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Lattice Degeneration of the Retina and Retinal Detachment
LATTICE DEGENERATION OF T H E RETINA AND R E T I N A L DETACHMENT PETER H.
J lORSE, M . D .
Philadelphia, Pennsylvania
Lattice degeneration, also known as pe ripheral palisade-like degeneration, snail tracks, circumferential or equatorial degen eration, occurs in from 6 to 8% of the population and is seen in from 20 to 3 1 % of patients with rhegmatogenous retinal separation. Usually, the lesions of lattice degeneration are oval, sharply demarcated, and circumferentially oriented at the equator or anterior to the equator. These patches of retinal thinning are frequently darkly pigmented. An arborizing network of white lines, often continuous with retinal blood vessels, pri marily venules, overlying liquefied vitreous, and vitreous traction at the margins of the lesions are commonly seen. The lattice patches often have a frosting of glistening, small, yellow-white dots on their surface. The lesions may be present in two, three, or four circumferentially parallel rows, or they may be radially oriented and posterior to the equator in some cases. Lattice degeneration is more common in the temporal than nasal quadrants, is more frequent superiorly than inferiorly, and has a predilection to occur in both eyes. The types of holes responsible for retinal detachment found in lattice degeneration are single or multiple round "trophic" holes within the patches of lattice, crescentic breaks at the extremity of a patch of lattice, From the Retina Service of the Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania School of Medicine and Presby terian-University of Pennsylvania Medical Center, Philadelphia, Pennsylvania. This study was sup ported in part by an unrestricted grant from P r e vent Blindness (Research to Prevent Blindness, Inc.). Presented in part before the University of Pennsylvania Ophthalmological Alumni Associa tion meeting, May 11, 1974. Reprint requests to Peter H. Morse, M.D., Scheie Eve Institute, Myrin Circle, SI N. 39th St., Philadelphia, P A 19104.
which look much like circumferentially ori ented horseshoe tears, and tears along the posterior margin of an island of lattice de generation. Horseshoe tears with a patch of lattice entirely within the flap are also seen and may represent a variation of posterior margin breaks. Some authors feel that mas sive preretinal retraction is more common in retinal detachments with lattice degenera tion.1-11 The purpose of this paper is to analyze 100 consecutive primary, nontraumatic, rheg matogenous lattice retinal detachment pa tients with respect to the type of break caus ing the detachment and to compare the ages and refractive errors of both lattice and nonlattice, phakic and aphakic primary, nontraumatic rhegmatogenous retinal detach ment patients. A group of patients with lat tice degeneration without retinal separation is analyzed as to age and refractive error for comparison. CLINICAL DATA
The total number of primary, nontraumatic, rhegmatogenous, lattice and nonlattice, retinal detachment patients was 260 with six bilateral cases (2.3%), for a total of 266 eyes. Three bilateral cases with one aphakic detachment in each set were found in both the lattice and nonlattice groups. The 105 aphakic retinal detachments were 40.4% of the total number of primary retinal de tachments. The 260 patients, 135 male and 125 fe male, ranged in age from 7 to 83 years with an average age of 57.9 years. The nonlattice retinal detachment patients numbered 160 (61.5%), 85 male and 75 fe male, with an age range of 7 to 83 years and an average age of 62.1 years. Eighty-two (51.3%) of the nonlattice de tachment patients were phakic, 39 male and
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43 female, ranging in age from 7 to 77 years These phakic patients, 36 male and 37 fe male, ranged from 15 to 80 years old with with an average age of 60.8 years. There were 78 aphakic nonlattice detach an average age of 62 years. Twenty-seven lattice patients (27%) with ment patients (48.8%), 45 men and 33 women, with an age range of 31 to 83 years, primary retinal separations were aphakic. These individuals accounted for 25.7% of the averaging 63.5 years of age. The total number of lattice patients was total number of aphakic retinal detachments 161, 84 male and 77 female, with an age in this series. Among the 27 patients, there range from 15 to 80 years and an average were 14 men and 13 women, ranging in age from 48 to 80 years with an average age of age of 48.4 years. Sixty-one patients (37.9%), 34 male and 61.9 years. 