retina Švehlíková g. lf upjs v košiciach prednosta: prof. mudr. juhás t., drsc
TRANSCRIPT
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
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 narrowing
b. 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 RETINOPATHY
Neovascularisation
Th – laser photocoagulation
Complication- HE, tractional retinal detachment
Proliferative DR
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
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.
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
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
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
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
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
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
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
RETINOBLASTOMA
Th 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.