Dr. Jatushan NG-Pooresatien;M.D.Department of OphthalmologyChonburi hospital

1.    basic anatomy of the retina and vitreous

2.    symptoms, signs, principles of treatments, sequelae and prevention of common retinal diseases

3.    significance of the floater and/of flashing symptoms

1. Basic anatomy of the retina and vitreous2. Symptoms, signs, sequelae, principles of

treatments, and prevention of common retinal diseases, eg.

2.1 Retinal vascular diseases 2.2 Macular degeneration 2.3 Retinal detachment

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion

2.2 Macular degeneration2.2.1 Age related macular degeneration2.2.2 Myopic macular degeneration

2.3 Retinal detachment2.3.1 Rhegmatogenous2.3.2 Exudative2.3.3 Tractional

Anterior segmentPosterior segment

กระจกตา(cornea)

เปลือกตา (eye lid)

ขนตา(eye lash)

เยื่อบุตา(conjunctiva)

80Occupying % ofvvvvvv vv vvv vvv

เป็น vvvvv vvvvvv ซึ่งประกอบด้วย collagen hyaluronic aci

d และ น้ำ�า

Anterior ติดกับ posterior lens capsule

posterior ติดกับ ILM of neurosensory retina

pars plana เรยีก บรเิวณนี�วา่ vitreous base

retinal vessel optic nerve ; Weiss ringmacular

มบีรเิวณท่ีติดแน่นกับ retina ได้แก่

MacularFoveaEquatorial retinaperipheral retina ; ora serrata

Rod and cone cell external limiting membrane outer nuclear layer (photorecepter cell body )

outer plexiform cell

inner nuclear layer ( bipolar cell ) (1st order neuron)

inner plexiform cell ganglion cell layer nerve fiber layer ( The axons of the ganglion cell layer)

internal limiting membrane

The ocular exit site of all retinal ganglion cell axons

Location nasal site of fovea 3-4 mm

Size V*H= 1.7*1.5 mm

Is the neural connection between the neurosensory retina and the lateral geniculate body

No photoreceptor cell

Absolute scotoma (Blind spot of Mariotte)

The ocular exit site of all retinal ganglion cell axons

Location from fovea to nasal site 3-4 mm

Size V:H 1.7:1.5 mm

degenerative process เชน่ Age related Macula Degeneration (AMD)

abnormal metabolic process เชน่ Diabetic retinopathy

Vascular occlusive diseases เชน่ โรค central หรอื branch retinal vein หรอื artery occlusion หรอื การเปล่ียนแปลงท่ีเราอาจพบได้ของ

เสน้เลือด เชน่ใน hypertensive retinopathy

systemic drug toxicity เชน่ การได้ยา Chloroquine derivatives หรอืยาใน กลุ่ม Phenothiazines

inflammatory process เชน่ uveitis หรอืการอักเสบของมา่นตา

infection เชน่ CMV retinitis

อาการตามวั โดยหากมจีอตาสว่น macula ผิด ปกติ ก็จะท้ำาใหม้ี central visual acuity ลดลง

แต่ในกรณีท่ีเป็นความผิดปกติของจอตาสว่นท่ีเป็นperipheral retina ก็จะท้ำาใหม้ผีลต่อการมอง

เหน็ด้านนอก หรอื การลดลงของความกวา้งในการ มองเหน็ (peripheral visual field defect)

ตาบอดกลางคืน(Nyctalopia) โรคของจอตาจะไมม่อีาการปวด เนื่องจากไมม่ี

pain receptor ท่ี retina

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy

- Branch retinal vein occlusion (BRVO)

- Central vein occlusion (CRVO)

Grade 0 no changes Grade 1 Barely detectable arterial

narrowing Grade 2 Obvious narrowing with focal

irregularities Grade 3 Grade 2 plus retinal

edema/hemorrhage and cotton wool spot Grade 4 Grade 3 plus disc swelling

Vasoconstrictive stage

vasospasmGeneralized arteriolar vasospasm

Sclerotic stage

•Intimal thickening•Hyperplasia of medial wall•Hyaline degeneration

•Severe generalized and focal arteriolar narrowing•AV nicking or nipping•Copper wiring

Exudative stage

•Disruption of blood-retina barrier•Necrosis of smooth m. & endothelium

•Microaneurysm•Hemorrhage•Hard exudate•Cotton wool spot

Cotton wool spot

hemorrhage

Severe elevated blood pressure Swelling of optic disk

Malignant HT

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion

CRA compressed the CRV in the vicinity of lamina cribosa , leading to turbulence, endothelial damage, and subsequent thrombus formation

10% have history of CRVO /BRVO

Systemic abnormalities association

Systemic associationArterial hypertensionDiabetes mellitusHyperviscosityIncrease intraocular pressure

