Retina Pps1

8/13/2019 Retina Pps1

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Vitreous

A water (99%) and Hyaluronic acid & collagen (1%) mix Optically clear, fills centre of globe

Firm adhesions

optic nerve

peripheral retina at ora serrata

retinal blood vessels

can produce retinal detachment when they tear loos

Normally shrinks : age Sineresis, Posterior vitreous detachment

Ophthalmology Department

Faculty of Medicine Diponegoro University

Kariadi General Hospital


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Vitreous

Abnormality

Floater / turbidity (Thindense)

Degeneration

Haemorrhage

Infection / inflammation (vitritis)

Flashes

Traction to retina





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PVD and retinal break





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Retina

Normal retina

Optic disc

Superior temporal arcades

Inferior temporal arcades

Macula

Fovea


Faculty of Medicine Diponegoro UniversityKariadi General Hospital


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Anatomy




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Anatomy

Retina layers




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Vision

Biochemistry of Vision:

Visual proteins : based on Vitamin A

Stimulation by light : a biochemical cascade

Electrophysiological changes

transmitted and modified through the layers of the retinatheganglion cellsthe optic nerve

Central Vision:

The foveola : the most detailed vision

High density of cones

Reduction in the inner layers reduce obstruction to light

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




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Vision

Retinal Pigment Epithelium:

The RPE

special metabolic and ionic conditions the rods and cones for normal vision

Aging changes Age Related Macular Degeneration

Highly vascular portion of the uvea

Supplies the outer retina




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Examination

Physical examiantion Slit Lamp Biomicrosopic with

Condensing Lens

Goldman three mirror

Ophthalmoscope

Direct

Indirect

Additional examination Fundus Photo Color

Fundus Fluorescein angiography

Ultrasonography




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Goldman Three Mirror Condensing Lens

Slit lamp Biomicroscopic




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Indirect Ophthalmoscope

Direct Ophthalmoscope




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Fundus Fluorescein angiography




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Optical coherence tomography




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Ultrasonography




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Retinal Abnormality

Dystrophy

Degeneration

Infection / Inflammation

Vascular

Detachment

Tumor




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Dystrophy

Retinitis Pigmentosa

StargardS Disease




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Hereditary degeneration

Fotoreceptor

Dysfunction, Loss and atrophy.

Autosomal recessiveAutosomal dominant

x-linked rescessive

1/3 no family history




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Symptom :

Niktalopia

Constricted visual field

Sign : Bone spiculelike

pigmentation in fundus

Arteriolar narrowing

Treatment Low vision aid

No direct medical treatment




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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 treatmentOphthalmology Department



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Stargardt disease




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Degeneration

Myopic degeneration

Age related macular degeneration




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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 Attention to complications that may occur.

Scleral buckling




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Myopic degeneration




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ARMD

The most common cause of central vision loss > 50 years of age (developed countries??)

Symptom

In the early stages

central vision may be blurred or distorted, with objectslooking an unusual size or shape and straight linesappearing wavy or fuzzy (quickly or over severalmonths).




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Dry Armd

Dry Armd / non-eksudatif (90%) Drusen (yellowish deposits of debris in retina)

Geographic Atrophic

Treatment 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 vision worsens




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Wet Armd

Wet Armd (10%) More progressive

Choroidal neovascularization

Treatment Laser photocoagulation (> 200 um)

Photodynamic therapy

Macular translocation

Sub macular surgery




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Dry ARMD

Wet ARMD




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Infection / Inflammation

Chorioretinitis toxoplasma (toxoplasmosis) intracellular protozoan Toxoplasma gondii.

Mammal and bird hosts. (intermediate host is the cat).

The most frequent causes of retinochoroiditis 75 % the world's general population

possessing some seropositive findings.




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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 veinocclusion in the vicinity of the inflammation, inthe actively involved eye.




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Funduscopically, active toxoplasmosis :

white-yellow choreoretinal lesions

vitreous cells.

inactive lesions in the fellow eye.




