RETINA

Švehlíková G.LF UPJS v KošiciachPrednosta: prof. MUDr. Juhás T., DrSc

RETINA

ANATOMY

RETINA 1. Retinal vascular diseases –

AH, CRAO, CRVO, Diabetic retinopathy,

2. Infections

3. Aquired Macular disorders – ARMD, Central serous chorioretinopathy, macular surface disorders

4. Hereditary fundus dystrophies

5. Retinal Detachment

5. Retinal tumors

1. RETINAL VASCULAR DISORDERS

FFLUORESCEIN ANGIOGRAPHY

Flourescein angiography - is a test to examine blood vessels in the retina and choroid

Normal FA

AH – HYPERTENSIVE ARTERIOLOPATHY, RETINOPATHY

- Prolonged hypertenzion

- Fundus picture –a. vasoconstriction –

arteriolar narrowingb. leakage – abnormal

vascular peremability – hemorages, exudates, retinal oedema

c. arteriolosclerosis – thickening of the vessel wall – changes at AV crossings

CENTRAL RET. ARTERY OCCLUSION Causes

Embolism – 1. from the heart 2. carotid a. disease

( cholesterol, fibrinoplatelet, calcific )

Vaso-obliteration – atherosclerosis, periarteritis – asociated with system. vascl., haematolog. disorders

CENTRAL RET. ARTERY OCCLUSION

Presentation -Acute loss of vision

Signs-retina – white, fovea in contras red -arterioles and venules – narrow

-central, branch

Treatment-Ocular massage, IOP ↓,

CENTRAL RET. VEIN OCCLUSION Predisposing factors

1. Systemic – age, systemic hypertension, diabetes ( vein is compressed by the thicked artery), blood hyperviscosity

2. Ocular - ↑IOP, hypermetropia, congenital abnormal.

CENTRAL RET. VEIN OCCLUSION

central, branch

Presentation-moderate loss of visula

acuity

Signs- tortuosity and dilatation

of retinal vein, - hemorrhages- cotton-wool spots- Optic disc oedema

Complication- CME, neovascularisation

DIABETIC RETINOPATHY Prevalence IDD 40%, NIDD

20%

Microangiopathy – reduction in the number of pericytes – distension of capillary walls, breackdown of the blood- retinal barier – leakage

The consequence of retinal non-perfusion is retinal ischaemia - hypoxia

Hypoxia – causes A-V shunts and neovascularisation

DIABETIC RETINOPATHYNonproliferative DR

Intraretinal HE, hard exudates, oedema

DIABETIC RETINOPATHY

Neovascularisation

Th – laser photocoagulation

Complication- HE, tractional retinal detachment

Proliferative DR

DIABETIC RETINOPATHY

Nonproliferative DR

Proliferative DR

NVE NVE FA

fluorescein angiography

Proliferative DR

RETINAL PHOTOCOAGULATION

2. INFECTIONS

THE MOST IMPORTANT CAUSES OF RETINAL VASCULITIS Idiopathic Behçet’s disease Multiple sclerosis Lupus erythematosus Wegener’s granulomatosis Polyarteritis nodosa Horton’s arteritis Sarcoidosis Tuberculosis Borreliosis (Lyme disease) Listeriosis Brucellosis Syphilis Viruses

3. AQUIRED MACULAR DISORDERS

AGE-RELATED MACULAR DEGENERATIONAMD

Types –

1. Atrophic- non-exudative – slowly progresive, 90%

2. Exudative – wet form – detachment of RPE, choroidal neovascularisation

ATROPHIC, DRY, NONEXUDATIVE AMD The most common type,

90%

Slowly progresive atrophy of the RPE and photoreceptors

Presentation – gradual mild- to – moderata impairment of vision over several month or years.

Drusen Deposition of abnormal

material in Bruch membrane

The Amsler grid is used to detect small irregularities in the central 20 degrees of the field of vision.

Is a quick and simple test that patients are asked to use to monitor changes in their vision

OCT Optical Coherence Tomography

(OCT) is a new imaging technique that provides high resolution and cross-sectional images of the eye

analogous to ultrasound, but instead of using of acoustic waves (as in ultrasound), it uses light to achieve micrometer axial resolution.

the axial resolution of OCT in retinal tissue is about 1-15 µm, which is 10 to 100 times better than ultrasound or MRI

anatomic layers within the retina can be differentiated and retinal thickness can be measured.

