RETINA Dr. G. Rajasekhar D.N.B, FRCS (Glasgow) RETINA ARTERY OCCLUSIONS VEIN OCCLUSIONS DIABETIC RETINOPATHY CENTRAL SEROUS RETINOPATHY HYPERTENSIVE RETINOPATHY MACULAR DEGENERATION RETINA ARTERY OCCLUSION CENTRAL RETINAL ARTERY OCCLUSION BRANCH RETINAL ARTERY OCCLUSION RETINA CRAO Sudden painless loss of vision h/o suggestive of risk factors like HTN, DM or embolic disease Vision PL + Relative afferent pupillary defect RETINA CRAO: RAPD RETINA CRAOFundus: Gross thinned out vessels artery > vein Some times emboli may be seen Segmentation of blood column- cattle truck appearance Diffuse clouding of macula with cherry red spot Primary optic atrophy develops after few weeks RETINA CRAO RETINA CRAO RETINA CRAO WITH CILIO RETINA ARTERY SPARING RETINA CRAO FFA RETINA BRAO Sudden painless loss of visual field h/o suggestive of risk factors like HTN, DM or embolic disease Visual field defect corresponding to site of occlusion respecting horizontal meridian Relative afferent pupillary defect RETINA BRVO RETINA ARTERY OCCLUSION Management No proven effective treatment Measures to reduce IOP Ocular massage IV acetzolamide Carbogen (95% oxygen + 5% CO 2 ) inhalation Paracentasis Evaluate for sourse of emboli and other risk factors RETINA CRVO Sudden painless loss of vision h/o suggestive of risk factors like HTN, DM or embolic disease Vision 6/12 to 2/60 Relative afferent pupillary defect +/- RETINA CRVO ISCHAEMIC TYPE NON-ISCHAEMIC TYPE RETINA CRVOISCHAEMIC RETINA CRVO ISCHAEMIC RETINA CRVONON-ISCHAEMIC RETINA CRVO NON-ISCHAEMIC RETINA BRVO Sudden painless loss of visual field h/o suggestive of risk factors like HTN, DM or embolic disease Visual field defect corresponding to site of occlusion respecting horizontal meridian RETINA BRVO RETINA COMPLICATIONS MACULAR EDEMA NEOVASCULARISATION OF RETINA NEOVASCULARISATION OF IRIS RETINA N V I RETINA VEIN OCCLUSION Management At regular intervals Observe the patient for development of NVD / NVE / NVI Monitor IOP FFA and LASER photocoagulation if there develops NVD / NVE / NVI Grid LASER burns for persistant macular edema Evaluate for risk factors RETINA CENTRAL SEROUS RETINOPATHY Painless rapid dimisision of vision Meta morphopsia Central haziness in the visual field RETINA CENTRAL SEROUS RETINOPATHY Vision 6/9 to 6/36 Vision gets corrected with addition of +1 to 1.50 D galsses Central scotoma Well circumscribed shallow elevation of retina in macula +/- sub retinal precipitates RING SIGN May include optic disc RETINA CENTRAL SEROUS RETINOPATHY RETINA CENTRAL SEROUS RETINOPATHY FFA RETINA CENTRAL SEROUS RETINOPATHY Treatment: Observation Rule out any source of tuberculosis Focal laser photo coagulation if CSR persists for more than 4 months or early recovery is required Diabetic Eye Disease Anterior Segment Manifest refractive changes Recurrent corneal epithelial erosions and reduced corneal sensitivity Blepharitis, styes and chalazion Conjunctival hyperaemia and MA Rubeosis Iridis & NVG Cataract formation III rd and VI th cranial nerve palsies DIABETIC RETINOPATHY RISK FACTORS DURATIONDURATION LEVEL OF CONTROLLEVEL OF CONTROL ASSOCIATED RISK FACTORS LIKEASSOCIATED RISK FACTORS LIKE SmokingSmoking PregnancyPregnancy HypertensionHypertension Renal failureRenal failure Carotid diseaseCarotid disease DIABETIC RETINOPATHY PATHOGENESIS Loss of pericytes Thickening of basement membrane Endothelial cell damage,proliferation Platelet aggregation Micro vascular occlusion Release of growth factors VASCULAR CHANGES DIABETIC RETINOPATHY IS A MICRO ANGIOPATHY AFFECTING MAINLY CAPILLARIES INTRA RETINAL CAPILLARY CLOSURE RETINAL ISCHAEMIA NEW VESSEL FORMATION IN RETINA & IRIS INCREASED VASCULAR PERMEABILITY DIFFUSE RETINAL OEDEMA LOCALISED RETINAL OEDEMA HARD EXUDATES CLASSIFICATION Non-proliferative Proliferative NON-PROLIFERATIVE DIABETIC RETINOPATHY STAGES Mild NPDR Mild NPDR Moderate NPDR Moderate NPDR Severe NPDR Severe NPDR Very severe NPDR Very severe NPDR MILD NPDR At least one