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Treatment

Alternative treatments Clindamycin Tetracycline Trimethoprim

Sulfamethoxazole, Oral steroid 20 to 80 mg PO

Daily 4 or 6 weeks. (after antibiotic treatment)




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Active toxoplasmosis

Inactive toxoplasmosis




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Retinal vascular disease

Diabetic retinopathy Hypertensive retinopathy

Oklusi pembuluh darah retina

Retinopati pada pe etc




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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 Macular Edema

Leakage plasma constituent and fluid in the macula




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Diabetic Retinopathy

Treatment NPDR

Glucose systemic abnormality control Hypertension

Dislipidemia, etc Edema makula Focal or grid laser photocoagulation Anti-VEGF Steroid intra vitreal or sub tenon

PDR

Pan Retina photocoagulation Vitrectomy Anti-VEGF




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NPDR




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PDR




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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:

Cotton Wool Spots Nerve Fiber Layer micro-infarcts to disruption of

axoplasmic transport Dot/Blot and flame shaped hemorrhages




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Hypertensive Retinopathy

Modified Scheie Classification

Grade 0 No changes

Grade 1 Minimal arteriolar narrowing

Grade 2 Obvious arteriolar narrowing with focalirregularities

Grade 3 Grade 2 + retinal hemorrhages and/orexudate

Grade 4 Grade 3 + swollen optic nerve (Malignanthypertension)




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Hypertensive Retinopathy

Management Lower the blood pressure gradually to

decrease risk of blindness and stroke




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Grade III

Grade IV




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Retinal vessel occlusion

Vena

Central (CRVO)

Cabang (BRVO)

Arteri Central (CRAO)

Cabang (BRAO)




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CRAO

Symptom Acut severe loss of vision

Amaurosis fugax

Sign

RAPD Pale / ischaemic retina

Cerry red spot

4-6 weeks : optic disc pale

Risk factor

Hypertension Dislipidemia

Hemorrhelogy abnormality

GCA




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Treatment

No effective therapy

90 minutes irreversible

Ocular massage Paracintesis

Carbogen inhalasion




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CRAO

Pale / ischaemic retina

Cerry red spot




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CRVO

Symptom Acut severe loss of vision

Pain less

Sign

RAPD Retinal and vitrous hemorrhage

Macular edema dan NVG

Optic disc edema

Risk factor Hypertension Dislipidemia

Hemorrhelogy abnormality

GCA Ophthalmology DepartmentFaculty of Medicine Diponegoro UniversityKariadi General Hospital


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CRVO

Treatment

No effective therapy

Laser photocoagulation




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CRVO




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ROP

A disease that occurs in premature infant and affect the blood vessel ofthe developing retina

Vascular shunts

Neovascularization

Tractional retinal detachment

A major cause of Blindness and Visual Impairment in premature

infant.

Fortunately

Regression : 80 %

Progression : 20 %

25 % poor visual outcome despite current treatment

Screening at first 1 month

NORMAL VASCULAR DEVELOPMENT


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Avascular zone Hypoxia Physiologic VEGF

4 months

8 months

1 2 months

After birth

NORMAL VASCULAR DEVELOPMENT

IN UTERO ENVIRONMENT

f


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Hyperoxia

Down regulated

VEGF

Retinopathy of Prematurity

Hypoxia

Up regulated

VEGF

Neovascularization

Avascular zone

Decrease normal

Vascularization


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Stage 1, distinct demarcation line

Stage 2, ridge between the avascular

and vascularized retina


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Stage 3, ridge with extraretinal proliferation

Stage 4, subtotal retinal detachment4a. macula involvement (-)

4b. macula involvement (+)


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ROP

Treatment

Threshold :

Laser photocoagulation, cryotherapy or anti-

VEGF

Retinal detachment

Vitrektomi


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Retinal Detachment

Detachment the nuero-sensory retina from theunderlying pigment epithelial layer bysubretinal fluid Exudativa

Uveal effusion (infection or inflammation) Treatment : Underlying disease

Rhematogenous Retinal break Treatment : Scleral Buckling, Vitrectomy

Tractional Proliferative DR Treatment : Vitrectomy




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Rhegmatogen RD




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Tractional RD

Exudative RD




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Tumor

Retinoblastoma Hemangioma choroid Tumor sub division


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Retina Pps1