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Retina

Anatomy of the Retina

The Ten Layers of the Retina


1. Pigment epithelium layer 2. Layer of rods and cones 3. External limiting membrane 4. Outer nuclear layer 5. Outer plexiform layer 6. Inner nuclear layer 7. Inner plexiform layer 8. Ganglion cell layer 9. Nerve fibre layer 10.Internal limiting membrane

Symptoms in retinal diseases


Night blindness Peripheral visual disturbance Central visual disturbance Color visual disturbance Metamorphopsia Micropsia Macropsia Photopsia Muscae volitantes (floaters) Without symptoms

Examinations

Visual Acuity Dark Adaptation Color vision (Ishihara) Visual field : confrontation test Goldmann perimetry Bjerrum tangent screen Octopus perimetry Ophthalmoscopy direct ophthalmoscopy indirect ophthalmoscopy biomicroscopy + contact lens/ Hruby lens/ +90 D lens

DIRECT OPHTHALMOSCOPY

External Light

Fundus Reflex

Lens Opacity

INDIRECT OPHTHALMOSCOPY

DIRECT

INDIRECT

BIOM

Specific Examinations
Fundus

fluorescein angiography (FFA) Ultrasonography (USG) Electroretinography

Fundus Fluorescein Angiography (FFA)

ULTRASONOGRAPHY of the NORMAL EYE

Diseases of the retina


Congenital Trauma Inflammation

anomalies

Retinal

detachment Vascular disorders Degeneration Neoplasma

Retinal diseases to be discussed


Retinal

detachment (ablatio retina) Retinal artery occlusion Retinal vein occlusion Diabetic retinopathy Hypertensive retinopathy Retinitis pigmentosa

Retinal Detachment
=

ablatio retina separatio retinae

condition where the sensoric retinal layer seperates from the retinal pigment epithelium layer (RPE)

Retinal Detachment Classification based on pathogenesis :

Rhegmatogenous RD Break/tear in the retina (degeneration/ trauma) fluid from the vitreus cavity enters sub-retina retina detached Nonrhegmatogenous RD Process behind retina (tumor/ inflammation) subretinal fluid retina detached Tractional RD Fibrosis in vitreus (bleeding/inflammation) retinal traction retina detached

Retinal Detachment
Subjective symptoms
Photopsia,

floaters

due to retinal traction, vitreous bleeding

Dark

shadow/curtain Vision

starts peripherally macular involvement or vitreous bleeding macular involvement (detached)

Reduced

Metamorphopsia

Retinal Detachment
Objective
Low

signs

IOP Relatively calm anterior segment Funduscopy

Detached retina greyish in color, elevated towards the vitreous cavity, vessels also elevated, surface often multi-lobulated

Retinal Tears
Cryo/ Laser Prophylaxis

Retinal Detachment

Retinal Detachment
Therapy
Rhegmatogenous

Tractional Nonrhegmatogenous

Surgery (Retinal repositioning)

towards

primary d. Surgical objectives


close the tear remove subretinal fluid remove vitreous traction

Retinal Artery Occlusion


A

condition where the retinal artery is occluded by an embolus Symptom: sudden visual loss without pain Two types :
Central

(CRAO) - occlusion behind the lamina cribrosa Branch (BRAO) - occlusion in front of lamina cribrosa

Retinal Artery Occlusion Causes : Arteriosclerosis Hypertension Carotid arterial disease Diabetes mellitus Valvular heart disease Others: oral contraception, trauma, coagulopathy, toxoplasmosis, etc.

Retinal Arterial Occlusion

Symptoms and signs: Sudden blurred vision (HM - LP) Calm anterior segment Funduscopy
cherry-red

spot (greyish pale retina except at the fovea) small arteries, uneven caliber small veins, segmental

Retinal Arterial Occlusion


Branch RAO If macula not involved, vision relatively stable Retina pale only at the involved area A/v changes only at the occluded branch Complications: Papil atrophy NVI + NVG Prognosis: Poor. Visual recovery only if : 1. Occlusion overcome within 1-2 hours after onset, 2. Occlusion temporary (spasm), 3. Cilioretinal artery present

CRAO

BRAO

Retinal Arterial Occlusion


Therapy: 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 eyeball inhalation of 95% O2 - 5% CO2 mixture

Look for cause

consult Internal Medicine

Retinal Venous Occlusion


Similar

to RAO, painless sudden loss of vision as presenting symptom Two types:


central

(CRVO) (BRVO)

occlusion behind lamina cribrosa occlusion in front of lamina cribrosa

branch

RVO

4-5 times more often than RAO

Retinal Venous Occlusion

Causes :

hypertension & arteriosclerosis (60%)

Common adventitial sheath at a-v crossing. Sclerosis --> vein compressed --> slowed flow --> thrombus --> occlusion

open angle glaucoma (40-70%) hyperviscosity (polycythemia, hyperli-pidemia, leukemia, etc) thromblophlebitis etc.