Dilated and tortuous retinal vein

swollen optic discRetinal hemorrhagemacular edemacotton wool spots

Non-ischemic (perfused) form Ischemic (non-perfused) form

capillary dropout of at least 10 disc area

Neovascularization of optic disc or retina

Neovascularization of Iris Vitreous hemorrhage

Treatment for associated medical conditions eg:Hypertension: Diabetes: Hyperlipidemia

Vasodilator drug ??? Steroid ??? Aspirin for decrease platelet

aggregation ??? Laser PRP for prevent neovascular glaucoma

More common in those with a history of systemic hypertension

10% of BRVO develop in second eye

Usually occur at an arteriovenous crossing

As CRVO in the distribution of blocked vessel

As CRVO

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion

1:10000 out patient ophthalmic visit

caused emboli phenomenon: thombosis: inflammation: systemic hypotension

Artherosclerosis related thrombosis at laminar cribosa

Emboli from carotid artery or heart

sudden painless severe vision loss

Retina become opaque edematous

cherry red spot

Glove(digital) massageAnterior chamber paracentesisO2+CO2(carbogen) combination inhalation therapy

Oral vasodilator systemic anticoagulant

sudden painless severe vision loss in part of visual field of the affected eye

Superficial retinal whitening is seen in the distribution of the fundus supplied by the vessel

Generally not given It is not particularly effective and prognosis is relatively good

Medical work up is important

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion

2.1 Retinal vascular diseases2.1.3 Diabetic retinopathy

- Nonproliferative- Proliferative- Diabetic macular edema

Is essentially a microangiopathy affecting the retinal precapillary arterioles,the capillaries, and the venules

Is unknownแต่เชื่อวา่การม ีhyperglycemia นานๆ เป็นสาเหตขุอง vascular endothelial damage

Pericyte cell loss

Increase platelet adhesiveness aggregation

Decreased deformability of red and white blood cell

Increase basement formation in the retinal cappiaries

Loss of autoregulation in the retinal vessels

Pericyte cell lost

Microaneurysm Retinal edema Hard exudate

Dot blot hemorrhageNPDR

Cotton wool spotsArteriolar narrowing

Venous change :- dilatation; looping;

beadingNPDR

NeovascularVitreous hemorrhage

Tractional retinal detachment

PDR

NPDR (Non Proliferative Diabetic Retinopathy)

PDR (Proliferative Diabetic Retinopathy)

CSME (clinical significant macular edema)

Medicine control blood glucose control lipid control blood pressure

Laser pan retinal photocoagulation (PRP)focal or grid laser

Surgery par plana vitrectomy

Type 1 หลังวนิิจฉัยโรค 5 ปีType 2 as soon as

possibleThen every year

ผู้ป่วยท่ีเป็น diabetes retinopathy อาจมคีวามชดัของตา

ปกติ แมอ้ยูใ่นระยะสดุท้าย Early detection and timely treatment can prevent vision

loss

2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion

A vanguard of mesenchymal cell initial growth outward in the nerve fiber layer from the region of the optic disc starting at 4-5 month of gestation

These mesenchymal cells give rise to retinal cappillary endothelial cells which then form the cappillary system

เสน้เลือด ท่ียงัไมถึ่ง periphery ได้รบัoxygen ในความเขม้ขน้ท่ีสงูกวา่ในครรถ์ เกิด vasoconstricttion and vasoobliteration และหยุดการเจรญิเติบโต

peripheral retina เกิดภาวะ relative hypoxia จงึมกีารสรา้ง angiogenic factors

Gestation 4 m36 wk to nasal 40 wk to temporal

Prematurity Low birth weightExcessive oxygen administration

Stage 1 defined as a thin structure with in the plane of the retina that separates vascularized from avascular retina

Stage 2 represents an elevated ridge that has extend beyond the plane of the retina

stage 3 there is extraretinal fibrovascular proliferration or neovascularizationat the ridge

Stage 4 there is a partial traction-like retinal detachment

stage 4A indicates extramacular retinal detachment

stage 4B indicates macular involvement

Stage 5 is defined as a total retinal detachment

significantly dilated and tortous retinal vessels in the posterior pole

vitreous haze iris vessel engorgement poor pupillary dilation

Indicates extensive vascular incompetence

Zone 1 circle 60 degree around disc

Zone 2 circle to nasal siteZone 3 remain temporal site

Number of clock hour involve

Cryopexy and /or laser indirect ophthalmoscopy

Scleral bucklingPars plana vitrectomy

Low birth weight <1500 gm

gestational age < 32 wkage 4-6 wk

2.2 Macular degeneration2.2.1 Age related macular degeneration2.2.2 Myopic macular degeneration

2.3 Retinal detachment2.3.1 Rhegmatogenous2.3.2 Exudative2.3.3 Tractional

Caused of legal blind in people over 50 years old

more than 200000 new cases are reported each year in the united states alone

An accumulation of undigested products of RPEcells under the basal

lamina of Bruch’s menbrane

Is characterized by Drusen , which appear as yellowish

concrescences beneath RPE, and by degenerative change

s in Bruch’menbrane and RPEcells

Non neovascular AMD (Dry type or Atropic type)

