retina - PowerPoint Presentation

Slide1

retina

Švehlíková G.LF UPJS v KošiciachPrednosta: prof. MUDr. Juhás T., DrScSlide2

retinaSlide3

Anatomy Slide4

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

tumorsSlide5

1. Retinal

vascular disordersSlide6

Ffluorescein

angiographyFlourescein

angiography

-

is a test to examine blood vessels in the retina

and

choroid

Normal

FASlide7

AH – hypertensive

arteriolopathy, retinopathy

Prolonged

hypertenzion

Fundus

picture

–

vasoconstriction

–

arteriolar

narrowing

leakage

–

abnormal

vascular

peremability

–

hemorages

,

exudates

,

retinal

oedema

arteriolosclerosis

–

thickening

of

the

vessel

wall

–

changes

at

AV

crossings

Slide8

Central ret

. artery occlusion

Causes

Embolism

–

from

the

heart

carotid

a.

disease

( cholesterol,

fibrinoplatelet

,

calcific

)

Vaso-obliteration

–

atherosclerosis

, periarteritis – asociated with system. vascl., haematolog. disorders Slide9

Central ret

. artery occlusion

Presentation

Acute

loss

of

vision

Signs

retina

–

white

,

fovea

in

contras

red

arterioles and venules – narrowcentral,

branch

Treatment

Ocular

massage

, IOP ↓, Slide10

Central ret

. vein occlusion

Predisposing

factors

Systemic

–

age

,

systemic

hypertension

, diabetes (

vein

is

compressed

by

the

thicked artery), blood hyperviscosityOcular - ↑IOP, hypermetropia, congenital abnormal.Slide11

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,

neovascularisationSlide12

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 - hypoxiaHypoxia

–

causes

A-V

shunts

and

neovascularisationSlide13

Diabetic retinopathy

Nonproliferative

DR

Intraretinal

HE,

hard

exudates

,

oedemaSlide14

Diabetic retinopathy

Neovascularisation

Th

– laser

photocoagulation

Complication

- HE,

tractional

retinal

detachment

Proliferative

D

RSlide15

Diabetic retinopathy

Nonproliferative

DR

Proliferative

DRSlide16

NVE

NVE FA

fluorescein

angiography

Proliferative

DRSlide17

Retinal photocoagulationSlide18

2. Infections Slide19

The most important causes of retinal vasculitis

IdiopathicBehçet’s diseaseMultiple sclerosis

Lupus

erythematosus

Wegener’s

granulomatosis

Polyarteritis

nodosa

Horton’s

arteritis

Sarcoidosis

Tuberculosis

Borreliosis

(Lyme disease)

Listeriosis

Brucellosis

Syphilis

VirusesSlide20

3. Aquired

macular disorders Slide21

Age-related macular

degenerationAMD

Types

–

Atrophic

-

non-exudative

–

slowly

progresive

, 90%

Exudative

–

wet

form

–

detachment

of

RPE, choroidal neovascularisationSlide22

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.DrusenDeposition of abnormal material in Bruch

membraneSlide23

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 visionSlide24

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.

t

he 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. Slide25

Atrophic AMD

Early – drusen

Late –

geographic

atrophySlide26

Exudative AMD

Less

common

,

vision

loss

fast

within

few

weeksIn isolation

or in

association

with

atrophic

AMDExudative detachment of the RPE Choroidal neovascularisationgrow from the choriocapillaris through defects in Bruch membr

.

