Senile Retinoschisis

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Original article contributed by: Alexander Barash, MD
All contributors: Alexander Barash, MD
Assigned editor: Peter A.Karth, MD
Review: Assigned status Not reviewed by Alexander Barash, MD on March 16, 2017.



Senile Retinoschisis
Classification and external resources
DiseasesDB 34521


Senile Retinoschisis is a microcystoid degeneration of the neurosensory retina, with splitting at the outer plexiform layer of the retina.

Disease Entity

Senile Retinoschisis, also called degenerative retinoschisis or acquired retinoschisis.

Disease

The prevalence is about 4% age 40+.

General Pathology

As above, this is a microcystoid degeneration of the neurosensory retina, with splitting at the outer plexiform layer of the retina.

History

Most patients are asymptomatic and this is an incidental finding. These patients may be referred to the retinal specialist with the presumptive diagnosis of retinal detachment.

Optos image of typical inferotemporal location of senile retinoschisis.

Physical examination/ Clinical diagnosis

  • Typical senile retinoschisis is a shallow elevation of inner retinal layers, whereas the reticular kind has the traditional appearance of bullous elevation.
  • You should see a relatively immobile transparent smooth or bullous elevation of inner layer wall. It will be dome shaped with uniform convexity and without corrugations often seen in a rhegmatogenous retinal detachment (RRD)
  • There can be an inner layer "beaten metal" or pitted appearance with minute glistening yellow-white surface dots, with minimal retinal pigment epithelium (RPE) alterations or atrophy.
  • The inferotemporal location is most common.
  • There will be no retinal tears, vitreous pigment cells, or demarcation lines unlike in a retinal detachment (RD)
  • Causes an absolute scotoma (vs a relative scotoma in a retinal detachment)
Splitting at outer plexiform layer in senile retinoschisis

Diagnostic procedures

  • You can check for an absolute scotoma with indirect ophthalmoscope perimetry: hold a scleral depressor on the observer's side of the condensing lens and document whether patient can see the depressor's shadow
  • Laser will blanch retinoschisis but not a rhegmatogenous retinal detachment (RRD)
  • Retinoschisis will not re-appose with scleral depression (no subretinal fluid to move out)
  • OCT shows a break in the outer plexiform layer (OPL) in retinoschisis and not detachment of retina from RPE (retinal detachment)
  • May be difficult to distinguish from longstanding retinal detachment (RD): A smooth or bullous elevation is also seen in retinal detachments, but characteristics for a (longer standing) retinal detachment are RPE alterations and demarcation lines

Differential diagnosis

  • Rhegmatogenous Retinal Detachment
  • Exudative Retinal detachment
  • Juvenile X-Linked Retinoschisis
  • Central Serous Chorioretinopathy

Management

Senile retinoschisis is usually benign but complications include:

Posterior extension or schisis cavity

  • The natural history is that this disease almost never progresses from where it's first observed, so resist lasering : most cases of posterior retinoschisis will not progress beyond 3 disc diameters from the macula and only a handful of cases of degenerative retinoschisis involving the macula have been reported. Additionally, no treatment, including laser, has been shown to halt the progression of retinoschisis.
  • Neither cataract surgery nor PVD have any adverse effect on retinoschisis (neither will cause it to progress - pathology is within the retina and not at the vitreoretinal interface.)

Outer wall breaks and "schisis detachment"

  • Outer wall breaks have a 10-27% incidence
  • Schisis detachments occur when schisis fluid accumulates in the subretinal space. They are usually large >3 disc diameters (DD), round, and posterior, with rolled edges. A ring of pigmentation indicates chronicity. In addition, subretinal fluid (SRF) typically doesn't extend past walls of schisis (viscous intraschisis fluid with mucopolysaccharides)

Progressive rhegmatogenous RD

  • Progressive rhegmatogenous RD (breaks in both inner and outer layer of breaks allow for vitreous to get into the subretinal space)
  • It's important to note that the patient may be asymptomatic due to the absolute scotoma in senile retinoschisis (doesn't mean no RRD!). However, this is very rare (occurs in 0.05% of patients with retinoschisis). Treatment only needs to close the inner retinal break (can leave outer retinal break). The schisis cavity will likely recur, and they will have an absolute scotoma even if it does not. Vitrectomy (PPV) is better for posteriorly located outer wall breaks and PVD, whereas a scleral buckle is better for anterior outer wall breaks, and absence of PVD, if treating surgically.

General treatment

As above.

Medical therapy

None.

Surgery

As above, you may consider vitrectomy or a scleral buckle in cases with retinal detachments and inner and outer retinal breaks.

Complications

As above, extension into the posterior pole, and outer and inner breaks leading to retinal detachment are possible but unlikely.

Prognosis

The natural history is that this disease almost never progresses from where it's first observed. Most people with senile retinoschisis do well and can be followed without intervention.

Additional Resources

  • American Academy of Ophthalmology. Retina/Vitreous: Degenerative retinoschisis Practicing Ophthalmologists Learning System, 2017 - 2019 San Francisco: American Academy of Ophthalmology, 2017.
  • Senile retinoschisis versus retinal detachment, the additional value of peripheral retinal OCT scans (SL SCAN-1, Topcon)
  • Managing Complications of Retinoschisis (Business of Retina - Fellows' Focus)
  • Imaging in Retinoschisis (ALEKSANDRA V. RACHITSKAYA, MD)
  • Surgical Treatment of Retinal Detachment Associated with Degenerative Retinoschisis (Seminars in Ophthalmology, 2014)