VITREO - VITREO - RETINARETINA

ANATOMYANATOMY

ANATOMYANATOMY

ANATOMYANATOMY

Fisiologi Fisiologi

Visual pathwayVisual pathway (Media refrakta)(Media refrakta) FotoreseptorFotoreseptor Nerve fiber layerNerve fiber layer Optic discOptic disc Jalur penglihatanJalur penglihatan Korteks penglihatanKorteks penglihatan

FisiologiFisiologi FotoreseptorFotoreseptor

Light impuls Light impuls nerve impuls nerve impuls Rod dan cone Rod dan cone

500 nm (blue-green)500 nm (blue-green) 430, 530, 575 (blue, green, red)430, 530, 575 (blue, green, red)

Makula Makula Cone >>, 1:1 dengan ganglion cellCone >>, 1:1 dengan ganglion cell Central vision, color visionCentral vision, color vision

Peripheral retinaPeripheral retina Peripheral visionPeripheral vision Night visioNight visio Rod >>Rod >>

PEMERIKSAANPEMERIKSAAN

1. Direct ophthalmoscope

2. Indirect ophthalmoscope

PEMERIKSAANPEMERIKSAAN

CONDENSING LENS

PEMERIKSAANPEMERIKSAAN

FUNDUS CAMERA

KELUHANKELUHAN

Penurunan VisusPenurunan Visus Metamorfopsia / mikropsia Metamorfopsia / mikropsia Kehilangan lapang pandangKehilangan lapang pandang Floaters / flashesFloaters / flashes Skotoma relatifSkotoma relatif

DiseasesDiseases

MaculaMacula Peripheral retinaPeripheral retina Retinal vascularRetinal vascular TumorTumor

Macula Macula

ARMDARMD Age related macular degenerationAge related macular degeneration

Macular dystrophiesMacular dystrophies

ARMDARMD Etiologi : unknownEtiologi : unknown Risk factorRisk factor

Caucasian race, female (slightly), family Caucasian race, female (slightly), family history, cigarette smokinghistory, cigarette smoking

TypeType Non-exudativeNon-exudative

Hard drusen (eosinophilic material between RPE and Hard drusen (eosinophilic material between RPE and Bruch’s membrane)Bruch’s membrane)

ExudativeExudative Soft drusenSoft drusen Choroidal neovascularisasiChoroidal neovascularisasi

ARMDARMD

Symptom Symptom Decrease visionDecrease vision MetamorfopsiaMetamorfopsia

ExaminationExamination Amsler gridAmsler grid Fundus examinationFundus examination FFA (fundus fluorescein angiography)FFA (fundus fluorescein angiography)

ARMDARMD

TreatmentTreatment Laser ?Laser ? Vitamin / anti-oxidant ?Vitamin / anti-oxidant ? Monitoring (fundus / amsler grid)Monitoring (fundus / amsler grid)

Stargardt’s diseaseStargardt’s disease

Bilateral symetric, autosomal recessiveBilateral symetric, autosomal recessive Yellow-white fleck lessionYellow-white fleck lession

lipofuscinlipofuscin

Peripheral retinaPeripheral retina

Retinal detachmentRetinal detachment RhegmatogenRhegmatogen

Retinal breakRetinal break Operative : scleral buckle, vitrectomyOperative : scleral buckle, vitrectomy

ExudativeExudative Collection fluid Collection fluid Degeneration, inflammation, infectiosDegeneration, inflammation, infectios causecause

TractionalTractional Diabetic retinopathyDiabetic retinopathy Operative : scleral buckle, vitrectomyOperative : scleral buckle, vitrectomy

Vascular Vascular CRVOCRVO

Central retina vein occlusionCentral retina vein occlusion BRVOBRVO

Branch retina vein occlusionBranch retina vein occlusion CRAOCRAO

Central retina artery occlusion Central retina artery occlusion Diabetic retinopathyDiabetic retinopathy Hypertensive retinopathyHypertensive retinopathy

CRVOCRVO

SymptomSymptom Sudden visual lossSudden visual loss

ComplicationComplication NeovascularizationNeovascularization Macular edemaMacular edema

TreatmentTreatment LaserLaser

Neovascular / macular edemaNeovascular / macular edema

CRVOCRVO

BRVOBRVO

SymptomSymptom Sudden visual lossSudden visual loss

Macular edema, macular ischemia and Macular edema, macular ischemia and vitreous hemorrhagevitreous hemorrhage

TreatmentTreatment LaserLaser Anticoagulant ?Anticoagulant ?

