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Medical Retina and Macular Diseases

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Presentation on theme: "Medical Retina and Macular Diseases"— Presentation transcript:

1 Medical Retina and Macular Diseases
Dr. Timothy Y. Y. Lai MBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth) Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong

2 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

3 Retinal Diseases Associated with Systemic Diseases

4 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

5 Diabetic Retinopathy Classification Non-proliferative (NPDR)
Mild Moderate Severe Proliferative (PDR)

6 Non-proliferative Diabetic Retinopathy (NPDR)
Pathogenesis Microvascular disease causing capillary damage Leakage of blood constituents into the retina Retinal hemorrhages Retinal edema Lipid exudation

7 Non-proliferative Diabetic Retinopathy (NPDR)
Dot and blot hemorrhage Hard exudate Cotton-wool spots Venous beading Venous loops

8 Non-proliferative Diabetic Retinopathy (NPDR)

9 Progression from NPDR to PDR
Stage Progression to PDR in 1 year Mild NPDR <5% Moderate NPDR 20% Severe NPDR 50%

10 Proliferative Diabetic Retinopathy (PDR)
Pathogenesis Retinal ischemia causing neovascularization May be asymptomatic if only neovascularization without hemorrhage

11 Neovascularization at Disc Neovascularization elsewhere
(NVD) Neovascularization elsewhere (NVE)

12 Causes of Visual Loss in DR
Macular Edema Complications of PDR Vitreous hemorrhage Fibrous tissue proliferation Retinal detachment

13 Microaneurysms Circinate exudate Retinal edema

14 Vitreous Hemorrhage Tractional Retinal Detachment Combined Retinal Detachment

15 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

16 Laser Photocoagulation
Outpatient procedure Topical Anesthesia Multiple Sessions In PDR, laser should be performed before vitreous hemorrhage and retinal detachment develops

17 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

18 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

19 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


21 Severe Hypertensive Retinopathy
Macular star Disc swelling

22 Hypertensive Retinopathy
Management Rule out secondary hypertension Control of hypertension

23 Vascular Retinopathies

24 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)

25 Retinal Arterial Occlusions
Symptoms Sudden, painless, marked loss of vision Immediate treatment within hours may be beneficial in some patients Systemic Associations Cardiovascular disease Carotid artery disease Temporal arteritis / inflammatory arteritis Coagulopathies

26 Central Retinal Artery Occlusion
Afferent Pupillary Defect Cherry Red Spot Retinal Edema Branch Retinal Artery Occlusion

27 Retinal Venous Occlusions
Symptoms Sudden painless loss of vision Various extent of visual loss Systemic Associations Diabetes Mellitus Hypertension Hematological diseases Vasculitis

28 Central Retinal Vein Occlusion
Branch Retinal Vein Occlusion

29 Laser photocoagulation
Macular edema Neovascular glaucoma Laser photocoagulation

30 Macular Diseases

31 Where is the macula? Choroid 鞏膜 Sclera 視網膜 Retina 角膜 Cornea 黃斑區 Macula
脈絡膜 Choroid 鞏膜 Sclera 視網膜 Retina 角膜 Cornea 黃斑區 Macula 晶體 Lens Iris 虹膜 視神經 Optic nerve Cilliary body 睫狀體

32 Fovea Macula

33 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)

34 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)

35 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

36 Decrease in color and contrast sensitivity
Symptoms of AMD – Early Decrease in color and contrast sensitivity

37 Symptoms of AMD – Intermediate
Impairment of central visual function

38 Symptoms of AMD – Intermediate
Metamorphopsia, distortion of central image

39 Symptoms of AMD – Late Central Scotoma

40 Hallmark of AMD Development of Drusen
Bruch’s Membrane Drusen

41 Early Dry AMD Asymptomatic
Examination reveals several small drusen or a few medium-sized drusen (63-124m)

42 Intermediate Dry AMD Many medium-sized drusen or 1 large drusen (>125m) Vision may be impaired

43 Advanced Dry AMD More severe visual impairment
Presence of drusen with degeneration of RPE Geographic atrophy

44 Dry AMD  Wet AMD Formation of New Vessels
Choroidal Neovascularization

45 Diagnosis Vision function testing Ophthalmolscopy
Visual acuity Amsler grid Ophthalmolscopy Fluorescein angiography

46 Early Diagnosis Amsler Grid Ask the following questions:
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? 5mm squares 10 cm x 10 cm

47 Self monitoring with Amsler Grid
Visual aids Self monitoring with Amsler Grid Normal Abnormal

48 Fluorescein angiography
Intravenous injection Uptake of fluorescein dye at the site of abnormal vessels - Size, Location, Activity

49 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

50 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

51 PDT with Verteporfin Step 2: Step 1: Nonthermal Laser Infusion
Application Step 1: Infusion

52 Mechanisms of action 1 2 Chain of reactions  vessel thrombosis
Non-thermal Laser 1 Drug infusion

53 .

54 High dose AREDS supplements
Beta-carotene Vitamin A Vitamin C Vitamin E Zinc Copper Decrease risk of progression from dry to wet AMD

55 Smoking and AMD 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%

56 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

57 Thank You

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