1. retina Švehlíková G. LF UPJS v Košiciach
Prednosta: prof. MUDr. Juhás T., DrSc

2. retina

3. Anatomy

4. 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 tumors

5. 1. Retinal vascular disorders

6. Ffluorescein angiography
Flourescein angiography - is a test to examine blood vessels in the retina and choroid
Normal FA

7. 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

8. 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

9. Central ret. artery occlusion
Presentation
Acute loss of vision
Signs
retina – white, fovea in contras red
arterioles and venules – narrow
central, branch
Treatment
Ocular massage, IOP ↓,

10. Central ret. vein occlusion
Predisposing factors
Systemic – age, systemic hypertension, diabetes ( vein is compressed by the thicked artery), blood hyperviscosity
Ocular - ↑IOP, hypermetropia, congenital abnormal.

11. 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, neovascularisation

12. 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 - hypoxia
Hypoxia – causes A-V shunts and neovascularisation

13. Diabetic retinopathy Nonproliferative DR
Intraretinal HE, hard exudates, oedema

14. Diabetic retinopathy Proliferative DR Neovascularisation
Th – laser photocoagulation
Complication- HE, tractional retinal detachment

15. Diabetic retinopathy
Nonproliferative DR
Proliferative DR

16. Proliferative DR
fluorescein angiography
NVE
NVE FA

17. Retinal photocoagulation

18. 2. Infections
differentiation between a primary affectionof the retina – retinochoroiditis and a primary affection of the choroid – chorioretinitis is not always possible

19. The most important causes of retinal vasculitis
Idiopathic
Behçet’s disease
Multiple sclerosis
Lupus erythematosus
Wegener’s granulomatosis
Polyarteritis nodosa
Horton’s arteritis
Sarcoidosis
Tuberculosis
Borreliosis (Lyme disease)
Listeriosis
Brucellosis
Syphilis
Viruses

20. 3. Aquired macular disorders

21. Age-related macular degeneration AMD
Types –
Atrophic- non- exudative – slowly progresive, 90%
Exudative – wet form – detachment of RPE, choroidal neovascularisation

22. 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.
Drusen
Deposition of abnormal material in Bruch membrane

23. 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 vision

24. 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.
the 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.
l Coherence Tomography (OCT) is a new imaging technique that provides unprecedented high resolution and cross-sectional images of the eye. The OCT scan allows microstructures of the eye to be imaged and shows different colour-coded layers of the retina. It is particularly useful in the diagnosis and management of eye conditions such as age-related macular degeneration, diabetic macular oedema, macular hole, epiretinal membrane, vitreo-macular traction syndrome and glaucoma. It has also become a gold standard in monitoring the efficacy of intravitreal anti-VEGF injections (Avastin or Lucentis) for age-related macular degeneration and tailoring treatment regime.
An OCT scan is very quick to perform and it is completely painless and non-invasive. Results are available instantaneously and it is a great way for patients to gain a better understanding of their eye condition.
Optical Coherence Tomography (OCT) is a new imaging technique that provides unprecedented high resolution and cross-sectional images of the eye. The OCT scan allows microstructures of the eye to be imaged and shows different colour-coded layers of the retina. It is particularly useful in the diagnosis and management of eye conditions such as age-related macular degeneration, diabetic macular oedema, macular hole, epiretinal membrane, vitreo-macular traction syndrome and glaucoma. It has also become a gold standard in monitoring the efficacy of intravitreal anti-VEGF injections (Avastin or Lucentis) for age-related macular degeneration and tailoring treatment regime.

