Retinal Holes and Tears
Retinal Holes and Tears
Atrophic Retinal Hole
An atrophy hole (retinal hole) is simply a full thickness degenerative loss of sensory retina as compared to an erosion or excavation which is a partial thickness loss of sensory retina. Since it is a simple degenerative process, it typically has a round configuration but sometimes it may be oval. The appearance is that of a round, red lesion (red at the base because of the increased view of the choriocapillaris). Sometimes there is a white collar which may represents a localized detachment (less than 1 disc diameter ((DD)) from the edge of the break) or encircling sensory retinal degeneration. The ability to be to see if the surrounding collar is detached will usually require scleral depression, a magnified view with a 3-mirror contact lens, precorneal lens with the slit lamp, or an OCT scan if it can be placed over the break. Retinal breaks are best seen with the green laser separation. The size varies from pinpoint to 1.5 DD. Atrophic holes are always found in areas of sensory retinal degeneration (most frequently found in lattice degeneration). They have about a 7% chance of progressing to a clinically significant detachment. They are most likely to be involved in a retinal detachment at the time of a PVD. Atrophic holes are not treated unless there are risk factors present (high myopia, vitreoretinal disease, occupation (boxer), family history of detachment, detachment in the fellow eye, intraocular surgery planned, etc).
Flap or Horseshoe Retinal Tear
A flap (horseshoe) tear results from vitreous traction that pulls a tear of sensory retina that almost always remains attached at the anterior margin of the break. However, occasionally, the flap may be pulled free (avulsed) and be seen as an elongated operculum floating above the break. The tearing of retina usually lifts the retina at the margins and thus, can produce white margins (sometimes known as wet margins). The most frequent cause of a flap tear is a PVD. The appearance is of a horseshoe-shaped red break with a flap pulled up into the vitreous cavity. The separated posterior vitreous cortex is usually attached to it (usually can’t be seen on ophthalmoscopy). Retinal breaks are best seen with the green laser separation. Flap tears are most often found between the ora serrata and the equator where the retina is thinner than in the posterior region. Because vitreous traction may have been pulling on the site (increased vitreoretinal adhesion) for months to years before the formation of a tear, this physical traction may cause reactive RPE hyperplasia in the retina. Therefore, pigment clumping may be present at the base of the tear or on the flap. Vitreous traction usually remains attached to the apex of the flap and thus, the chances of a detachment are significant. Sometimes there may be a white collar around the break that represents a localized detachment (less than 1 DD from the edge of the break). Symptomatic flap tears have been reported to have a 25% -90% incidence of progressing to a detachment. Therefore, essentially all flap tears are treated.
Operculated Retinal Tear
An operculated tear results from vitreous traction that pulls a plug of sensory retina out into the vitreous cavity (see illustration). The most frequent cause of an operculated tear is a PVD. The appearance is of a round (sometimes slightly out-of-round) red hole with an operculum (means cap) floating in the vitreous cavity internal to it and still attached to the separated posterior vitreous cortex. When the operculum is produced, this usually means that vitreous traction is released from the surface of the retina and thus, the chances of a detachment decrease significantly. Sometimes there may be a white collar around the hole that represents a localized detachment (less than 1 DD from the edge of the break). When the operculum is pulled into the vitreous cavity, it suffers degeneration and thus contracts to become smaller. These tears are most often found between the ora serrata and the equator where the retina is thinner than in the posterior region.
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