Retina Pps Dr Arief

Vitreo - Retina

Vitreo – Retina SubdivisionOphthalmology Department

Faculty of MedicineDiponegoro University / Kariadi General Hospital

Vitreous

• A water (99%) and Hyaluronic acid & collagen (1%) mix

• Optically clear, fills centre of globe

• Firm adhesions to optic nerve, peripheral retina at ora serrata and retinal blood vessels can produce retinal detachment when they tear loos

• Normally shrinks somewhat with age– Sineresis, Posterior vitreous detachment

Vitreous

• Abnormality – Floater / turbidity

• Degeneration, Haemorrhage, infection / inflammation

• Thin - dense

– Flashes• Traction to retina

Posterior Vitreous Detachment

Traction Vitreous / Retinal Break

Retina

Normal retina • Optic disc • Superior temporal arcades • Inferior temporal arcades • Macula • Fovea

Anatomy

Anatomy

• Retina layers

Vision

Biochemistry of Vision:• Visual proteins are based on Vitamin A • Stimulation by light causes a biochemical cascade • Electrophysiological changes are transmitted and

modified through the layers of the retina to the ganglion cells that form the optic nerve

Central Vision:• The foveola has the most detailed vision • High density of cones  • Reduction in the inner layers to reduce obstruction to

light • High (near 1:1) ratio of cones to ganglion cells

Vision

Retinal Pigment Epithelium:• The RPE provides special metabolic and ionic conditions

necessary for the rods and cones and is essential for normal vision

• Aging changes in the RPE result in Age Related Macular Degeneration

• Highly vascular portion of the uvea• Supplies the outer retina with much of its metabolic

requirements

Examination

• Physical examiantion– Slit Lamp Biomicrosopic with

• Condensing Lens• Goldman three mirror

– Ophthalmoscope• Direct• Indirect• Additional examination

– Fundus Photo Color– Fundus Fluorescein angiography– Ultrasonography

Goldman Three Mirror Condensing Lens

Slit lamp Biomicroscopic

Indirect Ophthalmoscope

Direct Ophthalmoscope

Fundus Fluorescein angiography

Ultrasonography

Retinal Abnormality

• Dystrophy

• Degeneration

• Infection / Inflammation

• Vascular

• Detachment

• Tumor

Dystrophy

• Retinitis Pigmentosa

• Stargard’S Disease

Retinitis Pigmentosa

• Hereditary degeneration– Fotoreceptor

• Dysfunction, Loss and atrophy.

• Autosomal recessive, autosomal dominant, x-linked rescessive and 1/3 no family history

Retinitis Pigmentosa

• Symptom : – Niktalopia– Constricted visual field

• Sign :– Bone spicule – like

pigmentation in fundus– Arteriolar narrowing

• Treatment– Low vision aid– No direct medical

treatment

Stargardt disease

• Juvenile macular dystrophy• Gen ABC4R on lp 21-22• Symptom

– Presentation on second decades– Gradual impairment of central vision

• Signs– Geographic atrophy– Fovea may be normal or non specific

• Treatment– Low vision aid– No direct medical treatment

Stargardt disease

Degeneration

• Myopic degeneration• Age related macular degeneration

Myopic degeneration

• Pathologic / high Myopia– Progressive elongation of the eye

• Thinning RPE and choroid• > - 6.00 D• Axial length > 26 mm• Liable to glaucoma and cataract

• Treatment– Limited to optical correction, intra-ocular pressure

control, and attention to complications that may occur. – Scleral buckling can prevent axial extension and may

minimize the toll of myopic macular degeneration on future visual function.

Myopic degeneration

ARMD

• The most common cause of central vision loss in persons older than 50 years of age in developed countries.

● Symptom● In the early stages

● central vision may be blurred or distorted, with objects looking an unusual size or shape and straight lines appearing wavy or fuzzy (quickly or over several months).

