Vitreo-Retina

Vitreo-Retina Subdivision
Ophthalmology Department
Faculty of Medicine and Health Sciences
Jenderal Soedirman University / Margono Soekarjo General Hospital

Vitreous
A water (99%) and Hyaluronic acid &
collagen (1%) mix
Optically clear, fills centre of globe
Firm adhesions to optic nerve, peripheral
retina at ora serrata and retinal blood
vessels can produce retinal detachment
when they tear loos
Normally shrinks somewhat with age
Sineresis, Posterior vitreous detachment

Vitreous
Abnormality
Floater / turbidity
Degeneration, Haemorrhage, infection /
inflammation
Thin - dense

Flashes
Traction to retina

Posterior
Vitreous
Detachment

Traction Vitreous /
Retinal Break

Retina

Normal retina

Optic disc
Superior temporal arcades
Inferior temporal arcades
Macula
Fovea

Anatomy

Anatomy
Retina layers

Vision
Biochemistry of Vision:
Visual proteins are based on Vit.A
Stimulation by light causes a
biochemical cascade
Electrophysiological changes are
transmitted and modified through the
layers of the retina to the ganglion
cells that form the optic nerve

Vision
Central Vision:
The foveola has the most detailed
vision
High density of cones
Reduction in the inner layers to
reduce obstruction to light
High (near 1:1) ratio of cones to
ganglion cells

Vision
Retinal Pigment Epithelium:
The RPE provides special metabolic and ionic conditions
necessary for the rods and cones and is essential for
normal vision
Aging changes in the RPE result in Age Related Macular
Degeneration
Highly vascular portion of the uvea
Supplies the outer retina with much of its metabolic
requirements

Examination
Physical examiantion
Slit Lamp Biomicrosopic with
Condensing Lens
Goldman three mirror

Ophthalmoscope
Direct
Indirect
Additional examination
Fundus Photo Color
Fundus Fluorescein angiography
Ultrasonography

Goldman Three Mirror

Condensing Lens

Slit lamp Biomicroscopic

Indirect Ophthalmoscope

Direct Ophthalmoscope

Fundus Fluorescein angiography

Ultrasonography

Retinal Abnormality

Dystrophy
Degeneration
Infection / Inflammation
Vascular
Detachment
Tumor

Dystrophy
Retinitis Pigmentosa
Stargards Disease

Retinitis Pigmentosa
Hereditary degeneration
Fotoreceptor
Dysfunction, Loss and atrophy.

Autosomal recessive, autosomal dominant,

x-linked rescessive and 1/3 no family
history

Retinitis Pigmentosa
Symptom :
Niktalopia
Constricted visual field
Sign :
Bone spicule like
pigmentation in fundus
Arteriolar narrowing

Treatment
Low vision aid
No direct medical
treatment

Stargardt disease
Juvenile macular dystrophy
Gen ABC4R on lp 21-22
Symptom
Presentation on second decades
Gradual impairment of central vision
Signs
Geographic atrophy
Fovea may be normal or non specific
Treatment
Low vision aid
No direct medical treatment

Stargardt disease

Degeneration
Myopic degeneration
Age related macular degeneration

Myopic degeneration
Pathologic / high Myopia
Progressive elongation of the eye
Thinning RPE and choroid
> - 6.00 D
Axial length > 26 mm
Liable to glaucoma and cataract
Treatment
Limited to optical correction, intra-ocular pressure
control, and attention to complications that may occur.
Scleral buckling can prevent axial extension and may
minimize the toll of myopic macular degeneration on
future visual function.

Myopic degeneration

ARMD

(Age Related Macular Degeneration)

The most common cause of central vision

loss in persons older than 50 years of age
in developed countries.
Symptom
In the early stages
central vision may be blurred or distorted,
with objects looking an unusual size or
shape and straight lines appearing wavy
or fuzzy (quickly or over several months).