Retinal Venous Occlusion

Symptoms and signs :


sudden loss of vision calm anterior segment funduscopy :


dilated and tortuous vein edema, hemorrhage, soft exudate

Complication :

NVG

30-35% of CRVO, 1-3 months after onset

CRVO

BRVO

Retinal Venous Occlusion

Branch RVO :

NVG seldom nasal branch --> no visual disturbance without NVG --> edema, hemorrhage, exudate slowly absorbed
medical therapy of no benefit laser photocoagulation look for cause --> consult Internal Medicine

Prognosis :

Therapy :

Diabetic Retinopathy
DR

is a retinal abnormality in a diabetic due to microangiopathy Almost always bilateral although the stages may be different incidence increased with duration of DM :
>

20 years > 30 years

50% retinopathy 80% more

Diabetic Retinopathy

Juvenile

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 Retinopathy
Signs :

microaneurysm retinal hemorrhage hard exudate soft exudate retinal edema collateral vessels (IRMA-IntraRetinal Microvasular Abnormalities) venous beading CNPA (Capillary Non Perfusion Area) neovascularization & gliosis

Diabetic Retinopathy

Complications
vitreous

hemorrhage tractional retinal detachment


Classification

nonproliferative

(background) = NPDR proliferative = PDR diabetic macular edema = DME

Diabetic Retinopathy

NPDR
early

: signs 1 to 8 severe = preproliferative


PDR
early

: + sign 9 severe : + complications

Mild NPDR

Photo

FFA

Severe NPDR

Venous Beading

NVD

PDR

Severe PDR

Diabetic Retinopathy Therapy


metabolic

control laser photocoagulation

indicated in

severe NPDR early PDR DME

vitrectomy

and retinal repositioning

in Vitreous Hemorrhage and Retinal Detachment complications

PRP

PRP

FOCAL

PARS PLANA VITRECTOMY

Hypertensive Retinopathy

Changes in the retina of a hypertensive patient is due to hypertension and arteriosclerosis changes due to hypertension :

arteriole attenuation focal constriction/spasm hemorrhage and exudate papil edema

changes due to arteriosclerosis :

changes in arteriole light reflex changes in a-v crossing

Hipertensive Retinopathy
Changes due to hypertension :

arteriole attenuation

normal A:V ratio 2:3 or 3:4 attenuation < 3:4 (e.g. 1:2, 1:3)

focal constriction hemorrhage hard exudate soft exudate papil edema

Hipertensive Retinopathy

Changes

due to arteriosclerosis

changes

in arteriole light reflex changes in a-v crossing


SCHEIE
5

classification(1953)

stages of hypertension and 5 stages of arteriosclerosis are used

Attenuation Focal Spasm

Venous Indentation

Hypertensive Retinopathy

CWS Hemorrhage

Hypertensive Retinopathy

Papil Edema

SCHEIE classification
Hypertension
Grade Attenuation Focal Hemorrhage Exudate Papil Spasm Edema

Arteriosclerosis
Light reflex A-v crossing

0 1 2 3

3:4 1:2 1:3 1:4

1:1
1:1 2:3 1:3 distal occl.

(-) (-) (-)

(-) (-) (-)

(-) (-) (-) (-) (+)

Yellow line Widened Copper Silver Fibrous thread

N
V.Inden V.Inden Dist dilat Similar to 3

(+)
(+)

(+)
(+)

soft thread

SCHEIE Classification
Hypertension 0 Grade 1 Grade 2 Grade 3 Grade 4 Arteriosclerosis 0 Grade 1 Grade 2 Grade 3 Grade 4

Hipertensive Retinopathy

Therapy
toward

the hypertension hypertensive signs may disappear; sclerotic signs persist


papil edema, focal constriction quickly disappear hemorrhage, soft exudate disappear within several weeks-months hard exudate disappear within 4-6 months or more

Retinitis Pigmentosa
A

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 :
Nightblindness Gradual

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

Retinitis Pigmentosa

Funduscopy :

attenuation of retinal vessels in the midperiphery bone-specule pigmentation esp. along vessels; retina slightly dirty grey in color
annular scotoma

Perimetry :

Therapy :

untreatable low vision aids (LVA) genetic counseling

Retinitis Pigmentosa