4-retina.ppt

RetinaDjonggi PanggabeanRetina Sub-departmentDept. of Ophthalmology Medical Faculty Padjadjaran University/ Cicendo Eye Hospital

Anatomy of the Retina

The Ten Layers of the Retina1. Pigment epithelium layer2. Layer of rods and cones3. External limiting membrane 4. Outer nuclear layer5. Outer plexiform layer6. Inner nuclear layer7. Inner plexiform layer8. Ganglion cell layer9. Nerve fibre layer10.Internal limiting membrane

Symptoms in retinal diseasesNight blindnessPeripheral visual disturbanceCentral visual disturbance Color visual disturbanceMetamorphopsiaMicropsiaMacropsiaPhotopsiaMuscae volitantes (floaters)Without symptoms

ExaminationsVisual AcuityDark AdaptationColor vision (Ishihara)Visual field : confrontation testGoldmann perimetryBjerrum tangent screenOctopus perimetryOphthalmoscopydirect ophthalmoscopyindirect ophthalmoscopybiomicroscopy + contact lens/ Hruby lens/ +90 D lens

DIRECTOPHTHALMOSCOPY

Fundus ReflexLens OpacityExternal Light

INDIRECTOPHTHAL-MOSCOPY

DIRECTINDIRECT

BIOM

Specific ExaminationsFundus fluorescein angiography (FFA)Ultrasonography (USG)Electroretinography

FundusFluoresceinAngiography(FFA)

ULTRASONOGRAPHYof the NORMAL EYE

Diseases of the retinaCongenital anomaliesTraumaInflammationRetinal detachmentVascular disordersDegenerationNeoplasma

Retinal diseases to be discussedRetinal detachment (ablatio retina)Retinal artery occlusionRetinal vein occlusionDiabetic retinopathyHypertensive retinopathyRetinitis pigmentosa

Retinal Detachment= ablatio retina separatio retinae A condition where the sensoric retinal layer seperates from the retinal pigment epithelium layer (RPE)

Retinal DetachmentClassification based on pathogenesis : Rhegmatogenous RDBreak/tear in the retina (degeneration/ trauma) fluid from the vitreus cavity enters sub-retina retina detached Nonrhegmatogenous RDProcess behind retina (tumor/ inflammation) subretinal fluid retina detached Tractional RDFibrosis in vitreus (bleeding/inflammation) retinal traction retina detached

Retinal DetachmentSubjective symptomsPhotopsia, floatersdue to retinal traction, vitreous bleedingDark shadow/curtainstarts peripherallyReduced Visionmacular involvement or vitreous bleedingMetamorphopsiamacular involvement (detached)

Retinal DetachmentObjective signsLow IOPRelatively calm anterior segmentFunduscopyDetached retina greyish in color, elevated towards the vitreous cavity, vessels also elevated, surface often multi-lobulated

Retinal TearsCryo/ LaserProphylaxis

Retinal Detachment

Retinal DetachmentTherapyRhegmatogenous

TractionalNonrhegmatogenous towards primary d. Surgical objectivesclose the tearremove subretinal fluidremove vitreous tractionSurgery(Retinal repositioning)

Retinal Artery OcclusionA condition where the retinal artery is occluded by an embolusSymptom: sudden visual loss without painTwo types :Central (CRAO) - occlusion behind the lamina cribrosaBranch (BRAO) - occlusion in front of lamina cribrosa

Retinal Artery OcclusionCauses :ArteriosclerosisHypertensionCarotid arterial diseaseDiabetes mellitusValvular heart diseaseOthers: oral contraception, trauma, coagulopathy, toxoplasmosis, etc.

Retinal Arterial OcclusionSymptoms and signs:Sudden blurred vision (HM - LP)Calm anterior segmentFunduscopycherry-red spot (greyish pale retina except at the fovea)small arteries, uneven calibersmall veins, segmental

Retinal Arterial OcclusionBranch RAOIf macula not involved, vision relatively stable Retina pale only at the involved areaA/v changes only at the occluded branchComplications:Papil atrophyNVI + NVGPrognosis:Poor. Visual recovery only if : 1. Occlusion overcome within 1-2 hours after onset, 2. Occlusion temporary (spasm), 3. Cilioretinal artery present

BRAOCRAO

Retinal Arterial OcclusionTherapy:The aim of treatment is to quickly recover the arterial circulation by lowering the IOP :paracentesis (AH aspirated 0.15 - 0.2 cc)Acetazolamide (Diamox) 500 mg. i.v.digital massage of eyeballinhalation of 95% O2 - 5% CO2 mixtureLook for cause consult Internal Medicine

Retinal Venous OcclusionSimilar to RAO, painless sudden loss of vision as presenting symptom Two types:central (CRVO) occlusion behind lamina cribrosabranch (BRVO)occlusion in front of lamina cribrosaRVO 4-5 times more often than RAO

Retinal Venous OcclusionCauses :hypertension & arteriosclerosis (60%)Common adventitial sheath at a-v crossing. Sclerosis --> vein compressed --> slowed flow --> thrombus --> occlusionopen angle glaucoma (40-70%)hyperviscosity (polycythemia, hyperli-pidemia, leukemia, etc)thromblophlebitisetc.