Into

the

sub

- RPE

spaceSlide27

AMD exudative

formChoroidal neovascularization

Disciform

scarSlide28

AMD exudative

formSlide29

Central serous

retinopathy

Idiopatic

,

self-limited

disease

of

young

or

midle-aged

adult

males

usualy

unilateral

,

localized

detachment of the sensory ret.Presentationsudden 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

functionSlide30

macular surface

disorders Idiopathic

macular

hole

Macular

puckerSlide31

Idiopathic macular

holePathogenesis:focal

contraction

of

the

perifoveal

vitreous

cortex

and

its separation

from

retinal

surface

Signs

round hole surrounded by o hako of retinal detachmentVA ↓Th: PPVresults : 60%Slide32

Macular Pucker

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

t

his causes wrinkling of the macula and subsequent distortion of central vision

-

metamorphopsia

t

hese

ERMs may grow as a result of aging, diabetes, trauma, inflammation, or previous eye surgerySlide33

4. Hereditary

fundus dystrophies Slide34

Hereditary degenerations

Photorector

dystrophies

-

Retinitis

pigmetosa

Dystrophies

of

RPE

-

fundus

flavimaculatus

Choroidal

dystrof

.

-

choroideremia, Gyrate atrophyAlbinismSlide35

Retinitis pigmentosa

group

of

hereditary

disorders

–

progressive

loss

of

photoreceptors

diffuse

,

usually

bilat

. , symetrical cones, rods - predominantPresentation – defective dark adaptation ( night blindes – nyctalopia

)Slide36

Myopic retinopathy

Degenerative

myopia

progresive

elongation

of

the

globe

is

followed by degenerative

changes

in

the

retina

and

choroidSigns- islands of chorioretinal atrophyatrophy around the optic discMacula – breaks in Bruch

memb

.,

neovascularisation

,

haemorarrhage

posterior

staphyloma

,

peripheral

degenerationSlide37

5. Retinal

detachmentSlide38

Retinal detachment

separation of the

sensory

retina

from

the

pigment

epitelium

Rhegmatogenous

–

retinal

break

Non-rhegmatogenes

-

tractional

exudative

Slide39

Rhegmatogenous retinal

detachmentAffects 1/10 000

rhegma

means break in

greek

It occurs in patients with

history of previous trauma to the eye

m

yop

y

peripheral retinal degenerations like

lattice degenerationSlide40

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

i

n the vitreous base, the collagen fibers are firmly attached to the underlying peripheral retina

o

ther

areas of firm vitreous attachment are

at

the optic disc

along the major vascular arcades

the edges of retinal scars

in areas of

vitreoretinal degenerationsSlide41

Posterior Vitreous Detachment (PVD)

With age the vitreous begins to liquefy and shrinkthis 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:

p

atients

with acute PVD experience flashes of light

–

photopsia

-

and/or "floaters"

f

lashes represent retinal stimulation from vitreous traction

floaters are shadow

sSlide42

Posterior Vitreous Detachment (PVD)

PVD might tear the retina at areas where the vitreous is firmly attachedwhen a piece of the retina is torn free, the remaining tear is called

operculated

tear

w

hen the torn retina remains adherent , we have a

flap or Horseshoe tear

f

lap 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 Slide43

peripheral retinal degenerations

Benign Predisposing perif

.

ret

.

degenerat

.Slide44

peripheral retinal degenerations

benignpredisposing Slide45

peripheral retinal degenerations

Benign snowflakes

Predisposing

snailtrackSlide46

Rhegmatogenous retinal

detachmentc

an 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

t

his 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

  Slide47

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 Slide48

Exudative Retinal

DetachmentDefinition:

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

.Slide49

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..Slide50

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 oilSlide51

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

Slide52

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 Slide53

6. Tumors

of the retinaSlide54

retinoblastoma

A retinoblastoma is a malignant tumor of early childhood that develops from immature retinal cells.one of 20000

births

i

n

30% of

all

cases

, it is

bilateral

manifests itself before the age of three in 90%

of

affected children

p

arents

observe

leukocoriaSlide55

retinoblastoma

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

cryotherapy

la

rger

tumors require

enucleationSlide56

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

p

atients

usually have

no ocular symptomsSlide57

haemangioma

are typically reddish to orangemany choroidal

hemangiomas

never grow or leak fluid and may be observed without

treatment

never

metastasize.Slide58

Questions and discussionSlide59

Thank you for your attention !