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RETINA
Švehlíková G.
LF UPJS v Košiciach
Prednosta: prof. MUDr. Juhás T., DrSc
RETINA
ANATOMY
RETINA
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1. Retinal vascular diseases –
AH, CRAO, CRVO, Diabetic
retinopathy,
2. Infections
3. Aquired Macular disorders –
ARMD, Central serous
chorioretinopathy, macular
surface disorders
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4. Hereditary fundus
dystrophies
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5. Retinal Detachment
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5. Retinal tumors
1. RETINAL VASCULAR
DISORDERS
FFLUORESCEIN ANGIOGRAPHY
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Flourescein
angiography - is a test
to examine blood
vessels in the retina
and choroid
Normal FA
AH – HYPERTENSIVE ARTERIOLOPATHY,
RETINOPATHY
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Prolonged hypertenzion
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Fundus picture –
vasoconstriction –
arteriolar narrowing
leakage – abnormal
vascular peremability –
hemorages, exudates,
retinal oedema
arteriolosclerosis –
thickening of the vessel
wall – changes at AV
crossings
a.
b.
c.
CENTRAL RET. ARTERY OCCLUSION
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1.
2.
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Causes
Embolism –
from the heart
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
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1.
2.
Predisposing factors
Systemic – age, systemic
hypertension, diabetes ( vein
is compressed by the thicked
artery), blood hyperviscosity
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
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Prevalence IDD 40%,
NIDD 20%
Microangiopathy –
reduction in the number of
pericytes – distension of
capillary walls,
breackdown of the bloodretinal barier – leakage
The consequence of retinal
non-perfusion is retinal
ischaemia - hypoxia
Hypoxia – causes A-V
shunts and
neovascularisation
DIABETIC RETINOPATHY
Nonproliferative DR
Intraretinal HE, hard
exudates, oedema
DIABETIC RETINOPATHY
Proliferative DR
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Neovascularisation
Th – laser
photocoagulation
Complication- HE,
tractional retinal
detachment
DIABETIC RETINOPATHY
Nonproliferative DR
Proliferative DR
Proliferative DR
fluorescein angiography
NVE
NVE FA
RETINAL PHOTOCOAGULATION
2. INFECTIONS
THE MOST IMPORTANT CAUSES OF
RETINAL VASCULITIS
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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 DEGENERATION
AMD
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1.
2.
Types –
Atrophic- nonexudative – slowly
progresive, 90%
Exudative – wet
form – detachment of
RPE, choroidal
neovascularisation
ATROPHIC, DRY, NONEXUDATIVE AMD
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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
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OCT
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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
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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 FORM
Choroidal
neovascularization
Disciform scar
AMD EXUDATIVE FORM
CENTRAL SEROUS
RETINOPATHY
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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 bloodretinal 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
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Idiopathic macular
hole
Macular pucker
IDIOPATHIC MACULAR HOLE
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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
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abnormal scar tissue
membrane - epiretinal
membrane, ERMwhich 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
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Photorector dystrophies
- Retinitis pigmetosa
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Dystrophies of RPE
- fundus flavimaculatus
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Choroidal dystrof.
- choroideremia, Gyrate
atrophy
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Albinism
RETINITIS PIGMENTOSA
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group of hereditary disorders
– progressive loss of
photoreceptors
diffuse, usually bilat. ,
symetrical
cones, rods - predominant
Presentation – defective dark
adaptation ( night blindes –
nyctalopia)
MYOPIC RETINOPATHY
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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
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separation of the
sensory retina from
the pigment epitelium
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Rhegmatogenous –
retinal break
Non-rhegmatogenes
- tractional
- exudative
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RHEGMATOGENOUS RETINAL DETACHMENT
Affects 1/10 000
 rhegma means break
in greek
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It occurs in patients
with
history of previous
trauma to the eye
myopy
peripheral retinal
degenerations like
lattice degeneration
POSTERIOR VITREOUS DETACHMENT (PVD)
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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)
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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
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Clinical Features:
patients with acute PVD experience
flashes of light – photopsia - and/or
"floaters"
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flashes represent retinal stimulation
from vitreous traction
floaters are shadows
POSTERIOR VITREOUS DETACHMENT (PVD)
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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
Management
The fundus should be carefully
examined to rule out retinal tears
the great majority of PVDs do not
cause a retinal tear
PERIPHERAL RETINAL DEGENERATIONS
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Benign
Predisposing perif.
ret. degenerat.
PERIPHERAL RETINAL DEGENERATIONS
benign
predisposing
PERIPHERAL RETINAL DEGENERATIONS
Benign
snowflakes
Predisposing
snailtrack
RHEGMATOGENOUS RETINAL DETACHMENT
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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
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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
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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
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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
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3. Vitrectomy with silicone oil
PPV
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PPV was first introduced in 1972,
20-gauge 3 port PPV became the
gold standard
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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
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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
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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
RETINOBLASTOMA
Th
 radiation therapy
delivered by plaques
of radioactive
ruthenium or iodine
(brachytherapy) and
cryotherapy
 larger tumors require
enucleation
ASTROCYTOMA
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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
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HAEMANGIOMA
are typically reddish
to orange
 many choroidal
hemangiomas never
grow or leak fluid and
may be observed
without treatment
 never metastasize.
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QUESTIONS AND DISCUSSION
THANK YOU FOR YOUR ATTENTION !