Senile Retinoschisis (RS) 

Updated: Sep 07, 2018
Author: Brian A Phillpotts, MD, MD; Chief Editor: Hampton Roy, Sr, MD 

Overview

Background

Senile retinoschisis (RS), also known as acquired or degenerative retinoschisis, is a primary, acquired, gradual splitting of the retina into at least 2 distinct layers. This condition is not senile or age related, as it has been reported in patients in the third decade of life (20-30 years).

Pathophysiology

Senile retinoschisis develops from the coalescence of intraretinal microcysts located in an area of peripheral cystoid degeneration near the ora serrata and extends posteriorly and circumferentially. This process leads to the splitting of the retina at the outer plexiform layer or, less commonly, at the inner nuclear layer.

Epidemiology

Frequency

United States

The prevalence of senile retinoschisis is high in the normal population (4-22% of individuals older than 40 years).

Mortality/Morbidity

Often, no visual changes occur, but retinal detachment may occur in a small percentage of patients, leading to visual field defects and/or decreased visual acuity.

Visual field defects may manifest as the schisis cavity extends posteriorly.

The schisis cavity may remain stable or slowly progress over several years.

Retinal detachment may result after the development of retinal holes in both the inner layer and outer layer of the schisis cavity or in the outer layer alone (16%).

Sex

The occurrence of senile retinoschisis is approximately equal in males and females.

Age

Senile retinoschisis is more common in patients older than 30 years, but it has been reported in patients younger than 30 years.

In a long-term follow-up study (n=946), the age-standardized prevalence of retinoschisis was 3.9% (95% confidence interval, 2.6-5.2) in persons aged 60-80 years.[1]

Prognosis

In a large study conducted by Byer, no change in visual acuity occurred over 9 years (from extension of senile retinoschisis or retinal detachment).[2]

Generally, senile retinoschisis does not progress. About 3.2-13.5% of cases progress within 9-10 years of diagnosis.

Even with anatomic correction, the visual field deficits are permanent.

Patient Education

Patients with senile retinoschisis should be informed about symptoms of retinal detachment.

 

Presentation

History

In the initial stages of senile retinoschisis, patients are generally asymptomatic; however, in the advanced stage of the disease, patients may complain of photopsia, floaters, and visual field loss.

Physical

Examination of senile retinoschisis is completed by using indirect ophthalmoscopy with scleral depression. Goldmann lens/slit lamp biomicroscopy examination also may be performed. Examination reveals the following findings:

  • A retinal elevation is present in the middle to the peripheral part of the retina, often in the lower temporal quadrant. In a long-term follow-up study of retinoschisis in elderly patients, the inferior temporal retinal quadrant had the most involvement at 44%. [1]
  • The elevated retinal surface is usually smooth, without folds/undulation, and may contain retinal blood vessels.
  • The inner layer may be transparent and difficult to visualize.
  • In advanced cases, the leading edge of the splitting retinal layers usually elevate acutely, resulting in a bullous cystic cavity.
  • The position of the schisis cavity is constant in shape, elevation, and position; it changes with head position without fluid shift.
  • Scleral depression fails to collapse the inner retinal layer.
  • Scleral depression reveals white-without-pressure of the outer retinal layer.
  • The retinoschisis rarely extends into the macular region.
  • Senile retinoschisis is not associated with operculated or horseshoe-shaped retinal tears.
  • Retinal detachments secondary to outer retinal layer holes alone tend to be shallow, small, and located around senile retinoschisis.
  • Retinal detachments secondary to inner retinal layer holes alone or combined with outer layer holes tend to be elevated and large to total detachments.
  • Senile retinoschisis is commonly bilateral but not necessarily symmetrical.
  • Outer layer holes are usually large, relatively limited in number, and obvious; inner layer holes are usually small, numerous, and not so obvious.

Causes

Preexisting peripheral cystoid degeneration

Complications

A low clinical risk exists of retinal detachment or extension into the posterior pole, leading to an absolute field defect.

 

DDx

 

Workup

Other Tests

Other tests used to evaluate senile retinoschisis include the following:

  • Fundus drawings
  • Visual field plotting (sharp absolute scotoma in senile retinoschisis; sloped relative to absolute in retinal detachment)
  • Low-power retinal laser test spot to rule out subretinal fluid, ie, retinal detachment (in very difficult cases)

Histologic Findings

Two histologic types of senile retinoschisis have been identified.

Flat type also is termed typical degenerative retinoschisis. Characteristics of this type include splitting at the outer plexiform layer, usually confined anterior to the equator, and not associated with holes.

Bullous type also is termed reticular degenerative retinoschisis. Characteristics of this type include splitting in the nerve fiber layer, often extends posterior to the equator, and often has outer layer holes that may lead to retinal detachment when associated with inner layer holes.

 

Treatment

Surgical Care

Surgery does not reestablish neuronal integrity of the split retina; therefore, it does not improve visual loss secondary to senile retinoschisis. Rarely, spontaneous resolution has been reported.

Surgery is undertaken to prevent retinal detachment, when inner and outer retinal holes are found without retinal detachment.

Surgery is performed if retinoschisis is associated with a retinal detachment.

For senile retinoschisis extending into the posterior pole, the following 2 procedures can be performed:

  • Demarcation of the advancing retinoschisis edge with photocoagulation and/or cryotherapy
  • Application of photocoagulation and/or cryotherapy to the entire outer layer with or without subretinal fluid (SRF) drainage to collapse the inner layer of the retinoschisis

Consultations

Vitreoretinal specialist

Long-Term Monitoring

Patients should have annual follow-up examinations for retinoschisis that is relatively flat, without breaks, and anterior to the equator.

Patients should receive follow-up care every 3-6 months for retinoschisis with breaks or with extension posterior to the equator; if patients remain stable, annual visits thereafter are indicated.

More frequent follow-up care is required in patients with symptoms of photopsia and floaters.