27 female, ranging from 15 to 73 years old There were only four aphakes (7%) with with an average age of 44 years, had lattice lattice degeneration without retinal separa degeneration without retinal separation. tion, two men and two women, 56 to 72 years Of the 161 patients with lattice degenera old, averaging 65 years old. In 103 eyes (100 patients), the type of tion, 107 (66.5%), 62 male and 45 female, aged 15 to 77 years with an average age of hole responsible for primary, rhegmato 46.4 years, had lattice degeneration in both genous retinal separation in lattice degenera tion was round in 42 eyes (40.8%), a break eyes. The primary lattice retinal detachment pa along the posterior margin of an island of tients numbered 100, or 38.5% of all pri lattice in 12 eyes (11.7%), a crescentic break mary, nontraumatic, rhegmatogenous retinal on the extremity of an island of lattice in detachments. There were 50 men and 50 nine eyes (8.7%), mixed pure lattice breaks women, ranging in age from 15 to 80 years (round, posterior margin, and crescentic) in with an average age of 51 years. Twelve pa ten eyes (9.7%), mixed lattice and nontients (12%) with primary retinal detach lattice breaks (predominantly horseshoe tears ments secondary to lattice degeneration had not in or near patches of lattice) in 26 eyes subclinical retinal detachments in the fellow (25.2%), and horseshoe tears with a patch of lattice entirely within the flap in four eye. Twenty-four (24%) of the primary retinal eyes (3.9%). detachment patients with lattice, 13 male and In 28 eyes (27 patients), primary aphakic 11 female, were less than 40 years old, with detachments associated with lattice degenera a range of 15 to 39 years and an average tion showed round breaks in six eyes age of 25.5 years. (21.4%), posterior margin breaks in two Among the 161 patients with lattice, an eyes (7.1%), crescentic breaks in three eyes additional 22 (13.7%), 15 men and seven (10.7%), mixed pure lattice breaks in three women, aged 21 to 74 years and an average eyes (10.7%), mixed lattice and nonlattice age of 49.9 years, had a history of previous breaks in 12 eyes (42.9%), and horseshoe scleral buckling operation in one eye prior tears with a patch of lattice in the flap in to examination at the Scheie Eye Institute. two eyes (7.1%). Sixty-three patients (63%) with primary In 103 eyes, the quadrants of the retina rhegmatogenous retinal separation and lat most frequently detached in primary lattice tice, 33 male and 30 female, with a 15- to retinal detachments were superotemporal in 77-year age range and an average age of 79 eyes (76.7%), inferotemporal in 59 eyes 49.3 years, had lattice degeneration in both (57.3%), superonasal in 53 eyes (51.5%), eyes. and inferonasal in 44 eyes (42.7%). Seven Of the 100 primary retinal detachment pa teen eyes (16.5%) were totally detached. tients with lattice, 73 (73%) were phakic. The number of holes in primary lattice
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TABLE 1
TABLE 2
REFRACTIVE ERROR IN PHAKIC PRIMARY NONTRAUMATIC RHEGMATOGENOUS RETINAL DETACHMENT PATIENTS
REFRACTIVE ERROR IN A P H A K I C PRIMARY NONTRAUMATIC RHEGMATOGENOUS R E T I N A L DETACHMENT P A T I E N T S
Refractive Spherical Equivalent > +8.00 > +4.00 to +8.00 >+2.00 to+4.00 +0.12 to +2.00 Piano - 0 . 1 2 to - 2 . 0 0 >-2.00 to-4.00 > - 4 . 0 0 to - 8 . 0 0 > -8.00 Total
Nonlattice No. of Eyes
„
/o
0 0 4 4.8 8 9.5 22 26.2 8 9.5 21 25.0 11 13.1 7 8.3 3 3.6 84 100 (82 patients)
Lattice No. of Eyes
of
/o
0 0 0 0 2 2.7 14 18.7 5 6.7 10 13.3 11 14.7 23 30.7 10 13.3 75 100 (73 patients)
detachments was one in 35 eyes (34%), two in 23 eyes (22.3%), three in eight eyes (7.8%), four in seven eyes (6.8%), five in 12 eyes (11.7%), and greater than five in 18 eyes (17.5%). The refractive error in the phakic primary nontraumatic, nonlattice, rhegmatogenous retinal detachment patients showed a slight preponderance of myopes, whereas the phakic lattice retinal detachment patients showed a much greater shift toward a my opic refractive error. All refractive errors were reduced to the spherical equivalent (Table 1). Among the aphakic lattice and nonlattice detachment patients there was little differ ence in the refractive error. In the four pa tients with a pronounced myopic shift in the aphakic correction of less than +1.50 diop ters, all were in the nonlattice group of aphakes (Table 2). The phakic lattice patients without retinal separation showed a moderate shift toward a myopic refractive error (Table 3). This myopic shift persisted even after excluding the 19 phakic patients who had previously undergone scleral buckling opera tions for retinal detachment in the fellow eye. Twelve of these patients had refractions ranging from —0.25 to —15.00 diopters,