Dry Armd

• Dry Armd (90%)– Drusen (yellowish deposits of debris in retina)– Atrophic

• Treatment– eat a diet rich in leafy green vegetables,

antioxidants,zinc, lutein and zeaxanthin.– avoid excessively bright sunlight (ultraviolet

(UV) rays and blue light)– don't smoke– contact a low vision specialist if vision worsens

Wet Armd

• Wet Armd (10%), More progressive– Choroidal neovascularization

• Treatment– Laser photocoagulation– Photodynamic therapy– Macular translocation– Sub macular surgery

Dry ARMD

Wet ARMD

Infection / Inflammation

• Chorioretinitis toxoplasma (toxoplasmosis)– intracellular protozoan Toxoplasma gondii.

• Mammal and bird hosts. – (The most common intermediate host is the cat).

– It is one of the most frequent causes of retinochoroiditis in humans, 75 % the world's general population possessing some seropositive findings.

Toxoplasmosis

• Symptoms – unilateral, mild ocular pain, blurred vision and

new onset of floating spots.• Clinical findings

– granulomatous iritis, vitritis, optic disc swelling, neuroretinitis, vasculitis and retinal vein occlusion in the vicinity of the inflammation, in the actively involved eye.

– Funduscopically, • active toxoplasmosis presents with white-yellow,

choreoretinal lesions and vitreous cells. • There may be old, inactive lesions in the fellow eye.

Treatment

• Eradicate the parasite and suppress the inflammatory response.

• Classic treatment regimen– pyrimethamine (a 75mg loading dose, followed

by 25mg PO BID administration) with sulfadiazine (2g loading dose, then 1g PO QID for 4 to 6 weeks).

– Concurrent folinic acid, 3 to 5mg PO twice weekly helps to minimize any bone marrow toxicity produced by the pyramethamine.

Treatment

• Alternative treatments • clindamycin, tetracycline, trimethoprim /

sulfamethoxazole, • After beginning antibiotic therapy, add oral

steroids at a dose of 20 to 80mg PO daily for four or six weeks

Active toxoplasmosis

Inactive toxoplasmosis

Retinal vascular disease

• Diabetic retinopathy• Hypertensive retinopathy• etc

Diabetic Retinopathy

• Hyperglycaemia• Loss of pericyte• Thickening of basement membrane• Alteration of coagulation state

• Non-proliferative DR– Microaneurism– Dot & blot intraretinal hemorrhage– Hard exudates– Dilatation and beading of retinal vein

• Proliferative DR– Neovascularization

• On the disc or else where

Diabetic Retinopathy

• Treatment– Glucose and other systemic abnormality

control– Laser photocoagulation– Vitrectomy

NPDR

PDR

Hypertensive retinopathy

• WHO definition– Systolic blood pressure >140 mm Hg – Diastolic blood pressure > 90 mm Hg

• HTN can affect the choroid, retina, and optic nerve

• Hypertension can cause:– Nerve Fiber Layer micro-infarcts, called Cotton

Wool Spots - due to disruption of axoplasmic transport

– Dot/Blot and flame shaped hemorrhages

Hypertensive Retinopathy

Modified Scheie Classification– Grade 0 No changes– Grade 1 Minimal arteriolar narrowing– Grade 2 Obvious arteriolar narrowing with

focal irregularities– Grade 3 Grade 2 + retinal hemorrhages

and/or exudate– Grade 4 Grade 3 + swollen optic nerve

(Malignant hypertension)

Hypertensive Retinopathy

• Management–Lower the blood pressure gradually to

decrease risk of blindness and stroke

Grade III

Retinal Detachment

• Detachment the nuero-sensory retina from the underlying pigment epithelial layer by subretinal fluid– Exudativa

• Uveal effusion (infection or inflammation)• Treatment : Underlying disease

– Rhematogenous• Retinal break• Treatment : Scleral Buckling, Vitrectomy

– Tractional• Proliferative DR• Treatment : Vitrectomy

Rhegmatogen RD

Tractional RD

Exudative RD

Tumor

• Retinoblastoma• Hemangioma choroid• Tumor sub division

Thank you