White without pressure’ (WWOP) has the same WWOP

appearance as WWP but is present without scleral
indentation.
Myopic Choroidal Atrophy

• Diffuse / circumscribed choroidal

depigmentation.
• commonly associated with thinning of the
overlying retina.
• occurs typically in the posterior pole and
equatorial area of high myopes
Fundus drawing
of peripheral
retinal
degenerations
REFERENCES

• Kanski’s clinical ophthalmology – 8th edition by Brad Bowling

• Ophthalmology 4th edition by Yanoff & Duker
• Peripheral Ocular Fundus 3rd edition by William L. Jones
THANK YOU