Refractive Spherical Equivalent
Nonlattice No. of Eyes
>+12.00 > + 1 0 . 0 0 to + 12.00 >+8.00to+10.0C 1 > +6.00 to +8.00 +4.00 t o + 6 . 0 0 +2.00 t o + 3 . 8 7 + 1.50 -4.50 -7.00 Total
21
Lattice
of /o
No. of Eyes
of
26.3
8
28.6
35.0 28 20.0 16 7.5 6 3.8 3 2.5 2 2.5 2 1.3 1 1.3 1 100 80 (78 patients)
/o
9 32.1 6 21.4 2 7.1 2 7.1 1 3.6 0 0 0 0 0 0 28 100 (27 patients)
with ten having a greater than —3.75 diopter myopic refractive error (Table 4). The three aphakic patients with prior his tory of scleral buckling operation on the fellow eye had refractive errors of +4.00, + 10.50, and +12.00 diopters. The four aphakic patients without pre vious history of scleral buckling operations in the lattice group without retinal separation had refractive errors of +7.00, +8.00, + 11.37, and +12.25 diopters. DISCUSSION 7
Schepens did not find equatorial latticeTABLE 3 REFRACTIVE ERROR IN PHAKIC LATTICE PATIENTS WITHOUT RETINAL DETACHMENT
Refractive Spherical Equivalent
No. of Patients
%
>+8.00 > + 4 . 0 0 to +8.00 > +2.00 to +4.00 +0.12 t o + 2 . 0 0 Piano - 0 . 1 2 to - 2 . 0 0 > - 2 . 0 0 to - 4 . 0 0 > - 4 . 0 0 to - 8 . 0 0 >-8.00 Total
0 0 2 11 8 7 7 10 12 57
0 0 3.5 19.3 14.0 12.3 12.3 17.5 21.1 100
V O L . 78, N O . 6
LATTICE DEGENERATION
like degeneration particularly associated with myopia. Straatsma and Allen1 noted a myopic shift in the refractive error of 31 patients with lattice degeneration operated on for retinal detachment or prophylactic treatment. Byer2 also noted a slight shift to the myopic side in 92 patients with lattice degeneration. In this series, the refractive error in phakic retinal detachment patients with lattice degeneration shows a shift to the myopic side, especially in the range of greater than — 4.00 diopters. The tendency to retinal separation is greater in the lattice myopes with a spherical equivalent refractive error greater than —4.00 diopters than in the phakic detachment series without lattice de generation. The refractive error in the nondetachment lattice patients also shows a myopic shift. This tendency persists when the 19 lattice patients previously operated for retinal de tachment in one eye are excluded from the group. Ten of the 19 patients (52.6%) had a spherical equivalent refractive error of greater than —3.75 diopters. Interestingly, the aphakic retinal detach ments showed relatively little difference be tween the lattice and nonlattice groups in the spherical equivalent refractive errors. The most frequent type of break responsi ble for retinal separation in patients with lattice degeneration has received scant attenTABLE 4 REFRACTIVE ERROR IN 38 PHAKIC NONDETACHMENT LATTICE PATIENTS OMITTING 1 9 PATIENTS WITH PREVIOUS SCLEUAL BUCKLING
Refractive Spherical Equivalent
No. of Eyes
%
> +8.00 >+4.00 to+8.00 > +2.00 to +4.00 +0.12 t o + 2 . 0 0 Piano - 0 . 1 2 to - 2 . 0 0 > - 2 . 0 0 to - 4 . 0 0 > - 4 . 0 0 to - 8 . 0 0 >-8.00 Total
0 0 0 9 5 5 5 6 8 38
0 0 0 23.7 13.2 13.2 13.2 15.8 21.1 100
933
tion. Diimas and Schepens6 made particular mention of "horseshoe" or crescentic retinal tears found along the edge of degenerated retina. They noted 40 horseshoe tears found in 30 eyes with lattice degeneration, 33 of which (82.5%) were closely related to is lands of lattice degeneration. They also found that horseshoe tears located around islands of lattice were almost equally di vided between those found at one extremity of the patch of lattice and those located at the posterior ettge, which is corroborated by our data. In this report, the round trophic holes within patches of lattice degeneration were predominantly responsible for retinal separa tion in phakic lattice patients. They were also the second most common type of break in aphakic lattice detachments and the most common cause in the aphakic lattice group of patients with respect to detachments caused by pure lattice breaks. In the aphakic lattice group, the mixed lattice and nonlattice breaks (predominantly horseshoe breaks not associ ated with patches of lattice) were the most common Underlying cause of retinal detach ment. This category of mixed lattice and ndhlattice breaks was the second most