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  • 2020–2021 BCSC Basic and Clinical Science Course™

    Go to Academy Store Learn more and Purchase.

    12 Retina and Vitreous

    Part II: Disorders of the Retina and Vitreous

    Chapter 16: Retinal Detachment and Predisposing Lesions

    Retinal Breaks

    A retinal break is defined as any full-thickness defect in the neurosensory retina. Breaks are clinically significant in that they may allow liquid from the vitreous cavity to enter the potential space between the sensory retina and the RPE, thereby causing a rhegmatogenous retinal detachment. Some breaks are caused by atrophy of inner retinal layers (holes); others result from vitreoretinal traction (tears). Breaks resulting from trauma are discussed in the next section. Retinal breaks may be classified as

    • flap, or horseshoe, tears

    • giant retinal tears

    • operculated holes

    • retinal dialyses

    • atrophic retinal holes

    A flap tear occurs when a strip of retina is pulled anteriorly by vitreoretinal traction, often in the course of a posterior vitreous detachment or trauma. A tear is considered symptomatic when the patient reports photopsias, floaters, or both. A giant retinal tear extends 90° (3 clock-hours) or more circumferentially and usually occurs along the posterior edge of the vitreous base. An operculated hole occurs when traction is sufficient to tear a piece of retina completely free from the adjacent retinal surface. A retinal dialysis is a circumferential, linear break that occurs at the ora serrata, with vitreous base attached to the retina posterior to the tear’s edge; it is commonly a consequence of blunt trauma. An atrophic hole is generally not associated with vitreoretinal traction and has not been linked to an increased risk of retinal detachment.

    • American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. San Francisco: American Academy of Ophthalmology; 2014. Available at: www.aao.org/ppp.

    Traumatic Breaks

    Blunt or penetrating eye trauma can cause retinal breaks by direct retinal perforation, contusion, or vitreous traction. Fibrocellular proliferation occurring later at the site of an injury may cause vitreoretinal traction and subsequent detachment. Also see Chapter 18 in this volume.

    Blunt trauma can cause retinal breaks by direct contusive injury to the globe through 2 mechanisms: (1) coup, adjacent to the point of trauma, and (2) contrecoup, opposite the point of trauma. Blunt trauma compresses the eye along its anteroposterior axis and expands it in the equatorial plane. Because the vitreous body is viscoelastic, slow compression of the eye has no deleterious effect on the retina. However, rapid compression of the eye results in severe traction on the vitreous base that may tear the retina.

    Contusion injury may cause large, ragged equatorial breaks, dialysis, or a macular hole. Traumatic breaks are often multiple, and they are commonly found in the inferotemporal and superonasal quadrants. The most common injuries are dialyses, which may be as small as 1 ora bay (the distance between 2 retinal dentate processes at the latitude of the ora serrata) or may extend 90° or more. Dialyses are usually located at the posterior border of the vitreous base but can also occur at the anterior border (Fig 16-11; Activity 16-1). Avulsion of the vitreous base may be associated with dialysis and is considered pathognomonic of ocular contusion. The vitreous base can be avulsed from the underlying retina and nonpigmented epithelium of the pars plana without tearing either one; generally, however, one or both are also torn in the process. Less common types of breaks caused by blunt trauma are horseshoe-shaped tears (which may occur at the posterior margin of the vitreous base, at the posterior end of a meridional fold, or at the equator) and operculated holes.

    Figure 16-11 Schematic illustration of retinal tears and holes. Part 1, Retinal breaks at borders of the vitreous base. A, Avulsion of vitreous base that lies free in the vitreous cavity. B, Dialysis of the ora serrata. C, Retinal tear at the posterior border of the vitreous base. D, Retinal tear at the anterior border of the vitreous base. Part 2, Retinal breaks with areas of abnormal vitreoretinal interface (lattice degeneration). E, Lattice degeneration with holes. F, Round holes in atrophic retina. Part 3, Retinal breaks associated with abnormal vitreoretinal attachments. G, Horseshoe-shaped tear at the posterior end of a meridional fold. H, Horseshoe-shaped tear in the equatorial zone. I, Tear with operculum in the overlying vitreous. J, Horseshoeshaped tear associated with an anomalous posterior extension of the vitreous base.

    (Illustration by Mark M. Miller.)

    ACTIVITY 16-1 Anatomy marker activity: Retinal tears and holes.

    Courtesy of Mark M. Miller and Colin McCannel, MD.

    Access all Section 12 activities at www.aao.org/bcscactivity_section12.

    Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.

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