The peripheral retina is defined as anterior portion of retina that begins 3mm posterior to the equator , extends past

the equator into the anterior portion of retina that ends at ora-serrata Ora serrata serrated junction between retina and ciliary body Tooth like extensions of retina into parsplana dentate process Areas of parsplana between two dentate process oral bay

 1. Intra-retinal Degenerations : microcystoid degenerations (Typical & Reticular) senile retinoschisis pars plana cysts 2. Retino-vitreal degenerations : Lattice degeneration Snail-track degeneration White with & without pressure 3. Chorioretinal degenerations : Paving stone degeneration diffuse chorioretinal degeneration

Peripheral retinal degenrations


Degenerations predisposing to retinal detachement Lattice degeneration Snail-track degeneration White without pressure degenerative retinoschisis tractional tufts


Degenerations not predisposing to retinal detachement paving stone degeneration microcystoid degeneration snow flake degeneration drusen honeycomb/reticular degeneration oral pigmentary degeneration

 Sharply demarcated , circumferentially oriented , spindle shaped area of retinal thinning between equator and vitreous base Discontinuity of ILM with variable atrophy of underlying sensory retina Supero-temporal region 6-8% of general population Bilateral in 50% MC in myopes Associated with Marfans , sticklers , Ehler-Danlos syndromes <1% of LD cause detachment

Lattice degeneration

Typical lattice
Network of white lines within spindle shaped islands of retinal thinning Variable RPE changes Small round holes within lesions are common

Varied presentations

complications

sequelae
Ischaemia within LD -> thinning -> atrophic holes -> condensation & adhesion of overlying pocket of liquified vitreous to the LD-> traction -> tears -> rhegmatogenous RD

Snail tract degenertion

Sharply demarcated circumferentially oriented bands of tightly packed snow flakes which give peripheral retina a white frost like appearance The islands are smaller than lattice Rarely associated with traction tears May be associated with large round holes

White with pressure

Distinctive milky white or opalescent appearance of the peripheral retina that is observed when examined with scleral depression Retina appears normal without depression It is common and seen in around 30 to 35% of eyes Infero-nasal quadrant least likely to be affected Incidence increases with age , no sex predilection Benign condition not associated with retinal breaks Must be carefully distinguished from a subclinical peripheral RD

White with out pressure

Distinctive white appearance of the peripheral retina without indentation Whiter than the retina in white with pressure and the choroidal markings are almost obscured Margins are sharply demarcated from normal retina Elderly and myopes Gaint retinal tear & RD may devalop at posterior border

Degenerative retinoschoisis
Splitting of sensory retina into outer ( choroidal ) layer inner ( vitreous ) layer Splitting occurs at the outer plexiform layer typical form nerve fibre layer reticular form Found in 5% of general population over 20yrs age 70% in hyperopic eyes B/L in 60-70%


Asymptomatic Starts in infero-temporal quadrants then progresses circumferentially & finally affects the entire periphery RD can occur only when outer retinal layer hole exists

Retinal tufts Cystic/non cystic / zonular retinal

traction tufts Cystic retinal traction tuft - congenital - small pyramid like projections of whitish retinal tissues into the vitreous cavity - cystic retinal degeneration occurs at the base of the tufts - severe vitreous traction may convulse a cystic tuft leading to RD Noncystic retinal tuft - smaller , acquired , more common ,doesnt predispose to RD


Zonular retinal traction tufts -congenital -usually single -Inferotemporal quadrant MC - found in the vitreous base & zonular fibres are attached to its apex -can cause significant retinal holes

 multiple rounded punched-out areas of choroidal and retinal atrophy Located between ora and equator with size of one to several disc diameters More common in infero-nasal and temporal quadrants Lesions are yellow-white in color with due to sclera being partly visible through the atrophic choroid . Large choroidal vessels seen running through the base Lesions have discrete margins which may be pigmented.- May become confluent Frequently bilateral, no sexual predilection increasingly common with age Benign lesions not associated with complications

Pavement stone degeneration

Snow flake degeneration

Multiple glistening yellowish white dots scattered diffusely in peripheral fundus Fibrillar condensation & liquefaction of vitreous is seen Associated with LD , SD , retinoschisis

Microcystoid degeneration Most frequent intra

retinaldegenerative lesion Characterized by small bubbles or vacuoles in the peripheral retina near ora These occur in the outer plexiform and inner nuclear layers of retina Mostly symmetrical, more in temporal retina than nasal, more superiorly than inferiorly Inner wall of a cyst may be absent giving impression of that of a retinal hole which is actually a pseudo-hole Does not predispose to retinal detachment

Reticular/honeycomb degeneration
Age related change Fine network of perivascular pigmentation which may extend posterior to the equator Caused by RPE degeneration Nasal quadrants

Reticular degeneration

microcystoid degeneration

Peripheral drusen
Often surrounded by rings of pigment Clusters of pale lesions surrounded by hyperpigmented borders

Parspalna cysts
Clear bullous elevation of non-pigmented ciliary epithelium of pars plana Usually more prominent temporally underneath the vitreous base Content is usually clear and has been found to contain hyaluronic acid Seen in 5 10 % of all eyes Bilateral in one third cases and show no sex predilection These are harmless lesions not associated with serious eye complications

management
In the absence of retinal breaks no prophylactic treatment is necessary unless following risk factors are present 1. RD in the fellow eye ( 10% risk in phakic , 20-36% in aphakic ) 2. Aphakia , pseudophakia , yag capsulotomy ( upto 3 fold more chance than phakics ) 3. High myopia 4. Strong family history of RD 5. An association with systemic disease

Treatment modalities
Cyrotherapy Slitlamp photocoagulation Indirect photocoagulation depends on location of lesion , clarity of media , pupil size

Laser photocoagulation
Smaller lesions , peripheral , equatorial , postequatorial lesions , dilated pupils Laser settings 200 micrometer spot size 0.1-0.2 seconds duration moderate intensity burns Surround the lesion with two rounds of confluent burns

cyrotherapy Preferred for larger areas , hazy

media and smaller pupils While viewing under indirect , gently indent the sclera with the tip of the probe Surround the lesion with single row of cryoapplication ( terminate freezing as soon as retina whitens ) New break formation can occur with in treated area due to excessive treatment