25. Atrophic AMD
Early – drusen
Late – geographic atrophy

26. Exudative AMD Less common, vision loss fast within few weeks
In isolation or in association with atrophic AMD
Exudative detachment of the RPE
Choroidal neovascularisation
grow from the choriocapillaris through defects in Bruch membr. Into the sub- RPE space

27. AMD exudative form
Choroidal neovascularization
Disciform scar

28. AMD exudative form

29. Central serous retinopathy
Idiopatic, self-limited disease of young or midle-aged adult males
usualy unilateral, localized detachment of the sensory ret.
Presentation
sudden 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 function

30. macular surface disorders
Idiopathic macular hole
Macular pucker

31. Idiopathic macular hole
Pathogenesis:
focal contraction of the perifoveal vitreous cortex and its separation from retinal surface
Signs
round hole surrounded by o hako of retinal detachment
VA ↓
Th: PPV
results : 60%

32. Macular Pucker
abnormal scar tissue membrane - epiretinal membrane, ERM- which grows over the surface to the macula
this causes wrinkling of the macula and subsequent distortion of central vision - metamorphopsia
these ERMs may grow as a result of aging, diabetes, trauma, inflammation, or previous eye surgery

33. 4. Hereditary fundus dystrophies

34. Hereditary degenerations
Photorector dystrophies - Retinitis pigmetosa
Dystrophies of RPE
- fundus flavimaculatus
Choroidal dystrof.
- choroideremia, Gyrate atrophy
Albinism

35. Retinitis pigmentosa group of hereditary disorders
– progressive loss of photoreceptors
diffuse, usually bilat. , symetrical
cones, rods - predominant
Presentation – defective dark adaptation ( night blindes – nyctalopia)

36. Myopic retinopathy Degenerative myopia
progresive elongation of the globe is followed by degenerative changes in the retina and choroid
Signs
- islands of chorioretinal atrophy
atrophy around the optic disc
Macula – breaks in Bruch memb., neovascularisation, haemorarrhage
posterior staphyloma, peripheral degeneration

37. 5. Retinal detachment

38. Retinal detachment
separation of the sensory retina from the pigment epitelium
Rhegmatogenous – retinal break
Non-rhegmatogenes
- tractional
exudative

39. Rhegmatogenous retinal detachment
Affects 1/10 000
rhegma means break in greek
It occurs in patients with
history of previous trauma to the eye
myopy
peripheral retinal degenerations like lattice degeneration

40. 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
mm-wide circumferential zone of vitreous
in the vitreous base, the collagen fibers are firmly attached to the underlying peripheral retina
other areas of firm vitreous attachment are at
the optic disc
along the major vascular arcades
the edges of retinal scars
in areas of vitreoretinal degenerations

41. Posterior Vitreous Detachment (PVD)
With age the vitreous begins to liquefy and shrink
this 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: patients with acute PVD experience flashes of light – photopsia - and/or "floaters"
flashes represent retinal stimulation from vitreous traction
floaters are shadows

42. Posterior Vitreous Detachment (PVD)
PVD might tear the retina at areas where the vitreous is firmly attached
when a piece of the retina is torn free, the remaining tear is called operculated tear
when the torn retina remains adherent , we have a flap or Horseshoe tear
flap 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

43. peripheral retinal degenerations
Benign
Predisposing perif. ret. degenerat.

44. peripheral retinal degenerations
benign
predisposing

45. peripheral retinal degenerations
Benign
snowflakes
Predisposing
snailtrack

46. Rhegmatogenous retinal detachment
can 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
this 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

47. 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

48. Exudative Retinal Detachment
Definition:        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.

49. 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..

50. 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 oil

51. 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

52. 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

53. 6. Tumors of the retina

54. retinoblastoma
A retinoblastoma is a malignant tumor of early childhood that develops from immature retinal cells.
one of births
in 30% of all cases, it is bilateral
manifests itself before the age of three in 90% of affected children
parents observe leukocoria

55. retinoblastoma Th
radiation therapy delivered by plaques of radioactive ruthenium or iodine (brachytherapy) and cryotherapy
larger tumors require enucleation

56. 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
patients usually have no ocular symptoms

57. haemangioma are typically reddish to orange
many choroidal hemangiomas never grow or leak fluid and may be observed without treatment
never metastasize.

58. Questions and discussion

59. Thank you for your attention !