Retina Pps1
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Transcript of 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
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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PVD and retinal break
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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Retina
Normal retina
Optic disc
Superior temporal arcades
Inferior temporal arcades
Macula
Fovea
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Anatomy
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Anatomy
Retina layers
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Goldman Three Mirror Condensing Lens
Slit lamp Biomicroscopic
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Indirect Ophthalmoscope
Direct Ophthalmoscope
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Fundus Fluorescein angiography
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Optical coherence tomography
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Ultrasonography
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Retinal Abnormality
Dystrophy
Degeneration
Infection / Inflammation
Vascular
Detachment
Tumor
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Dystrophy
Retinitis Pigmentosa
StargardS Disease
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Retinitis Pigmentosa
Hereditary degeneration
Fotoreceptor
Dysfunction, Loss and atrophy.
Autosomal recessiveAutosomal dominant
x-linked rescessive
1/3 no family history
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Retinitis Pigmentosa
Symptom :
Niktalopia
Constricted visual field
Sign : Bone spiculelike
pigmentation in fundus
Arteriolar narrowing
Treatment Low vision aid
No direct medical treatment
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Stargardt disease
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Degeneration
Myopic degeneration
Age related macular degeneration
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Myopic degeneration
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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).
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Dry ARMD
Wet ARMD
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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.
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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.
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Funduscopically, active toxoplasmosis :
white-yellow choreoretinal lesions
vitreous cells.
inactive lesions in the fellow eye.
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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)
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Active toxoplasmosis
Inactive toxoplasmosis
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Retinal vascular disease
Diabetic retinopathy Hypertensive retinopathy
Oklusi pembuluh darah retina
Retinopati pada pe etc
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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NPDR
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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PDR
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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)
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Hypertensive Retinopathy
Management Lower the blood pressure gradually to
decrease risk of blindness and stroke
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Grade III
Grade IV
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Retinal vessel occlusion
Vena
Central (CRVO)
Cabang (BRVO)
Arteri Central (CRAO)
Cabang (BRAO)
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Treatment
No effective therapy
90 minutes irreversible
Ocular massage Paracintesis
Carbogen inhalasion
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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CRAO
Pale / ischaemic retina
Cerry red spot
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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CRVO
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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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
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Rhegmatogen RD
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Tractional RD
Exudative RD
Ophthalmology Department
Faculty of Medicine Diponegoro UniversityKariadi General Hospital
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Tumor
Retinoblastoma Hemangioma choroid Tumor sub division
Ophthalmology Department