Peripheral retinal degenerations: multimodal imaging–guided risk stratification and clinical decision-making

Introduction: Peripheral retinal degenerations (PRD) encompass a broad spectrum of peripheral retinal alterations, ranging from benign atrophic changes to tractional lesions associated with retinal tears (RT) and rhegmatogenous retinal detachment (RRD). Despite increasing detection with modern peripheral imaging, the clinical relevance and management of many PRD remain controversial. This review aims to provide an imaging guided, risk based framework for PRD evaluation and management, emphasizing the role of posterior vitreous detachment (PVD), selective prophylactic intervention, and emerging AI-assisted risk stratification and decision support concepts. Methods: A narrative literature search was conducted in PubMed, Scopus, and Web of Science (January 2000 to September 2025) using predefined terms related to PRD, vitreoretinal traction, RT, RRD, PVD, ultra widefield (UWF) imaging, and peripheral OCT. Of 842 records identified, 29 studies met inclusion criteria and were qualitatively synthesized. Results: PRD can be functionally stratified into low risk atrophic lesions (paving stone degeneration, WWOP), intermediate entities (degenerative retinoschisis), and high risk tractional lesions (lattice degeneration, snail track degeneration, retinal tufts). PVD represents the key biomechanical event linking PRD with RT and RRD, particularly during acute symptomatic stages. UWF imaging and SS-OCT improve visualization of peripheral morphology and vitreoretinal interface abnormalities, enabling differentiation between benign lesions, tractionally unstable configurations, and subclinical RRD. Current evidence supports selective prophylactic laser photocoagulation in eyes with symptomatic RT, fellow eye RRD, or OCT confirmed tractional instability, while routine treatment of asymptomatic low risk PRD is not justified. AI-assisted decision support may help standardize risk interpretation by integrating multimodal imaging features with clinical risk modifiers within a human in the loop model. Conclusion: PRD management should be individualized using integrated clinical assessment and multimodal imaging, with intervention targeted to tractional instability and meaningful risk modifiers.