common type in the phakic group of lattice detach ments and points up the danger of vitreous traction in nondegenerated foci of the retina in this combined vitreoretinal degeneration. The more frequent findings of horseshoe tears in addition to lattice breaks in the aphakic patients may well relate to greater vitreous mobility after cataract extraction, which predisposes to retinal traction tears. Patients with lattice degeneration and reti nal detachment have a younger age range than the nonlattice detachment patients. Lat tice with and without detachment is common ly seen in patients younger than 40 years old. Of special note is the 24% incidence among lattice retinal detachlnent patients of indi viduals less than 40 years old with an aver age age of 25.5 years. The average age of all lattice retinal de tachment patients was 51 years, compared to
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62.1 years for nonlattice detachments. T h e aphakic nonlattice patients averaged 63.5 years, whereas the aphakic lattice patients averaged 61.9 years, showing little difference between the two groups. However, aphakic lattice retinal separation accounted for 25.7% of all aphakic retinal detachments in this series, which emphasized the danger of lattice degeneration in aphakes and patients being considered for cataract surgery. These data should encourage strong con sideration of prophylactic cryoretinopexy in young active patients with lattice degenera tion and holes, especially with small subclinical detachments, as well as in young or old patients with lattice degeneration who are aphakic or being considered for cataract ex traction. These data also point out that the round trophic holes in islands of lattice degenera tion are not entirely benign and are a promi nent underlying cause of retinal detachment in lattice patients. Frequently, in discussions of prophylactic cryoretinopexy, round holes are dismissed as being low risk, and no distinction is made between isolated round holes and round holes associated with lattice degeneration which carry a more guarded prognosis. SUMMARY
One hundred patients with lattice de generation of the retina and phakic and aphakic retinal detachments were analyzed and compared to 160 patients with nonlattice phakic and aphakic retinal detachments. Sig nificant findings included the younger age of phakic retinal detachment patients with lat tice degeneration and a high risk of aphakic retinal detachment in patients with lattice
DECEMBER, 1974
degeneration. A myopic shift of the refrac tive error occurred in phakic lattice detach ment patients as well as in lattice patients without retinal separation. The round trophic hole was the most common type of retinal break in phakic lattice detachments and the second most common type of break in aphakic lattice detachment. T h e most com mon breaks in aphakic lattice detachments included mixed lattice and nonlattice breaks, with the nonlattice breaks almost invariably being horseshoe tears not associated with patches of lattice degeneration. REFERENCES
1. Straatsma, B. R., and Allen, R. A . : Lattice degeneration of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 66:600, 1962. 2. Byer, N. E . : Clinical study of lattice degenera tion of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 69:1064, 1965. 3. Michaelson, I. C.: Role of a distinctive choroido-retinal lesion in the pathogenesis of retinal hole. Br. J. Ophthalmol. 40:527, 1956. 4. Halpern, J. I . : Routine screening of the retinal periphery. Am. J. Ophthalmol. 62 :99, 1966. 5. Okun, E . : Gross and microscopic pathology in autopsy eyes. 3. Retinal breaks without detach ment. Am. J. Ophthalmol. 51:369, 1961. 6. Dumas, J., and Schepens, C. L.: Chorioretinal lesions predisposing to retinal breaks. Am. J. Ophthalmol. 61:620, 1966. 7. Schepens, C. L . : Subclinical retinal detach ments. Arch. Ophthalmol. 47:593, 1952. 8. Boniuk, M., and Butler, F. C.: An autopsy study of lattice degeneration, retinal breaks and retinal pits. In McPherson, A. (ed.) : New and Controversial Aspects of Retinal Detachment. New York, Hoeber, 1968, p. 59. 9. Meyer-Schwickerath, G.: Indications and limitations of light coagulation of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 63:725, 1959. 10. Tolentino, F. I., Schepens, C. L., and Free man, H. M. : Massive preretinal retraction. Arch. Ophthalmol. 78:16, 1967. 11. Streeten, B. W., and Bert, M.: The retinal surface in lattice degeneration of the retina. Am. J. Ophthalmol. 74:1201, 1972.
