VITREORETINAL PATHOLOGYMr A Manna – http://about.me/ashmanna

Vitreoretinal ASTO – Wolverhampton Eye Infirmary

28 August 2012

CONTENTS

► Indirect Ophthalmoscopy

► Technique

► Retinal Breaks

► Treatment

► Retinal Detachment

► Assessment

► Pathological Myopia

► Ocular and systemic features

INDIRECT OPHTHALMOSCOPY

INDIRECT OPHTHALMOSCOPY

► Introduce yourself.

INDIRECT OPHTHALMOSCOPY

► Observe external cues:

► High myopic glasses: myopic degeneration, staphyloma, laser for retinal tear

► Hearing aid: RP

► Etc.

INDIRECT OPHTHALMOSCOPY

► Lie patient on couch

► Make sure enough room to move around patient

INDIRECT OPHTHALMOSCOPY

► Adjust everything:

► Headband

► IPD: adjust by shining light on back of hand

► Dim room lights

► Make sure you use the 28D or 20D lens the right way up

INDIRECT OPHTHALMOSCOPY

► Look at the fundus:

► Move lens away from eye until stereoscopic image obtained (5cm for 20D lens)

► Tilt lens to reduce reflections

INDIRECT OPHTHALMOSCOPY

► Examine:

► Optic Disc

► Retinal Vessels

► Macula

► Peripheral retina in all cardinal positions

INDIRECT OPHTHALMOSCOPY

► Indent:

► To view between equator (14mm from limbus) and pars plana (Spiral of Tillaux)

INDIRECT OPHTHALMOSCOPY

► Draw: (useful to have notes upside down)

► Red: retinal arterioles, retinal haemorrhage, microaneurysms, neovascularisation, retinal break

► Blue: retinal venules, detached retina, outline of retinal break or hole

► Yellow: exudate, oedema

► Green: vitreous opacity (e.g. haemorrhage)

► Brown: pigmentation, detached choroid

► Black: ora serrata, drusen, hyperpigmentation

INDIRECT OPHTHALMOSCOPY

Lens Magnification

Field of view

Image Principal use

+14 BIO 4x 40o Inverted, Reversed, Real

Fundus lesion

+20 BIO 3x 45o Routine examination

+30 BIO 2x 50o Child, small pupil, media opacity

http://www.volk.com/main/compare/indirectbio.html

INDIRECT OPHTHALMOSCOPY

Done!

RETINAL TEARS

► What to treat?

RETINAL TEARS

► Treat all symptomatic tears/holes

► Notes to VR Consultant

► If low risk, discharge with Retinal Detachment Warning

► If treatment not complete, ring me and I will complete treatment within a week

► My job is twofold:

► Laser up to ora

► Look for other breaks

RETINAL TEARS

► Anything that doesn’t need lasering?

RETINAL TEARS

► Tear more dangerous than Hole

► Pigmentation is reassuring

► Symptomatic breaks more dangerous than incidental finding

► Worrying factors:

► Cataract surgery esp. with vitreous loss

► Myope

► FHx RD

► Marfan, Stickler, Ehlers-Danlos

RETINAL DETACHMENT

RETINAL DETACHMENT

► What the Vitreoretinal Surgeon wants to know:

► History (symptoms, duration, VF defect, trauma), vision, POH, Myopia, Systemic Conditions (connective tissue disease, suitability for GA), FHx RD, Tobacco dust, extent of RD (clock hours, how close to macula, shallow, bullous, dome), Is the retina translucent? Are there lines of pigment around the detachment? Does the fellow eye have Retinoschisis? If mac-on, keep NBM for now (just in case). DO NOT promise immediate surgery!!! 

HIGH MYOPIA

WHAT TO DO WHILE WAITING

► 1. NBM

► 2. DO NOT promise immediate surgery. Consent "Right/Left Retinal Detachment Repair".

► 3. Admit to D4

► 4. Is patient happy for LA instead of GA?

► 5. Nurses to phone Nucleus Theatres to see what's on the emergency list.

► 6. Inform on-call theatre staff and ask if surgery next morning (07:30) is an option.

► 7. Take 2 patient stickers to Nucleus Theatres and book the case for tonight AND tomorrow morning.

► Dialysis, trauma related, young patient, avulsion of vitreous base may give bucket-handle. If no RD, laser. If RD, usualy progress slowly due to healthy vitreous gel in young individuals.

Don’t miss the elephant in the room

EXUDATIVE RD

► Convex, smooth (not corrugated)

► Mobile, with ‘shifting fluid’ phenomenon

► Systemic disease: Harada disease, toxaemia of pregnancy

EXUDATIVE RD

► Causes:

► Choroidal tumours: melanomas, haemangiomas, metastases

► Inflammation: Harada, scleritis

► Bullous CSR: rare

► Iatrogenic: RD surgery, PRP

► CNVM

► Hypertensive choroidopathy: toxaemia of pregnancy

► Idiopathic: Uveal effusion syndrome

PVR IN LONGSTANDING RDS

► Grade A (minimal) PVR: diffuse vitreous haze and tobacco dust. Pigmented clumps under retina.

