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Findings posing NO IMMEDIATE THREAT TO VISION (Clinically insignificant) Normal variations

Name Meridional folds & Complexes - Folds = glial cell proliferation, breaks at posterior border are possible, but rarely develop RD Enclosed Oral Bays -congenital developmental variation Visible Characteristics/location Elevated, grey-white retinal tissue redundancies most often superior nasal Radial orientation Probability 25% of the population, 50% bilaterally Mx Routine annual exams Educate as to signs (SN) and symptoms (SX) or RD Consider retinal consult if tears develop but usually on if symptomatic Annual exams, sclera indentation (to help find). ED: SN/SX of RD

Brownish (Reddish brown) island of non-pigmented pars plana epithelium isolated from the rest of the pars plana DDX retinal breaks: gradually sloping orderly border with sclera indentation vs. SHARPLY demarcated edge of a break

6% of pop. 15-20% chance of associated retinal break (rare detachment)

Developmental abnormalities
Vitreoretinal Tufts (3 types: Non-cystic, zonular) greyish white tufts of tissue at the VR interface, usually located between the equator and ora. Tractional will/may see RPE hyperplasia near or within the tuff. Retinal breaks may occur associated with vitreous liquefaction, syneresis, or vitreous detachment. NON-CYSTIC - Base of tuff <0.1 mm diameter 72% of Routine annual exams - Glial cells - Intrabasal location, usually inferonasal population ED: SN/SX of RD proliferation, no - No associated retinal breaks within vitreous base with 50% attachment to - Indistinguishable from cystic degeneration (bad!) bilaterally vitreous - Usually in clusters, may degenerate - Decapitation of tufts by avulsion produce tiny floating spherical fragments ZONULAR - Posterior displacement of zonual attachments to the 15% - Developmental peripheral retina population abnormality - Larger size, anterior angulation and closeness to ora (small - LONG with Anterior Bulbous or pointed tip number)

Base of tufts associated with tropic changes of adjacent retinal cystoid spaces, retinal thinning, and occasionally full thickness holes High incidence of associated retinal breaks but low incidence of RD since they are located in vitreous base Glistening or opalescent white nodule within a retinal dentate process extending over the pars plana. Bright white or dark Usually superior temporal 20% of population Self-limiting and benign Annual exam No association with diseases Never treated Useful as a landmark for localization. Beign/routine Watch for retinoschisis Routine exams usually benign and self-limiting Watch for development of holes and degenerative retinoschisis

Peripheral Degenerations
Oral Pearls - Histopathologic correlated to posterior pole drusen Cystoid degeneration - cystic spaces within retina cause appearance of thick retina about DD from ora. -

Bigger cysts when joins together, theyll separate the retina. Hazy grey with enclosed hazy red dots Two types (but clinically indistinguishable): Typical (middle) and Reticular (superficial layers) Often associated with vitreal strands Usually temporal and/or superior Inner layer holes can develop Non-pigmented areas between equator and ora Usually inferior 5 to 7 oclock. Often RPE hyperplasia Deep layers missing, no breaks in inner retina

100% of the population by age 8

Primary chorioretinal atrophy (pavingstone or cobblestone) - Choriocpillaris occlusion with subsequent RPE and retinal tissue loss Pars plana cysts - Separation of nonand pigmented ciliary epithelial. - Histopathologic

27% >20 years old 33% bilateral, m:f = 3:1

Routine examinations

Smooth convex cyst of variable size immediately anterior to ora Conform to the individual oral bays, often consecutive Seen best with scleral indentation Mostly temporal

3-8% of the population

Monitor annually, retinology if tear present.

equivalent to a sensory RD White-without-pressure - Disorganization of the nerve fibre layer resulting from an abnormal VR relationship White-with-pressure

Looks like blisters 1/3 to 3 DD in size Often associated with traumatic RD or posterior uveitis Translucent grey area bounded posterior by a reddish brown line; migratory Associated with lattice degeneration, posterior staphylomas and local RD.