J lORSE, M . D .
Philadelphia, Pennsylvania
Lattice degeneration, also known as pe ripheral palisade-like degeneration, snail tracks, circumferential or equatorial degen eration, occurs in from 6 to 8% of the population and is seen in from 20 to 3 1 % of patients with rhegmatogenous retinal separation. Usually, the lesions of lattice degeneration are oval, sharply demarcated, and circumferentially oriented at the equator or anterior to the equator. These patches of retinal thinning are frequently darkly pigmented. An arborizing network of white lines, often continuous with retinal blood vessels, pri marily venules, overlying liquefied vitreous, and vitreous traction at the margins of the lesions are commonly seen. The lattice patches often have a frosting of glistening, small, yellow-white dots on their surface. The lesions may be present in two, three, or four circumferentially parallel rows, or they may be radially oriented and posterior to the equator in some cases. Lattice degeneration is more common in the temporal than nasal quadrants, is more frequent superiorly than inferiorly, and has a predilection to occur in both eyes. The types of holes responsible for retinal detachment found in lattice degeneration are single or multiple round "trophic" holes within the patches of lattice, crescentic breaks at the extremity of a patch of lattice, From the Retina Service of the Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania School of Medicine and Presby terian-University of Pennsylvania Medical Center, Philadelphia, Pennsylvania. This study was sup ported in part by an unrestricted grant from P r e vent Blindness (Research to Prevent Blindness, Inc.). Presented in part before the University of Pennsylvania Ophthalmological Alumni Associa tion meeting, May 11, 1974. Reprint requests to Peter H. Morse, M.D., Scheie Eve Institute, Myrin Circle, SI N. 39th St., Philadelphia, P A 19104.
which look much like circumferentially ori ented horseshoe tears, and tears along the posterior margin of an island of lattice de generation. Horseshoe tears with a patch of lattice entirely within the flap are also seen and may represent a variation of posterior margin breaks. Some authors feel that mas sive preretinal retraction is more common in retinal detachments with lattice degenera tion.1-11 The purpose of this paper is to analyze 100 consecutive primary, nontraumatic, rheg matogenous lattice retinal detachment pa tients with respect to the type of break caus ing the detachment and to compare the ages and refractive errors of both lattice and nonlattice, phakic and aphakic primary, nontraumatic rhegmatogenous retinal detach ment patients. A group of patients with lat tice degeneration without retinal separation is analyzed as to age and refractive error for comparison. CLINICAL DATA
The total number of primary, nontraumatic, rhegmatogenous, lattice and nonlattice, retinal detachment patients was 260 with six bilateral cases (2.3%), for a total of 266 eyes. Three bilateral cases with one aphakic detachment in each set were found in both the lattice and nonlattice groups. The 105 aphakic retinal detachments were 40.4% of the total number of primary retinal de tachments. The 260 patients, 135 male and 125 fe male, ranged in age from 7 to 83 years with an average age of 57.9 years. The nonlattice retinal detachment patients numbered 160 (61.5%), 85 male and 75 fe male, with an age range of 7 to 83 years and an average age of 62.1 years. Eighty-two (51.3%) of the nonlattice de tachment patients were phakic, 39 male and
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43 female, ranging in age from 7 to 77 years These phakic patients, 36 male and 37 fe male, ranged from 15 to 80 years old with with an average age of 60.8 years. There were 78 aphakic nonlattice detach an average age of 62 years. Twenty-seven lattice patients (27%) with ment patients (48.8%), 45 men and 33 women, with an age range of 31 to 83 years, primary retinal separations were aphakic. These individuals accounted for 25.7% of the averaging 63.5 years of age. The total number of lattice patients was total number of aphakic retinal detachments 161, 84 male and 77 female, with an age in this series. Among the 27 patients, there range from 15 to 80 years and an average were 14 men and 13 women, ranging in age from 48 to 80 years with an average age of age of 48.4 years. Sixty-one patients (37.9%), 34 male and 61.9 years. 