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Transcript of Medical Retina and Macular Diseases Dr. Timothy Y. Y. Lai MBBS, MMedSc, MRCSEd, FCOphthHK,...
![Page 1: Medical Retina and Macular Diseases Dr. Timothy Y. Y. Lai MBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth) Department of Ophthalmology and Visual Sciences.](https://reader033.fdocuments.net/reader033/viewer/2022052618/55140e01550346d8488b4f24/html5/thumbnails/1.jpg)
Medical Retina and Macular Diseases
Dr. Timothy Y. Y. LaiMBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth)
Department of Ophthalmology and Visual Sciences
The Chinese University of Hong Kong
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Medical Retina• A specialty that deals with the investigation and
non-surgical treatment of retinal disorders
• Retinal diseases associated with systemic diseases– Diabetic Retinopathy– Hypertensive Retinopathy
• Vascular retinopathies• Medical macular diseases
– Age-related Macular Degeneration
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Retinal Diseases Associated with
Systemic Diseases
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Diabetic Retinopathy
• One of the leading causes of blindness• Risk factors
– Duration of diabetes• 80% of type I and 70% of type II diabetics have
retinopathy after 15 yrs
– Type of diabetes mellitus– Control of hyperglycemia– Hypertension– Associated renal disease– Pregnancy
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Diabetic Retinopathy
• Classification– Non-proliferative (NPDR)
• Mild• Moderate• Severe
– Proliferative (PDR)
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• Pathogenesis– Microvascular disease causing capillary
damage– Leakage of blood constituents into the retina
• Retinal hemorrhages• Retinal edema• Lipid exudation
Non-proliferative Diabetic Retinopathy (NPDR)
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Non-proliferative Diabetic Retinopathy (NPDR)
• Dot and blot hemorrhage
• Hard exudate
• Cotton-wool spots
• Venous beading
• Venous loops
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Non-proliferative Diabetic Retinopathy (NPDR)
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Progression from NPDR to PDR
Stage Progression to PDR
in 1 year
Mild NPDR <5%
Moderate NPDR 20%
Severe NPDR 50%
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Proliferative Diabetic Retinopathy (PDR)
• Pathogenesis– Retinal ischemia causing neovascularization
• May be asymptomatic if only neovascularization without hemorrhage
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Neovascularization at Disc(NVD)
Neovascularization elsewhere(NVE)
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Causes of Visual Loss in DR
• Macular Edema
• Complications of PDR– Vitreous hemorrhage– Fibrous tissue proliferation– Retinal detachment
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MicroaneurysmsCircinate exudateRetinal edema
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Vitreous Hemorrhage Tractional Retinal Detachment
CombinedRetinal Detachment
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Diabetic Retinopathy
• Treatment– Laser photocoagulation
• Focal or grid: for macular edema • Pan-retinal photocoagulation: for PDR
– Control of systemic disease• Hyperglycemia• Hypertension• Renal disease
– Vitreous surgery
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Laser PhotocoagulationOutpatient procedureTopical AnesthesiaMultiple Sessions
In PDR, laser should be performed before vitreous hemorrhage and retinal detachment develops
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Diabetic Retinopathy
• Early identification of the disease and prompt referral to the ophthalmologist
• Dilate your patients for examination with ophthalmoscope regularly
• Prompt treatment reduces risk of visual loss by 50%
• Patients may be asymptomatic but still have advanced PDR
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Hypertensive Retinopathy
• Focal or generalized narrowing of retinal arteries associated with hypertension
• Clinical features– Cotton-wool spots– Hard exudates– Macular star– Macular edema– Retinal hemorrhage– Optic disc swelling
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Hypertensive Retinopathy
Grade Ophthalmoscopy Features
1 Mild arteriolar narrowing (copper-wiring)
2 Marked arteriolar narrowing with deflection of veins at AV crossing (silver wiring and AV nipping)
3 2 + Flame-shaped hemorrhage, cotton-wool spots
4 3 + Disc swelling
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Severe Hypertensive Retinopathy
Macular star Disc swelling
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Hypertensive Retinopathy
• Management– Rule out secondary hypertension– Control of hypertension
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Vascular Retinopathies
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Retinal Vascular Occlusions
• Venous occlusion more common than arterial occlusion
• Pathogenesis– Arterial occlusion – embolus
• Central retinal artery occlusion (CRAO)• Branch retinal artery occlusion (BRAO)
– Venous occlusion – abnormal blood flow• Central Retinal Vein Occlusion (CRVO)• Branch Retinal Vein Occlusion (BRVO)
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Retinal Arterial Occlusions
• Symptoms– Sudden, painless, marked loss of vision– Immediate treatment within 24-48 hours may
be beneficial in some patients
• Systemic Associations– Cardiovascular disease– Carotid artery disease– Temporal arteritis / inflammatory arteritis– Coagulopathies
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Central Retinal Artery Occlusion
Branch Retinal Artery Occlusion
Afferent Pupillary DefectCherry Red SpotRetinal Edema
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Retinal Venous Occlusions
• Symptoms– Sudden painless loss of vision– Various extent of visual loss
• Systemic Associations– Diabetes Mellitus– Hypertension– Hematological diseases– Vasculitis
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Central Retinal Vein Occlusion
Branch Retinal Vein Occlusion
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Macular edema Neovascular glaucoma
Laser photocoagulation
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Macular Diseases
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Where is the macula?