30% of population (5% <20 yo, 66% >70 Yo, 10X more in AA)

Annual exam (6mo f/u if WWOP: near lattice, scalloped borders, elevated tractional membrane, progressive vitreous degeneration)

Congenial hypertrophy of the RPE (CHRPE) - Enlarged RPE cells and choriocapillaris atrophy

Pigmented Ocular Fundus Lesions (POFLs) - Bear Track - Punch out lesions

Optical phenomenon of the retinal similar to WWOP Patches of retinal appear translucent grey or whitened upon sclearal depression Used to be known as halo nevus 2DD Dark gray to black areas of variable size Typically flat with surrounding hypopigmented area Scotomata occur in the affected areas that become more dense with age Associated with familial adenomatous polyposis (FAP) Various types of POFLs in FAP (Autosomal Dominance) Small dark lesions in peripheral fundus near vortices Larger more characteristic ovoid, tear-shaped, or coffee bean shaped lesions are closer to the posterior pole. Some POFLS have dephm. Halo/ post depigm. Tail Depigm. Lacunae also possible. Use 3 mirror exam to not miss lesions.

Annual exam

Multiple POFLs is specific (>90%) sensitive (70% - 80%) marker for adenomatou polyposis (through lack of POFLs does not preclude diagnosis)

FAP (Familila adenomatous polyposis)/gardner syndrome: hundreds of adenomatous colonic polyps, adenocarcinoma of colon inevitably develops unless the colon is resected prophylactically NO ASSOCIATION WITH SOLITARY PATCHES OF CHRPE Examine other family members**

Peripheral (Senile) Pigmentary degeneration Aka Reticular - Granular pigment between the ora and equator

Often accompanied by peripheral degenerative drusen - Pigment may cuff venules or be bone spicule-like (not RP) - Caused by degenerating RPE with pigment scattered in sensory retina with loss of photoreceptors and sclerosis of the choriocapillaris Findings which MAY pose a THREAT to vision Lattice Degeneration - A space of absent vitreous (lacuna) overlies the - Well demarcated thinning (possibly some glial tissue) localised inner - Sclerotic vessels (a or v) appear as white lines retinal thinning following vessels with vitreous - 1-4 DD in length and -2 DD in width condensation and - Posterior lesions are wider exaggerated VR - WWOP is frequently found along the borders of attachments at the lattice, as are overlying vitreous lacunae borders - Lattice with holes are common inferiorly and lattice with sclerosed vessels more common superiorly - Often confused with scisis when lattice has led to subclinical RD, and also with tufts Atropic Holes in Lattice Never any symptoms, never any VR traction Gradual decrease in the thickness of the retina Usually very small <1/4DD 2:1 inferior retina Maybe the first noticed feature of the lattice lesion Atrophic holes in lattice may slowly collect SR fluid beneath them (subclinical detachment) Majority when first diagnosed already are surrounded with a very narrow rim of SR fluid SUBCLINICAL DETACMENT: extending more than 1 DD beyond the retinal break, but no more than 2 DD posterior to the equator Linear or horseshoe shaped

20% >40 yo, usually bilateral

Routine exams self-limiting and benign

Prevalence 610 % reached by age 10 Bilateral in 3348% 80% show RPE

Linear Tears alongside

29-43% of lattice lesions have atrophic holes (increases with age) Symptoms: Aphakia or pseudophakia, significant VR traction, Miotic use 20-40% of

Educate all patients with lattice on SN/SX of RD. Asymptomaic F/U yearly Flashes or floater 6 mo Atrophic holes (Asymptomatic) and no risk factors 6 mo. Marginal breaks retinal consult (28-35% chance of RD) NO prophylactic treatment unless: Fellow eye RD, symptomatic tears, strong family history of RD, eye with lattice is aphakic or soon to

Lattice - Tears at posterior margin of lattice

Risk is greatest for juxtabasal or extrabasal lattice

surgical RD had lattice; but only 1-5% of lattice get an RD (7yrs)

become aphakic or highly myopic Examine symptomatic px q 6 mo. Most flap tears with lattice are treated, although may have more post-treatment problems

Acquired Retinoschisis - Separation of the sensory retina

Most located inferotemporal with 70% progressing post. To equator Absolute scotoma 60% have vitreous liquefaction, 25% have a break in at least one of the layers of the schisis, 40% have breaks in both layers <10% degenerative Progression of the RS will terminate if a PVD occurs since the vitreous traction is relieved Chance of RD 0.024% Best seen with sclera indentation Layers are separate but move together because of viscous substance in schisis cavity

<10% show progression, expansion, or retinal break

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