Retinal Venous OcclusionSymptoms and signs :sudden loss of visioncalm anterior segmentfunduscopy :dilated and tortuous veinedema, hemorrhage, soft exudateComplication :NVG30-35% of CRVO, 1-3 months after onset

CRVOBRVO

Retinal Venous OcclusionBranch RVO :NVG seldomnasal branch --> no visual disturbancePrognosis :without NVG --> edema, hemorrhage, exudate slowly absorbedTherapy :medical therapy of no benefitlaser photocoagulationlook for cause --> consult Internal Medicine

Diabetic RetinopathyDR is a retinal abnormality in a diabetic due to microangiopathy Almost always bilateral although the stages may be differentincidence increased with duration of DM :> 20 years50% retinopathy> 30 years80% more

Diabetic RetinopathyJuvenile onset DM : delayed onset of DR. Mature onset DM (age > 40 yrs) : onset sooner Good metabolic control will delay the onset of DR Main cause of new blindness in the US

Diabetic RetinopathySigns :microaneurysmretinal hemorrhagehard exudatesoft exudateretinal edema collateral vessels (IRMA-IntraRetinal Microvasular Abnormalities)venous beadingCNPA (Capillary Non Perfusion Area)neovascularization & gliosis

Diabetic RetinopathyComplications :vitreous hemorrhagetractional retinal detachmentClassification :nonproliferative (background) = NPDRproliferative = PDRdiabetic macular edema = DME

Diabetic RetinopathyNPDR early : signs 1 to 8severe = preproliferativePDRearly : + sign 9severe : + complications

Mild NPDRPhotoFFA

Severe NPDRVenous Beading

PDRNVDSevere PDR

Diabetic RetinopathyTherapymetabolic controllaser photocoagulationindicated insevere NPDR early PDR DMEvitrectomy and retinal repositioningin Vitreous Hemorrhage and Retinal Detachment complications

PRPPRPFOCAL

PARS PLANA VITRECTOMY

Hypertensive RetinopathyChanges in the retina of a hypertensive patient is due to hypertension and arteriosclerosis changes due to hypertension :arteriole attenuationfocal constriction/spasmhemorrhage and exudatepapil edema changes due to arteriosclerosis :changes in arteriole light reflexchanges in a-v crossing

Hipertensive RetinopathyChanges due to hypertension :arteriole attenuationnormal A:V ratio 2:3 or 3:4attenuation < 3:4 (e.g. 1:2, 1:3)focal constrictionhemorrhagehard exudatesoft exudatepapil edema

Hipertensive RetinopathyChanges due to arteriosclerosischanges in arteriole light reflexchanges in a-v crossing

SCHEIE classification(1953)5 stages of hypertension and 5 stages of arteriosclerosis are used

AttenuationFocal SpasmVenous IndentationHypertensiveRetinopathy

HypertensiveRetinopathyPapil EdemaCWSHemorrhage

SCHEIE classificationHypertensionArteriosclerosisAttenuationFocalSpasmHemorrhageExudatePapilEdemaLight reflexA-v crossingGrade012343 : 41 : 21 : 31 : 4soft thread1 : 11 : 12 : 31 : 3distaloccl.(-)(-)(-)(+)(+)(-)(-)(-)(+)(+)(-)(-)(-)(-)(+)Yellow lineWidenedCopperSilverFibrous threadNV.IndenV.IndenDist dilatSimilar to 3

SCHEIE ClassificationHypertension Arteriosclerosis 0 0Grade 1 Grade 1Grade 2Grade 2Grade 3Grade 3Grade 4Grade 4

Hipertensive RetinopathyTherapy :toward the hypertensionhypertensive signs may disappear; sclerotic signs persistpapil edema, focal constriction quickly disappearhemorrhage, soft exudate disappear within several weeks-monthshard exudate disappear within 4-6 months or more

Retinitis PigmentosaA hereditary disease in which a pigmentary degeneration of the retina occurs Characteristically there is a progressive degeneration of the photoreceptors and RPE most severe if X-linked recessive, least severe if autosomal dominant

Retinitis Pigmentosa Subjective symptoms :NightblindnessGradual reduction of visual acuity up to less than 6/60 within 4 - 10 years. In X-linked this occurs usually earlier (reading disturbance at age 20, blindness at age 40)often accompanied by hearing disturbance

Retinitis PigmentosaFunduscopy :attenuation of retinal vessels in the midperiphery bone-specule pigmentation esp. along vessels; retina slightly dirty grey in color Perimetry :annular scotomaTherapy :untreatablelow vision aids (LVA)genetic counseling

Retinitis Pigmentosa