視網膜Retina
脈絡膜Choroid鞏膜
Sclera角膜Cornea
晶體Lens
Iris 虹膜
Cilliary body睫狀體
視神經Optic nerve
黃斑區Macula
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Fovea
Macula
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Macular Diseases
• Common surgical macular diseases– Macular hole– Epiretinal membrane
• Common medical macular diseases– Age-related macular degeneration (AMD)– Myopic maculopathy – Central serous chorioretinopathy (CSC)
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Age-related Macular Degeneration (AMD)
• Leading cause of severe vision loss in people > 50 years in the western world
• Visual loss due to drusens / RPE degeneration or development choroidal neovascularization (CNV)
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Age-related Macular Degeneration (AMD)
• Two forms– Dry (non-neovascular) AMD (80% to 90%)
– Wet (neovascular) AMD (10% to 20%)
• 90% of vision loss is caused by wet form of AMD
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Decrease in color and contrast sensitivity
Symptoms of AMD – Early
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Impairment of central visual function
Symptoms of AMD – Intermediate
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Metamorphopsia, distortion of central image
Symptoms of AMD – Intermediate
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Central Scotoma
Symptoms of AMD – Late
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Bruch’sBruch’sMembraneMembrane
Bruch’sBruch’sMembraneMembrane
DrusenDrusenDrusenDrusen
Hallmark of AMDDevelopment of Drusen
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Early Dry AMD
• Asymptomatic
• Examination reveals several small drusen or a few medium-sized drusen (63-124m)
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Intermediate Dry AMD• Many medium-
sized drusen or 1 large drusen (>125m)
• Vision may be impaired
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Advanced Dry AMD
• More severe visual impairment
• Presence of drusen with degeneration of RPE
• Geographic atrophy
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ChoroidalChoroidalNeovascularizatioNeovascularizationn
ChoroidalChoroidalNeovascularizatioNeovascularizationn
Dry AMD Wet AMDFormation of New Vessels
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Diagnosis
• Vision function testing–Visual acuity
–Amsler grid
• Ophthalmolscopy
• Fluorescein angiography
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• Amsler Grid • Adequate lighting• Wear reading glasses • Hold the Amsler grid at
normal reading distance (about 30cm)
• Cover one eye at a time • Stare at the center dot
• Ask the following questions:
• Are any of the lines wavy, missing, blurry, or discolored?
• Are any of the boxes different in size or shape from the others?
Early Diagnosis
5mm squares10 cm x 10 cm
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Self monitoring with Amsler Grid
Normal Abnormal
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Intravenous injection
Uptake of fluorescein dye at the site of abnormal vessels
- Size, Location, Activity
Fluorescein angiography
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Management of AMD• Treatment for neovascular AMD
– Laser photocoagulation– Submacular surgery– Photodynamic therapy (PDT) with Verteporfin– Anti-angiogenesis therapy (Anti-VEGF)
• Prevent progression to advanced AMD– Antioxidants– Quit smoking
• Low-vision aids
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Laser Photocoagulation
• Non-selective thermal laser photocoagulation– Destroy CNV– Irreversible damage to the
overlying retina and RPE– Side effects of immediate
scotoma or drop in central vision
– CNV persist or recur in 50% of patients
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Step 1:Step 1:InfusionInfusion
Step 2:Step 2:Nonthermal LaserNonthermal Laser
ApplicationApplication
PDT with Verteporfin
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Mechanisms of action
• Chain of reactions vessel thrombosis
Non-thermal Laser
Drug infusion1
2
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..
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High dose AREDS supplements
• Beta-carotene• Vitamin A• Vitamin C• Vitamin E• Zinc • Copper
• Decrease risk of progression from dry to wet AMD
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• Most important risk factors for AMD• Smokers have 300% to 400% more risk in
developing AMD than non-smokers• Even passive smoking increase the risk of AMD by
30% to 40%
Smoking and AMD
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Prevention is better than cure
• Increasing prevalence of AMD due to aging and western life-style
• Recognize and correct risk factors– Quit smoking– Healthy diet
• Self screening test in high-risk group• Regular dilated fundus examination to
evaluate AMD findings
Early diagnosis is the key to save vision
![Page 57: Medical Retina and Macular Diseases Dr. Timothy Y. Y. Lai MBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth) Department of Ophthalmology and Visual Sciences.](https://reader033.fdocuments.net/reader033/viewer/2022052618/55140e01550346d8488b4f24/html5/thumbnails/57.jpg)
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