► Grade B (moderate) PVR: wrinkling of inner retinal surface, tortuosity of blood vessels, retinal stiffness, decreased mobility of vitreous gel, rolled edges of retinal breaks

► Grade C (marked) PVR: full thickness rigid retinal folds. Heavy vitreous condensation and strands. Described as Anterior/Posterior + Clock hours.

HIGH MYOPIA

HIGH MYOPIA

► Refractive error > -6D and axial length > 26mm

► 0.5% of population

► Maculopathy commonest cause of visual loss

Pale tessellate (tigroid) appearance due to diffuse attenuation of the RPE with visibility of large choroidal vessels.

Focal chorioretinal atrophy characterised by visibility of the larger choroidal vessels and eventually the sclera

‘Lacquer cracks’ consist of ruptures in the RPE-Bruch membrane-choriocapillaris complex characterised by fine, irregular, yelow lines, often branching and criss-crossing at the posterior pole

Fuchs spot is a raised, circular, pigmented lesion that may develop after a macular haemorrhage has absorbed

Subretinal ‘coin’ haemorrhages, which may be intermittent, may develop from lacquer cracks in the absence of CNV

Staphylomas are due to expansion of the globe and scleral thinning. They may be peripapillary or involve the posterior pole and be associated with macular hole formation.

HIGH MYOPIA

► Foveal retinoschisis: in the absence of macular hole.

► Peripapillary detachment: asymptomatic, innocuous, yellow-orange elevation of the RPE and sensory retina at the inferior border of the myopic conus.

HIGH MYOPIA

► Associations:

► Cataract

► POAG

► Pigmentary glaucoma

► ROP can be related to subsequent high myopia

► Amblyopia uncommon, but can be there due to anisometropia

► Systemic:

► Stickler

► Marfan

► Ehlers-Danlos

► Pierre-Robin

HIGH MYOPIA

► Associations:

► Cataract

► POAG

► Pigmentary glaucoma

► ROP can be related to subsequent high myopia

► Amblyopia uncommon, but can be there due to anisometropia

► Systemic:

► Stickler

► Marfan

► Ehlers-Danlos

► Pierre-Robin

Stickler SyndromeHereditary arthro-ophthalmopathyAbnormal vitreousHigh myopiaOrofacial abnormalityDeafnessArthropathyMitral valve prolapseAD inheritance with variable expressivity

Commonest inherited cause of retinal detachment in children.

HIGH MYOPIA

► Associations:

► Cataract

► POAG

► Pigmentary glaucoma

► ROP can be related to subsequent high myopia

► Amblyopia uncommon, but can be there due to anisometropia

► Systemic:

► Stickler

► Marfan

► Ehlers-Danlos

► Pierre-Robin

Marfan SyndromeConnective tissue disorder – mutation of fibrillin gene on chromosome 15q.Tall, thin, long limbs compared with trunkArachnodactyly, joint hypermobilityGothic palateDilatation of ascending aorta, aortic incompetence, heart failure, mitral valve disease, aortic dissection

Ectopia lentis, myopia, RD

AD inheritance with variable expressivity.

HIGH MYOPIA

► Associations:

► Cataract

► POAG

► Pigmentary glaucoma

► ROP can be related to subsequent high myopia

► Amblyopia uncommon, but can be there due to anisometropia

► Systemic:

► Stickler

► Marfan

► Ehlers-Danlos

► Pierre-Robin

Ehlers-Danlos syndrome type 69 subtypes, but only type 4 and 6 affect the eye.Rare, usually AR disorder of collagen caused by deficiency of procollagen lysyl hydroxylase.

Thin hyperelastic skin.Hypermobile joints.Cardiovascular disease: bleeding diathesis, dissecting aneurysms, spontaneous rupture of large blood vessels, mitral valve prolapse

Ocular fragility with increased vulnerability to mild trauma, high myopia, retinal detachment, keratoconus

HIGH MYOPIA

► Associations:

► Cataract

► POAG

► Pigmentary glaucoma

► ROP can be related to subsequent high myopia

► Amblyopia uncommon, but can be there due to anisometropia

► Systemic:

► Stickler

► Marfan

► Ehlers-Danlos

► Pierre-Robin

Pierre-Robin syndrome

Micrognathia, small tongue, cleft soft palate, high-arched palate.

Jaw that is very small with small (receding) chinJaw that is far back in the throatRepeated ear infectionsSmall opening in the roof of the mouth, which causes chokingTeeth that appear when the baby is born (natal teeth)Tongue that is large compared to the jaw