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RETINA
Dr. Gilbert WS Simanjuntak Bagian IP Mata FK-UKI SMF IP Mata RS PGI Cikini
while they were saying among themselves it COULD NOT be done, BEHOLD IT WAS DONE
Helen Keller
Retina
Thin, semitransparent, multilayered sheet of neural tissue Lines the inner aspect of the posterior two-thirds of the wall of the globe Anterior ending point: ora serrata The retina and and retinal pigment epithelium are easily separated: subretinal space
2 3 4
Thickness:
0.1 mm at the ora serrata 0.23 mm at the posterior pole
5 6
Area 1.5 mm in diameter, yellowish pigmentation resulting from the presence of luteal pigment (xanthophyll): macula
7 8 9 10
The Vitreous
Blood supply from two sources:
Outer third (outer plexiform and outer nuclear layers, the photoreceptors, and the RPE): choriocapillaris Inner two-thirds: branches of the central retinal artery
Fovea supplied entirely by the choriocapillaris Retinal blood vessels non fenestrated endothelium: inner blood-retinal barrier RPE: outer retinal-blood barrier
Comprises two-thirds of the volume and weight of the eye Outer surface: the hyaloid membrane Vitreous base: firm attachment throughout life to the pars plana epithelium and the retina immediately behind the ora serrata Also attach to the lens capsule and optic disc
Examination
Slitlamp/biomicroscope examination (+60D, +78D, +90D):
Anterior segment (rubeosis iridis, cataract, etc) PVD (Weiss ring) Syneresis Vitreous hemorrhage Fibrovascular proliferation
Direct/Indirect Ophthalmoscope
B-scan Ultrasonography
diagnostic and prognostic, especially in media haze (corneal scar, small pupil/posterior synechiae, dense cataract or vitreous opacification)
Vitreous Disorders
Vitreous floaters Asteroid hyalosis: little/no effect upon vision Acute vitreous collaps: syneresis, photopsia
It should be assumed that patients with new floaters or photopsia have retinal tears or detachment until proved otherwise by thorough examination with an indirect ophthalmoscope
Intraocular Tumors
Retinoblastoma Retinal angioma
Vision affected by uxudation or bleeding from the tumor vessels Photocoagulation, diathermy or cryotherapy are treatment modalities Life-endangering of childhood The normal retinoblastoma gen, present in every individual, is a supresor gene or anti-oncogene Exophytic and/or exophytic, extend through the optic nerve to the brain Large tumor: enucleation; small: radiotherapy, cryotherapy, photocoagulation and/or chemotherapy
25% of diabetic population have some degree of diabetic retinopathy (DR) 5% are affected by more severe disease (proliferative retinopathy) Prevalence increases with the duration of diabetes, consequences of prolonged hyperglycemia After 20 years of hyperglycemia, develop some degree of DR
nearly all in type I DM more severe proliferation 60% in type II DM older patients, visual loss due to macular edema
Type-1 should be referred at least 3 year after the onset, type-2 at the time of examination. Diabetic pregnant women should be examined in the first trimester. Any sign of severe NPDR or more should be treated. Re-examined every 3 months until parturition
Technique :
Spot size 50-100 microns, one spot width apart Duration <100 ms Power adequate to obtain definite whitening around the m.a. or leakage site
Vitrectomy in DME
A rare, more subtle traction-induced complication with macular edema induced by the contraction of a taut, persistently attached posterior hyaloid
does not respond to focal or grid laser respond to surgical release of the traction clinically : prominent and thickened posterior hyaloid, VA <20/80
Smiddy WE, Flynn HW. Surv Ophthalmol 1999
If new vessels appear to be active and significant vitreous/preretinal hemorrhage are occuring, additional PHC strongly considered LIO is useful to fill-in the far periphery in cases continued NV activity after good PRP
Artery Occlusions
venous obstruction venous pressure intraretinal hges macular edema decreased vision
HCRO :
Ischemic (hemi-hemorrhagic retinopathy) Non-ischemic (hemi venous stasis ret.)
BRVO :
Major BRVO Macular BRVO
Systemic
Hypertension, DM, Cardiovascular disease (CAD), increased hematocrit and plasma viscosity Odds ratio for ischemic :
4.8 for hypertension 2.7 for DM 2.1 for CAD 2.1 for 1-globulin
Complications
Vitreous hemorrhage Neovascular glaucoma Retinal detachment
Results :
Intraoperative decompression achieve in all 15 patients 80% VA postoperative ~ preoperative 67% VA improved, with average gain 4 lines of vision 20% had worse VA, average 2 lines
Macular Diseases
Macular Hole
Postop-REVA 20/40
Stage 4a
Stage 4b
Plus Disease
Mekanisme Perlekatan Retina Normal Aposisi: 1. Tekanan hidrostatik dari TIO 2. Perbedaan tekanan osmotik antara koroid dan rongga subretina 3. Transpor metabolik ion-ion oleh EPR Lain-lain: interdigitasi vili, MIP Melepas: 4. Gerakan bola mata 5. Gravitasi 6. Traksi vitreus 7. PVD
Laser Profilaksis
Retina robek, belum terjadi pelepasan retina [1] Bibir robekan dan daerah sekitarnya difotokoagulasi laser [2] Terjadi sikatriks korioretina yang tidak dapat dilalui oleh cairan ablasio retina tercegah [3] Dapat juga dengan kriopeksi [4] [1] [4]
[3]
[2]
Pemasangan Bakel
Prabedah
Pascabedah
Retinopeksi - Krio
- Diatermi - Laser
F. Indirek ulang
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THANK YOU
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