Dry ARMD
Dry ARMD (90%)
Drusen (yellowish deposits of debris in retina)
Atrophic

Treatment
eat a diet rich in leafy green vegetables,
antioxidants,zinc, lutein and zeaxanthin.
avoid excessively bright sunlight (ultraviolet
(UV) rays and blue light)
don't smoke
contact a low vision specialist if vision worsens

Wet ARMD
Wet Armd (10%), More progressive
Choroidal neovascularization

Treatment
Laser photocoagulation
Photodynamic therapy
Macular translocation
Sub macular surgery

Dry ARMD

Wet ARMD

Infection / Inflammation
Chorioretinitis toxoplasma (toxoplasmosis)
intracellular protozoan Toxoplasma
gondii
Mammal and bird hosts.
(The most common intermediate
host is the cat).
It is one of the most frequent causes of
retinochoroiditis in humans, 75 % the
world's general population possessing
some seropositive findings.

Toxoplasmosis
Symptoms
unilateral, mild ocular pain, blurred vision and
new onset of floating spots.
Clinical findings
granulomatous iritis, vitritis, optic disc swelling,
neuroretinitis, vasculitis and retinal vein
occlusion in the vicinity of the inflammation, in
the actively involved eye.
Funduscopically:
active toxoplasmosis presents with whiteyellow, choreoretinal lesions and vitreous
cells
There may be old, inactive lesions in the
fellow eye

Treatment
Eradicate the parasite and suppress the
inflammatory response.
Classic treatment regimen
pyrimethamine (a 75mg loading dose, followed
by 25mg PO BID administration) with
sulfadiazine (2g loading dose, then 1g PO QID
for 4 to 6 weeks).
Concurrent folinic acid, 3 to 5mg PO twice
weekly helps to minimize any bone marrow
toxicity produced by the pyramethamine.

Treatment
Alternative treatments
clindamycin, tetracycline, trimethoprim /
sulfamethoxazole,
After beginning antibiotic therapy, add oral
steroids at a dose of 20 to 80mg PO daily
for four or six weeks

Active toxoplasmosis

Inactive toxoplasmosis

Retinal vascular disease

Diabetic retinopathy
Hypertensive retinopathy
etc

Diabetic Retinopathy
Hyperglycaemia
Loss of pericyte
Thickening of basement membrane
Alteration of coagulation state

Non-proliferative DR
Microaneurism
Dot & blot intraretinal hemorrhage
Hard exudates
Dilatation and beading of retinal vein

Proliferative DR
Neovascularization
On the disc or else where

Diabetic Retinopathy
Treatment
Glucose and other systemic abnormality control
Laser photocoagulation
Vitrectomy

NPDR

PDR

Hypertensive retinopathy
WHO definition
Systolic blood pressure >140 mm Hg
Diastolic blood pressure > 90 mm Hg
HT can affect the choroid, retina, and optic
nerve
Hypertension can cause:
Nerve Fiber Layer micro-infarcts, called
Cotton Wool Spots - due to disruption of
axoplasmic transport
Dot/Blot and flame shaped hemorrhages

Hypertensive Retinopathy
Modified Scheie Classification
Grade 0 No changes
Grade 1 Minimal arteriolar narrowing
Grade 2 Obvious arteriolar narrowing with
focal irregularities
Grade 3 Grade 2 + retinal hemorrhages and/
or exudate
Grade 4 Grade 3 + swollen optic nerve
(Malignant hypertension)

Hypertensive Retinopathy
Management
Lower the blood pressure gradually to
decrease risk of blindness and stroke

Grade III

Grade IV

Retinal Detachment
Detachment the nuero-sensory retina from
the underlying pigment epithelial layer by
subretinal fluid
Exudativa
Uveal effusion (infection or inflammation)
Treatment : Underlying disease

Rhematogenous
Retinal break
Treatment : Scleral Buckling, Vitrectomy

Tractional
Proliferative DR
Treatment : Vitrectomy

Rhegmatogen RD

Tractional RD

Exudative RD

Tumor
Retinoblastoma
Hemangioma choroid
Tumor sub division

Thank you