27 female, ranging from 15 to 73 years old There were only four aphakes (7%) with with an average age of 44 years, had lattice lattice degeneration without retinal separa degeneration without retinal separation. tion, two men and two women, 56 to 72 years Of the 161 patients with lattice degenera old, averaging 65 years old. In 103 eyes (100 patients), the type of tion, 107 (66.5%), 62 male and 45 female, aged 15 to 77 years with an average age of hole responsible for primary, rhegmato 46.4 years, had lattice degeneration in both genous retinal separation in lattice degenera tion was round in 42 eyes (40.8%), a break eyes. The primary lattice retinal detachment pa along the posterior margin of an island of tients numbered 100, or 38.5% of all pri lattice in 12 eyes (11.7%), a crescentic break mary, nontraumatic, rhegmatogenous retinal on the extremity of an island of lattice in detachments. There were 50 men and 50 nine eyes (8.7%), mixed pure lattice breaks women, ranging in age from 15 to 80 years (round, posterior margin, and crescentic) in with an average age of 51 years. Twelve pa ten eyes (9.7%), mixed lattice and nontients (12%) with primary retinal detach lattice breaks (predominantly horseshoe tears ments secondary to lattice degeneration had not in or near patches of lattice) in 26 eyes subclinical retinal detachments in the fellow (25.2%), and horseshoe tears with a patch of lattice entirely within the flap in four eye. Twenty-four (24%) of the primary retinal eyes (3.9%). detachment patients with lattice, 13 male and In 28 eyes (27 patients), primary aphakic 11 female, were less than 40 years old, with detachments associated with lattice degenera a range of 15 to 39 years and an average tion showed round breaks in six eyes age of 25.5 years. (21.4%), posterior margin breaks in two Among the 161 patients with lattice, an eyes (7.1%), crescentic breaks in three eyes additional 22 (13.7%), 15 men and seven (10.7%), mixed pure lattice breaks in three women, aged 21 to 74 years and an average eyes (10.7%), mixed lattice and nonlattice age of 49.9 years, had a history of previous breaks in 12 eyes (42.9%), and horseshoe scleral buckling operation in one eye prior tears with a patch of lattice in the flap in to examination at the Scheie Eye Institute. two eyes (7.1%). Sixty-three patients (63%) with primary In 103 eyes, the quadrants of the retina rhegmatogenous retinal separation and lat most frequently detached in primary lattice tice, 33 male and 30 female, with a 15- to retinal detachments were superotemporal in 77-year age range and an average age of 79 eyes (76.7%), inferotemporal in 59 eyes 49.3 years, had lattice degeneration in both (57.3%), superonasal in 53 eyes (51.5%), eyes. and inferonasal in 44 eyes (42.7%). Seven Of the 100 primary retinal detachment pa teen eyes (16.5%) were totally detached. tients with lattice, 73 (73%) were phakic. The number of holes in primary lattice
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DECEMBER, 1974
TABLE 1
TABLE 2
REFRACTIVE ERROR IN PHAKIC PRIMARY NONTRAUMATIC RHEGMATOGENOUS RETINAL DETACHMENT PATIENTS
REFRACTIVE ERROR IN A P H A K I C PRIMARY NONTRAUMATIC RHEGMATOGENOUS R E T I N A L DETACHMENT P A T I E N T S
Refractive Spherical Equivalent > +8.00 > +4.00 to +8.00 >+2.00 to+4.00 +0.12 to +2.00 Piano - 0 . 1 2 to - 2 . 0 0 >-2.00 to-4.00 > - 4 . 0 0 to - 8 . 0 0 > -8.00 Total
Nonlattice No. of Eyes
„
/o
0 0 4 4.8 8 9.5 22 26.2 8 9.5 21 25.0 11 13.1 7 8.3 3 3.6 84 100 (82 patients)
Lattice No. of Eyes
of
/o
0 0 0 0 2 2.7 14 18.7 5 6.7 10 13.3 11 14.7 23 30.7 10 13.3 75 100 (73 patients)
detachments was one in 35 eyes (34%), two in 23 eyes (22.3%), three in eight eyes (7.8%), four in seven eyes (6.8%), five in 12 eyes (11.7%), and greater than five in 18 eyes (17.5%). The refractive error in the phakic primary nontraumatic, nonlattice, rhegmatogenous retinal detachment patients showed a slight preponderance of myopes, whereas the phakic lattice retinal detachment patients showed a much greater shift toward a my opic refractive error. All refractive errors were reduced to the spherical equivalent (Table 1). Among the aphakic lattice and nonlattice detachment patients there was little differ ence in the refractive error. In the four pa tients with a pronounced myopic shift in the aphakic correction of less than +1.50 diop ters, all were in the nonlattice group of aphakes (Table 2). The phakic lattice patients without retinal separation showed a moderate shift toward a myopic refractive error (Table 3). This myopic shift persisted even after excluding the 19 phakic patients who had previously undergone scleral buckling opera tions for retinal detachment in the fellow eye. Twelve of these patients had refractions ranging from —0.25 to —15.00 diopters,