ATROPHIC AMD

Early – drusen Late – geographic atrophy

EXUDATIVE AMD Less common, vision loss

fast within few weeks

In isolation or in association with atrophic AMD

Exudative detachment of the RPE

Choroidal neovascularisation

- grow from the choriocapillaris through defects in Bruch membr. Into the sub- RPE space

AMD EXUDATIVE FORMChoroidal neovascularization Disciform scar

AMD EXUDATIVE FORM

CENTRAL SEROUS RETINOPATHY

Idiopatic, self-limited disease of young or midle-aged adult males

usualy unilateral, localized detachment of the sensory ret.

Presentation sudden blurred vision in one eye,

associated with metamorphopsia FAG – breakdown of the blood-

retinal barrier whitch allows the passage of fluorescein into subretinal space

Prognosis 80% spontaneous resolution,

normal vision within 1-6 month 20% resolve within 12 month Prolonged detachment or recurrent

attacks – permanent impairment of visual function

MACULAR SURFACE DISORDERS

Idiopathic macular hole

Macular pucker

IDIOPATHIC MACULAR HOLE

Pathogenesis:- focal contraction of the

perifoveal vitreous cortex and its separation from retinal surface

Signs- round hole surrounded

by o hako of retinal detachment

- VA ↓- Th: PPV- results : 60%

MACULAR PUCKER abnormal scar tissue

membrane - epiretinal membrane, ERM- which grows over the surface to the macula

this causes wrinkling of the macula and subsequent distortion of central vision - metamorphopsia

these ERMs may grow as a result of aging, diabetes, trauma, inflammation, or previous eye surgery

4. HEREDITARY FUNDUS DYSTROPHIES

HEREDITARY DEGENERATIONS- Photorector dystrophies

- Retinitis pigmetosa

- Dystrophies of RPE - fundus flavimaculatus

- Choroidal dystrof. - choroideremia,

Gyrate atrophy

- Albinism

RETINITIS PIGMENTOSA

- group of hereditary disorders

- – progressive loss of photoreceptors

- diffuse, usually bilat. , symetrical

- cones, rods - predominant

- Presentation – defective dark adaptation ( night blindes – nyctalopia)

MYOPIC RETINOPATHY Degenerative myopia progresive elongation of the

globe is followed by degenerative changes in the retina and choroid

Signs - islands of chorioretinal

atrophy atrophy around the optic

disc Macula – breaks in Bruch

memb., neovascularisation, haemorarrhage

posterior staphyloma, peripheral degeneration

5. RETINAL DETACHMENT

RETINAL DETACHMENT- separation of the

sensory retina from the pigment epitelium

- Rhegmatogenous – retinal break

- Non-rhegmatogenes

- tractional- exudative

RHEGMATOGENOUS RETINAL DETACHMENT

Affects 1/10 000 rhegma means break

in greek

It occurs in patients with

- history of previous trauma to the eye

- myopy - peripheral retinal

degenerations like lattice degeneration

POSTERIOR VITREOUS DETACHMENT (PVD)

In healthy eyes of young patients, the vitreous is a clear gel that fills the vitreous cavity

vitreous consists mostly of water (99 %) as well as hyaluronic acid and a meshwork of fine collagen fibrils

important area is the vitreous base - 3-4 -mm-wide circumferential zone of

vitreous in the vitreous base, the collagen fibers

are firmly attached to the underlying peripheral retina

other areas of firm vitreous attachment are at

- the optic disc- along the major vascular arcades- the edges of retinal scars- in areas of vitreoretinal degenerations

POSTERIOR VITREOUS DETACHMENT (PVD) With age the vitreous begins to

liquefy and shrink this normal process usually starts

between 45 and 55 years of age

PVD is the separation of the vitreous from the posterior portion of the retina

prevalence of PVD increases with age, with axial length, and following cataract surgery and trauma

Clinical Features:patients with acute PVD experience flashes of light – photopsia - and/or "floaters"

flashes represent retinal stimulation from vitreous traction

floaters are shadows

POSTERIOR VITREOUS DETACHMENT (PVD)

PVD might tear the retina at areas where the vitreous is firmly attached

when a piece of the retina is torn free, the remaining tear is called operculated tear

when the torn retina remains adherent , we have a flap or Horseshoe tear

flap tears are more likely to progress into retinal detachment than operculated tears, because of the continuing vitreal traction on the retinal flap

ManagementThe fundus should be carefully examined to rule out retinal tears

the great majority of PVDs do not cause a retinal tear

PERIPHERAL RETINAL DEGENERATIONS

Benign

Predisposing perif. ret. degenerat.

