Atrophic Holes
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Disease Entity
Round hole of retina without detachment ICD-10 H33.32 (non-billable); retinal breaks without detachment ICD-10 H33.3 (billable)
Disease
An atrophic retinal hole is a break in the retina not associated with vitreoretinal traction.
Etiology and Risk Factors
Idiopathic atrophic retinal hole is the most common presentation. There are no generally accepted risk factors for this condition but lesions have been cited more often in younger myopic patients. It has been estimated about 5% of the general population has atrophic holes. Atrophic holes often present in the peripheral (temporal or superior) retina. There appears to be no sex predilection.
General Pathology
Atrophic retinal holes are full thickness retina breaks often existing in the peripheral retina. They are the result of atrophic changes/thinning within the sensory retina that is not induced by vitreous adhesions. Often, these lesions are found in association with lattice degeneration. The incidence of this association has been reported as high as 43%.
Pathophysiology
Retinal holes are the result of chronic atrophy of the sensory retina. These lesions often take a round or oval shape. It has been postulated that the pathogenesis of this lesion stems from an atrophic pigmented chorioretinopathy that is associated with retinal vessel sclerosis and a disturbance of the overlying vitreous. As the blood supply to the retina is shut down, the retinal tissue subsequently dies in conjunction with degeneration of the surrounding vitreous. This pathology precludes traction of the vitreous to the underlying sensory retina.
Primary prevention
There are no preventative measures to the development of atrophic retinal holes.
Diagnosis
This is a clinical diagnosis based on history and clinical exam, including slit lamp and dilated fundus examination.
History
Patients with atrophic retinal holes generally present for routine ocular examinations. This type of lesion is generally an incidental finding. Some patients may present with a complaint of photopsias (flashing lights) or other visual disturbance if associated with a symptomatic posterior vitreous detachment.
Physical examination
Slit lamp examination with special attention to the peripheral fundus is important in the evaluation of this disorder. An indirect ophthalmologic examination with scleral depression may be required to indentify retinal holes adjacent to the ora serrata.
Careful attention should be used when examining myopic patients and those patients with lattice degeneration due to the increased incidence in these populations.
Signs
Retinal holes are full thickness breaks in the sensory retina. They may be surrounded by pigmentation, especially if chronic and embedded withing a patch of lattice degeneration. As mentioned prior, they take a round or oval shape and lack a "tag" that is seen with a classic horseshoe tear. Subretinal fluid may accompany these lesions. Subretinal fluid, if present, may involve up to 360 degrees of the lesion's edge and spread slowly under the surrounding retina resulting in either a symptomatic or asymptomatic retinal detachment.
Symptoms
Atrophic holes are asymptomatic in a majority of patients. If associated with a retinal detachment patients may experience visual symptoms such as photopsias, floaters, or loss of visual field.
Clinical diagnosis
The diagnosis of an atrophic retinal hole is a clinical one. There are no studies currently used to diagnose or classify this type of retinal pathology. To differentiate this lesion from an operculated retinal hole, a clinician needs to look for an isolated detachment of the sensory retina adherent to the overlying vitreous without traction to the edges of the retinal hole. The absence of vitreoretinal traction, round/oval shape, and a free retinal flap will also assist in differentiating this lesion from a horseshoe retinal tear.
Diagnostic procedures
Atrophic retinal holes are diagnosed during routine clinical examination. Depending on how far into the peripheral retina the lesions are located a clinician has the option of using either direct or indirect ophthalmoscopy. Scleral depression is sometimes needed to fully assess the pathology.
Direct ophthalmolscopy utilizes a slit lamp for the examination and the choice of either a non contact 78 or 90 diopter lens (various other similar lenses are available) versus a Goldmann triple mirror contact lens. The 78 and 90 diopter lens provides an image of the retina which is best for viewing the posterior pole and mid periphery of the fundus. A skilled physician can often times manipulate the slit lamp and provide patient direction which allows for a good view of the peripheral fundus. The Goldmann triple mirror lens is designed specifically to allow for a broader view of the fundus to include the posterior pole and extend out to the ora serrata and ciliary body. Other wide angle contact lenses can be used as well.
Widefield funduscopic photography (e.g., Optos) can be beneficial in documenting atrophic retinal holes.
Laboratory test
No laboratory tests are indicated in cases of atrophic retinal holes.
Differential diagnosis
The clinical appearance of atrophic retinal holes is very characteristic. Despite this there are several possible diagnoses that should be considered which include horseshoe retinal tear, lattice degeneration, operculated retinal hole, snailtrack degeneration, and retinoschisis. Sometimes round area of normal retina when surrounded by white without pressure may appear like a retinal hole on clinical examination.
Management
General treatment
There is no mandatory therapy for this condition in general. According to the Preferred Practice Patterns set forth by the American Academy of Ophthalmology, treatment is rarely recommended for atrophic retinal holes. Some studies suggest that prophylactic laserpexy may be considered for eyes with retinal holes when there are active symptoms, when there is accompanying subretinal fluid, or when a retinal detachment already exists in the patient’s fellow eye.
Medical therapy
There is currently no medical therapy required for this condition.
Medical follow up
See above. Return and retinal detachment precautions should be carefully discussed with these patients, especially since many of them have concurrent myopia and lattice degeneration which increase the risk of a retinal detachment.
Surgery
Surgical procedures (laserpexy) are rarely recommended for this condition. See above.
However, if there is documented progression of subretinal fluid around the hole, most retina specialists will recommend barricade laser.
When atrophic holes are the primary cause of macula off/ macula threatening retinal detachment in young, phakic patients without a posterior vitreous detachment present, scleral buckling may be preferred over vitrectomy.
Surgery (buckling or vitrectomy) should also be considered in retinal detachment approaching the arcade, though laser delimitation may also be an option.
Prognosis
The prognosis for atrophic retinal holes is good. There is a low risk of retinal detachments in patient with round holes, and the incidence of atrophic holes in the general population is low as well.
References
- Kanski, Jack. Clinical Ophthalmology 5th edition. Butterworth-Heinemann; 2003:359-371
- Preferred Practice Patterns: Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. AAO 2008
- Byer N. Subclinical Retinal Detachment Resulting from Asymptomatic Retinal Breaks. Ophthalmology 2001; 108:1499-1504
- Gonzales C,Gupta A, Schwartz S,et al.The fellow eye of patients with phakic rhegmatogenous retinal detachment from atrophic holes of lattice degeneration without posterior vitreous detachment. Br J Ophthalmol 2004 88: 1400-1402
- Michaelson I. Role of a Distinctive Choroido-retinal Lesion in the Pathogenesis of Retinal Hole: A Clinical and Pathological Report. Br J Ophthalmol 1956 40: 527-535
- Sigelman J. Vitreous Base Classification of Retinal Tears: Clinical Application. Surv Ophthalmol 25:59-74, 1980