Neovascular AMD (WET AMD)

Produces progressive atrophy of pigment epithelium and the choriocappillaris

No neovascularization

An exudative macular detachment is caused by leakage from CNVM or form RPE detachment

subretinal fluid often is hemorrhage and hard exudate

Decrease central vision may be sudden or chronic

Metamorphopsia

SunglasssupplementsLaser for NeovascularPhotodynamic therapyAnti-VEGF

In very large eyes the retina and

choriocapillaris are thin

Thinning of macular pigment epithelium

Peripapillary atrophyTilting of the optic disc

Early finding

Breaks in Bruch’s membrane ( lacquer cracks)

Posterior staphyloma Small macular hemorrhage Formation CNVMs Severe macular atrophy Macular hole may causes macular

detachment

Late finding

Laser photocoagulation for CNVMs

Treatment for retinal detachment

is characterized by progressive atrophy of the rods and cones. In most cases; there is associated migration of pigment epithelial cells into the retina

สาเหต ุ เป็นได้ทั�ง AR ; X-linked recessive อาการรุนแรง เกิดเรว็ (early childhood) หรอื AD เกิดชา้ ( middle age)

อาจแบง่ออกเป็นสองกลุ่ม type1 rods ถกู affect ก่อนcones และ type2 cones ถกู affect ก่อน rods

Clinical feature type1 scotopic vision and peripheral vision ลดลง สว่น central visual acuity ในระยะเริม่ต้นมกัจะดี ต่อมาลดลงเนื่องจาก macular atrophy; cystoid macular edema; typical posterior subcapsular cataract

Fundus finding จะพบ vitreous cell and opacities; narrowed arteries; diffuse depigmentation of the RPE; and comma-shaped intraretinal proliferation of pigment cells ( bone spicules ) สว่น waxy pallor of the optic disc จะพบในระยะสดุท้าย

Type2 มกัไมม่อีาการ night blindness จนกวา่ visual field จะลดลงกวา่ 10 องศา

photopic ERG is more severely effect than is the scotopic

Photocoagulation Burn Photodisruption Burst

Photocoagulation เป็น Thermal laser ใชห้ลักวา่ แสงเลเซอรถ์กู absorb โดย tissue แล้วเปล่ียนเป็นความรอ้นท่ีสงูพอจนท้ำาให ้ tissue เกิด coagulation หรอื denature cellular componants ใชร้กัษาพวก diabetic retinopathy หรอื sealing of retina holes (Argon laser)

A seperation of the neurosensory

retina from the pigment

epithelium and choroid

ภาวะที่มกีารแยกระหวา่ง neuro-sensory retinaและ RPE

Rhegmatogenous Nonrhegmatogenous

•Exudative retinal detachment•Tractional retinal detachment

Clinical course and pathophysiology of retinal detachment

Rhegmatogenous retinal detachment เกิดจากการม ีretinal break (retinal hole; retinal tear ) และ fluid ( liquefied vitreous )ท่ีเกิดจากการเสื่อมของ vitreous ไหล เขา้ potential space ระหวา่ง neuroretinal and pigment retinal epithelium จนท้ำาให ้มกีารแยกชั�น กันเกิดขึ�น

R etin a l b reak L iq u e fied vitreou s

R h eg m atog en ou s re tin a l d e tach m en t

R E TIN A L TE A R R E TIN A L H O L E

R E TIN A L B R E A K

floa te r flas h in g V .A . d rop

sym p tom

Close holeDrain subretinal fluidPermanent scar

Exudative retinal detachment (Exudative; Hemorrhagic retinal detachment ) เกิดเน่ืองจากมกีารสะสม fluid ใต้ sensory retina ซึ่งสว่นใหญ่เกิดจากโรคของ RPE and choriod

Tractional retinal detachment มกัเกิดจาก proliferative diabetic retinopathy; proliferative vitreoretinopathy; retinopathy of prematurity; ocular trauma.

Traction forces ท่ีดึง retina ออกจาก RPE อาจมาจาก vitreal; epiretinal or subretinal menbrane ซึ่งเกิดจาก fibroblast; glial and RPE cell