PERIPHERAL RETINAL DEGENERATIONSbenign predisposing

PERIPHERAL RETINAL DEGENERATIONS

Benign snowflakes

Predisposing snailtrack

RHEGMATOGENOUS RETINAL DETACHMENT can occur once there is a

retinal break liquid vitreous passes through the

break and goes under the retina retina will then start to detach

from the underlying tissue

most tears occur in the peripheral retina → the detachment will first cause loss of a portion of the side vision

this can be seen as a curtain or dark shadow involving the peripheral vision. As the detachment extends towards the macula, the shadow will also enlarge. Central vision will be lost if the macula detaches

 

TRACTION RETINAL DETACHMENT

Definition:       The retina is pulled into the vitreous cavity by transvitreal traction

Etiology:        Diabetic Retinopathy, PVR, old penetrating injuries...

Clinical Features:        The detached retina is smooth, immobile, and concave toward the pupil. No breaks are usually found on ophthalmoscopy.

Management:         Vitrectomy, with release of vitreous tractions is required

EXUDATIVE RETINAL DETACHMENT Definition:

       The result of collection of fluid beneath an intact sensory retina.

Etiology:        Choroidal neoplasm (e.g melanoma), chorioretinal inflammatory diseases, malignant hypertension (as in toxemia of pregnancy), hemorrhage from a sub retinal neo-vascular membrane( as in AMD), systemic vascular and inflammatory diseases.

Clinical Features:smooth, transparent retinal elevation

- no retinal breaks nor pigment clumps or red blood cells in the vitreous are identified

Management- treat the underlying condition if

possible.

MANAGEMENT

Each procedure requires location of the tear and treating the retina around its edges by cryotherapy or laser in order to create firm adhesions between the sensory retina and the RPE layer and preventing detachmnent.

- Pneumatic retinopexy is best done for superior breaks

- The gas bubble will expand and being lighter than the ocular fluids, will migrate upward to tamponade superior breaks

- Positioning - if the break is in the posterior pole (close to the macula), the patient should remain face down.

- If the break was in the right temporal retina, he should lie flat on his left side.

- Positioning should be applied for the first 2 weeks..

MANAGEMENT 1. Scleral Buckle: 

               - silicone explant - over the sclera 360

degrees - in order to indent the sclera and make it apposed to the underlying detached retina.

2. Pneumatic Retinopexy: - Intra-ocular injection of gas ( air or

expandable gas) in order to tamponade the retinal detachment and break while the choroidal adhesions form

  3. Vitrectomy with silicone oil

PPV PPV was first

introduced in 1972, 20-gauge 3 port

PPV became the gold standard

Surgical Indications Pars plana vitrectomy is commonly

recommended for the following conditions :

Macular hole Macular pucker Vitreomacular traction Refractory macular edema Vitreous hemorrhage Tractional retinal detachment Rhegmatogenous retinal

detachment Dislocated intraocular lens Refractory uveitis Retained lens material Intraocular foreign bodies Floaters

PPV - COMPLICATIONS

Cataract, the most common complication

Endophthalmitis Retinal tear Retinal detachment Suprachoroidal hemorrhage Vitreous hemorrhage Optic neuropathy Phototoxicity Raised intraocular pressure,

usually from gas or oil tamponade

Hypotony

6. TUMORS OF THE RETINA

RETINOBLASTOMA A retinoblastoma is a

malignant tumor of early childhood that develops from immature retinal cells.

one of 20000 births in 30% of all cases, it is

bilateral manifests itself before

the age of three in 90% of affected children

parents observe leukocoria

RETINOBLASTOMATh radiation therapy

delivered by plaques of radioactive ruthenium or iodine (brachytherapy) and cryotherapy

larger tumors require enucleation

ASTROCYTOMA An astrocytoma or

astrocytic hamartoma is a benign tumor that develops from the astrocytes of the neuroglial tissue

are rare belong to the

phakomatoses and are presumably congenital disorders

patients usually have no ocular symptoms

HAEMANGIOMA are typically reddish

to orange many choroidal

hemangiomas never grow or leak fluid and may be observed without treatment

never metastasize.

QUESTIONS AND DISCUSSION

THANK YOU FOR YOUR ATTENTION !