Refractive Spherical Equivalent
Nonlattice No. of Eyes
>+12.00 > + 1 0 . 0 0 to + 12.00 >+8.00to+10.0C 1 > +6.00 to +8.00 +4.00 t o + 6 . 0 0 +2.00 t o + 3 . 8 7 + 1.50 -4.50 -7.00 Total
21
Lattice
of /o
No. of Eyes
of
26.3
8
28.6
35.0 28 20.0 16 7.5 6 3.8 3 2.5 2 2.5 2 1.3 1 1.3 1 100 80 (78 patients)
/o
9 32.1 6 21.4 2 7.1 2 7.1 1 3.6 0 0 0 0 0 0 28 100 (27 patients)
with ten having a greater than —3.75 diopter myopic refractive error (Table 4). The three aphakic patients with prior his tory of scleral buckling operation on the fellow eye had refractive errors of +4.00, + 10.50, and +12.00 diopters. The four aphakic patients without pre vious history of scleral buckling operations in the lattice group without retinal separation had refractive errors of +7.00, +8.00, + 11.37, and +12.25 diopters. DISCUSSION 7
Schepens did not find equatorial latticeTABLE 3 REFRACTIVE ERROR IN PHAKIC LATTICE PATIENTS WITHOUT RETINAL DETACHMENT
Refractive Spherical Equivalent
No. of Patients
%
>+8.00 > + 4 . 0 0 to +8.00 > +2.00 to +4.00 +0.12 t o + 2 . 0 0 Piano - 0 . 1 2 to - 2 . 0 0 > - 2 . 0 0 to - 4 . 0 0 > - 4 . 0 0 to - 8 . 0 0 >-8.00 Total
0 0 2 11 8 7 7 10 12 57
0 0 3.5 19.3 14.0 12.3 12.3 17.5 21.1 100
V O L . 78, N O . 6
LATTICE DEGENERATION
like degeneration particularly associated with myopia. Straatsma and Allen1 noted a myopic shift in the refractive error of 31 patients with lattice degeneration operated on for retinal detachment or prophylactic treatment. Byer2 also noted a slight shift to the myopic side in 92 patients with lattice degeneration. In this series, the refractive error in phakic retinal detachment patients with lattice degeneration shows a shift to the myopic side, especially in the range of greater than — 4.00 diopters. The tendency to retinal separation is greater in the lattice myopes with a spherical equivalent refractive error greater than —4.00 diopters than in the phakic detachment series without lattice de generation. The refractive error in the nondetachment lattice patients also shows a myopic shift. This tendency persists when the 19 lattice patients previously operated for retinal de tachment in one eye are excluded from the group. Ten of the 19 patients (52.6%) had a spherical equivalent refractive error of greater than —3.75 diopters. Interestingly, the aphakic retinal detach ments showed relatively little difference be tween the lattice and nonlattice groups in the spherical equivalent refractive errors. The most frequent type of break responsi ble for retinal separation in patients with lattice degeneration has received scant attenTABLE 4 REFRACTIVE ERROR IN 38 PHAKIC NONDETACHMENT LATTICE PATIENTS OMITTING 1 9 PATIENTS WITH PREVIOUS SCLEUAL BUCKLING
Refractive Spherical Equivalent
No. of Eyes
%
> +8.00 >+4.00 to+8.00 > +2.00 to +4.00 +0.12 t o + 2 . 0 0 Piano - 0 . 1 2 to - 2 . 0 0 > - 2 . 0 0 to - 4 . 0 0 > - 4 . 0 0 to - 8 . 0 0 >-8.00 Total
0 0 0 9 5 5 5 6 8 38
0 0 0 23.7 13.2 13.2 13.2 15.8 21.1 100
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tion. Diimas and Schepens6 made particular mention of "horseshoe" or crescentic retinal tears found along the edge of degenerated retina. They noted 40 horseshoe tears found in 30 eyes with lattice degeneration, 33 of which (82.5%) were closely related to is lands of lattice degeneration. They also found that horseshoe tears located around islands of lattice were almost equally di vided between those found at one extremity of the patch of lattice and those located at the posterior ettge, which is corroborated by our data. In this report, the round trophic holes within patches of lattice degeneration were predominantly responsible for retinal separa tion in phakic lattice patients. They were also the second most common type of break in aphakic lattice detachments and the most common cause in the aphakic lattice group of patients with respect to detachments caused by pure lattice breaks. In the aphakic lattice group, the mixed lattice and nonlattice breaks (predominantly horseshoe breaks not associ ated with patches of lattice) were the most common Underlying cause of retinal detach ment. This category of mixed lattice and ndhlattice breaks was the second most common type in the phakic group of lattice detach ments and