microaneurysm MODERATE NPDR MODERATE NPDR Hemorrhages and / or MA Soft exudates, venous beading SEVERE NPDR H/Ma in all 4 quadrants VB in two or more quadrants IRMA in at least one quadrant quadrant The rule VERY SEVERE NPDR Any two or more of severe NPDR PROLIFERATIVE DIABETIC RETINOPATHY NVD or NVE or NVI Preretinal or vitreous haemorrhage Fibrous tissue proliferation NVD or NVE NVD or NVE NVD or NVE Preretinal &Vitreous Haemorrhage NVD >1/3 1/2DA NVE 1/2DA And pre retinal or vitreous hemorrhage Traction retinal detachment seen in PDR Advanced Diabetic Retinopathy MACULAR EDEMA Retinal thickening within 2 disc diameters of the centre of the macula. Focal diabetic maculopathy Circumscribed retinal thickening Associated complete or incomplete circinate hard exudates Focal leakage on FA Focal photocoagulation Good prognosis Diffuse diabetic maculopathy Diffuse retinal thickening Generalized leakage on FA Guarded prognosis Grid photocoagulation Frequent cystoid macular oedema Variable impairment of visual acuity Ischaemic diabetic maculopathy Macula appears relatively normal Capillary non-perfusion on FA Poor visual acuity Treatment not appropriate Thickening of the retina located 500m from the center of the macula Hard exudates with thickening of the adjacent Retina A zone of retinal thickening, 1DA or larger in size located 1DA from the center of the macula ROLE OF FLOURESCEIN ANGIOGRAPHY CSMECSME Capillary loss Capillary loss Flourescein leakage Flourescein leakage ROLE OF FLOURESCEIN ANGIOGRAPHY Capillary loss leakage leakage Capillary loss leakage leakage Ischemic maculopathy CSMENVE Ischemic maculopathy CSMENVE MANAGEMENT Diabetic Retinopathy Management The effect of the photocoagulation burn: Reduced local and global retinal oxygen demandReduced local and global retinal oxygen demand Enhanced transmission of oxygen from choroidEnhanced transmission of oxygen from choroid Breaks the metabolic chain of events leading to advanced diabetic eye diseaseBreaks the metabolic chain of events leading to advanced diabetic eye disease CSME All areas of macular thickening must be treated For leakage - focal photocoagulation For diffuse thickening - macular grid photocoagulation Do not treat avascular zones Treatment of clinically significant macular edema For microaneurysms in centre of hard exudate rings located m from centre of fovea Focal treatment Gentle whitening or darkening of microaneurysm ( m, 0.10 sec) For diffuse retinal thickening located more than 500 m from centre of fovea and 500 m from temporal margin of disc Grid treatment Gentle burns ( m, 0.10 sec), one burn width apart Spot size ( m ) depends on contact lens magnification Gentle intensity burn ( sec) Follow-up 4 to 8 weeks Area covered by complete PRP Initial treatment is burns Laser panretinal photocoagulation Indications for vitreo retinal surgery Retinal detachment involving macula Severe persistent vitreous haemorrhage Dense, persistent premacular haemorrhage Progressive proliferation despite laser therapy HYPERTENSIVE RETINOPATHY A set of vascular and retinal changes seen in hypertensives as a response to chronic rise of blood pressure. Fundus changes seen are Narrowing Leakage AV crossing changes Choiroidal changes HYPERTENSIVE RETINOPATHY Narrowing HYPERTENSIVE RETINOPATHY Leakage HYPERTENSIVE RETINOPATHY AV crossing changes HYPERTENSIVE RETINOPATHY AV crossing changes HYPERTENSIVE RETINOPATHY Stageing of retinopathy Stage 1: focal narrowing of areteries Stage 2: generalised narrowing with AV crossing changes Stage 3: stage 2 + haemorrhages and exudates Stage 4: stage 3 + papilloedema HYPERTENSIVE RETINOPATHY Choridal: Infarcts HYPERTENSIVE RETINOPATHY Choridal: Pigmentary changes HYPERTENSIVE RETINOPATHY Choridal: Rarely bilateral exudative retinal detachment can occur ( E.g.: Toxemia of pregnancy) Hypertensive retinopathy occurs in pure form only in younger individuals with out vascular sclerosis Retinopathy of prematurity Thank you