BRVOBRVO

CRAOCRAO

SymptomSymptom Amaurosis fugaxAmaurosis fugax Sudden visual lossSudden visual loss

TherapyTherapy 90 minutes complete occlusion90 minutes complete occlusion ParacentesisParacentesis

↓ ↓ intraocluar pressure, ↑ perfusionintraocluar pressure, ↑ perfusion Inhaled mixture O2 / CO2Inhaled mixture O2 / CO2

CRAOCRAO

D.R.D.R.

HyperglycemiaHyperglycemia Type I / II (3-5 years after onset)Type I / II (3-5 years after onset)

Refer Refer I : 3 yearsI : 3 years II : difficult to determine the onsetII : difficult to determine the onset

At the time of diagnosisAt the time of diagnosis

Type :Type : NPDR NPDR

Nonproliferative DRNonproliferative DR Proliferative DRProliferative DR

NPDRNPDR

Microaneurysms (MMicroaneurysms (MAA), hemorrhages), hemorrhages (Hem) (Hem), , hard exudates (HE), cotton wool spots (CWS),hard exudates (HE), cotton wool spots (CWS), intraretinal microvascular abnormalities intraretinal microvascular abnormalities (IRMAs), venous beading (VB)(IRMAs), venous beading (VB) & & new vessels new vessels (NV)(NV)

New AAO classification CP Wilkinson et al. Ophthalmology 2003; New AAO classification CP Wilkinson et al. Ophthalmology 2003; 110: 1677110: 1677 NoneNone Mild NPDRMild NPDR MA onlyMA only Moderate NPDR Moderate NPDR More than MA less than severeMore than MA less than severe Severe NPDR Severe NPDR 4: 2: 1 rule: >20 Hems 4 quads; 4: 2: 1 rule: >20 Hems 4 quads;

Venous bead 2 quads; IRMA 1 Venous bead 2 quads; IRMA 1 quadquad

PDRPDR NV or VHNV or VH

NPDRNPDR

TREATMENT:

• control of hyperglycemia, hypertension, cholesterol

• laser

PDRPDR

Sign :Sign : NeovascularizationNeovascularization

ComplicationComplication Neovascular glaucomaNeovascular glaucoma Tractional retinal detachmentTractional retinal detachment

TreatmentTreatment Laser, vitrectomyLaser, vitrectomy

PDRPDR

Hypertensive retinopathyHypertensive retinopathy

PathophysiologyPathophysiology

In response to arterial hypertension :In response to arterial hypertension :

Affected differently

Supply by difference system of blood vessel

• Retinal• Choroid• Optic Nerve

• Retinopathy

• Choroidopathy

• Optic disc edema

Hypertensive RetinopathyHypertensive Retinopathy Retinal vasculature protected by Retinal vasculature protected by

metabolic and myogenic mechanismmetabolic and myogenic mechanism

Retinal arteriolar constriction

Increase BP

Autoregulation

Maintain blood flow despite changes in perfusion pressure

Hypertensive RetinopathyHypertensive Retinopathy

Chronic stage

• Diffuse narrowing arteriolar

• Arteriovenous nicking

• Retinal depression sign precapillary arterial occlusion inner retina infarct

smooth muscle cells necrose

Hypertensive RetinopathyHypertensive Retinopathy

Acute stage

(rapid rise of BP and arteriolar constriction)

precapillary retinal arterioles occluded

Destroy ability to constrict

• Focal vasodilatation

• Transmission high BP to endothelium of smaller vessel

• Damage endothelium smaller vesselLeakage plasma and

formed blood

smooth muscle cells necrose

Hypertensive RetinopathyHypertensive Retinopathy

Acute stage

(rapid rise of BP and arteriolar constriction)

precapillary retinal arterioles occluded

Leakage plasma and formed bloodIschemia

Macula

Visual acuity affected

Treatment : control hypertension