points up the danger of vitreous traction in nondegenerated foci of the retina in this combined vitreoretinal degeneration. The more frequent findings of horseshoe tears in addition to lattice breaks in the aphakic patients may well relate to greater vitreous mobility after cataract extraction, which predisposes to retinal traction tears. Patients with lattice degeneration and reti nal detachment have a younger age range than the nonlattice detachment patients. Lat tice with and without detachment is common ly seen in patients younger than 40 years old. Of special note is the 24% incidence among lattice retinal detachlnent patients of indi viduals less than 40 years old with an aver age age of 25.5 years. The average age of all lattice retinal de tachment patients was 51 years, compared to
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AMERICAN JOURNAL OF OPHTHALMOLOGY
62.1 years for nonlattice detachments. T h e aphakic nonlattice patients averaged 63.5 years, whereas the aphakic lattice patients averaged 61.9 years, showing little difference between the two groups. However, aphakic lattice retinal separation accounted for 25.7% of all aphakic retinal detachments in this series, which emphasized the danger of lattice degeneration in aphakes and patients being considered for cataract surgery. These data should encourage strong con sideration of prophylactic cryoretinopexy in young active patients with lattice degenera tion and holes, especially with small subclinical detachments, as well as in young or old patients with lattice degeneration who are aphakic or being considered for cataract ex traction. These data also point out that the round trophic holes in islands of lattice degenera tion are not entirely benign and are a promi nent underlying cause of retinal detachment in lattice patients. Frequently, in discussions of prophylactic cryoretinopexy, round holes are dismissed as being low risk, and no distinction is made between isolated round holes and round holes associated with lattice degeneration which carry a more guarded prognosis. SUMMARY
One hundred patients with lattice de generation of the retina and phakic and aphakic retinal detachments were analyzed and compared to 160 patients with nonlattice phakic and aphakic retinal detachments. Sig nificant findings included the younger age of phakic retinal detachment patients with lat tice degeneration and a high risk of aphakic retinal detachment in patients with lattice
DECEMBER, 1974
degeneration. A myopic shift of the refrac tive error occurred in phakic lattice detach ment patients as well as in lattice patients without retinal separation. The round trophic hole was the most common type of retinal break in phakic lattice detachments and the second most common type of break in aphakic lattice detachment. T h e most com mon breaks in aphakic lattice detachments included mixed lattice and nonlattice breaks, with the nonlattice breaks almost invariably being horseshoe tears not associated with patches of lattice degeneration. REFERENCES
1. Straatsma, B. R., and Allen, R. A . : Lattice degeneration of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 66:600, 1962. 2. Byer, N. E . : Clinical study of lattice degenera tion of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 69:1064, 1965. 3. Michaelson, I. C.: Role of a distinctive choroido-retinal lesion in the pathogenesis of retinal hole. Br. J. Ophthalmol. 40:527, 1956. 4. Halpern, J. I . : Routine screening of the retinal periphery. Am. J. Ophthalmol. 62 :99, 1966. 5. Okun, E . : Gross and microscopic pathology in autopsy eyes. 3. Retinal breaks without detach ment. Am. J. Ophthalmol. 51:369, 1961. 6. Dumas, J., and Schepens, C. L.: Chorioretinal lesions predisposing to retinal breaks. Am. J. Ophthalmol. 61:620, 1966. 7. Schepens, C. L . : Subclinical retinal detach ments. Arch. Ophthalmol. 47:593, 1952. 8. Boniuk, M., and Butler, F. C.: An autopsy study of lattice degeneration, retinal breaks and retinal pits. In McPherson, A. (ed.) : New and Controversial Aspects of Retinal Detachment. New York, Hoeber, 1968, p. 59. 9. Meyer-Schwickerath, G.: Indications and limitations of light coagulation of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 63:725, 1959. 10. Tolentino, F. I., Schepens, C. L., and Free man, H. M. : Massive preretinal retraction. Arch. Ophthalmol. 78:16, 1967. 11. Streeten, B. W., and Bert, M.: The retinal surface in lattice degeneration of the retina. Am. J. Ophthalmol. 74:1201, 1972.