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ANATOMY REVIEW
Vitreous
Attached to retina
Internal limiting membrane by fibrils at 3 points: Ora (strongest) Optic disc
(around ONH) at macula (ring around macula weakest
Retina
Inner limiting membrane
Nerve fibre layer (biggest
BV)
Ganglion cell layer
Inner plexiform layer
Inner nuclear layer
Outer plexiform layer
Outer nuclear layer
External limiting
membrane
Photoreceptor layer
RPE layer
Bruchs membrane
Choroid
1. Inner Retina
Vessels
Function
Histology
Clinical
2. Outer retina
Vessels
Clinical
Inner retina
Sensory retina
Outer retina
(Avascular)
Choroid
3. RPE Layer
Attachm
ent
Function
Clinical
4. Bruchs membrane
Def
Part of choroid
The only elastic layer
Function
In young eyes, it is smooth and ensures regular alignment of
RPE
Separates choriocapillaris from retina
Clinical
All systemic diseases affecting collagen and elastic tissue will
affect Bruchs
Layer changes with age and is involved in many disease
processes
Breaks in Bruchs allow for sub-retinal fluid and
neovascularization (from choroid)
Bruchs and RPE are closely related and disease in one usually
affects the other
Compromise to Bruchs can lead to compromise to choroid
layer and RPE
5. Choroid
Vessels
Vortex
veins
6. Sclera
- Avascular
- Relies on episcleral and choroidal BV
7. Macula
Vessels
Clinical
No vessels
Nurtured by choriocapillaris
Cherry red spot in CRAO
Sensory
retina
4. Retinal Hole
Def
Morph
Association
Managemen
Clinical
5. Choroidal Scar
Aetiology
Toxoplasmosis
Result of inflammation or subretinal haemorrhages
Def
Well-defined white area indicative of scar tissue, or absence of
retinal and choroidal ttissue
Morph
Often lesions are big (1-2DD)
Fluffy white region around lesion (Foglight) = ACTIVE (Indicates cells
in vitreous)
6. Choroidal naevus
Presentatio
Can become malignant
n
Morph
Size = 0.25DD to 7DD
Colour = greenish/gray and faded compared to RPE
hyperpigmentation
Feathery but defined borders
Managemen
If larger than 4DD, refer
t
Document shape (H and V) and elevation/flatness
If drusen is observed superficially, it is a good sign
Drusen reflects (lack of absorption of lipofucin)
Tests
With Red Free Filter, choroidal naevi seem to disappear/get less
7. Choroidal melanoma
Clinical
Lipofucin = waste product of RPE layer = metabolic problem
Orange = malignancy (Showing choroiddal blood vessels due to
thinning of RPE
Managemen
Cobalt plaque-ing
t
Radiation therapy
Enucleation
Morph
Clinical
Aetiology
Occur in NFL
Flame shaped haemorrhages
Yellow/white centre
If seen in young px > associated with leukaemia (spot is due to
accumulation of WBC)
Hx important
In adult, white spot may be fibrin or cotton wool spot (If close to
large blood vessel, possible infarction)
Diabetes
Hypertension
Connective tissue diseases
Other inflammatory vascular diseases (lupus, anaemia)
Presentatio
n
Location
Aetiology
Pathogenesi
s
Tx
4. Drusen
Morph
Location
Def
Presentatio
n
Pathophys
Clinical
Test
Morph
Clinical
Morph
Clinical
DDX
Associated
conditions
Small
Localized RPE dysfunction
Definite borders
If area grows or involves Bruchs and groups together, it can become
soft/confluent drusen
Soft/Confluent
Larger
Fluffier borders
Associated with pathological situations
Peripheral = Not a problem
Macular area = problem
Almost looks like cotton wool spots
Difference: no pathology + under retinal vessels
ARMD
Peripheral, retinal degeneration
NFL
Aetiology
secondary to vascular diseases with retinal hypoxia
HIV Diabetes Hypertension SLE BV infarct disease
6. Retinal neovascularisation
Aetiology
Secondary to retinal ischemia or hypoxia (precipitated by stimulus)
Morph
Very fragile and lacey
Location
Between NFL and ILM
Or between ILM and vitreous (very superficial)
Categories
Neovascularisation at the disc (NVD)
Neovascularisation elsewhere (NVE)
Clinical
Vessels tend to leak and haemorrhage
Results in fibrosis and later retinal traction
Main cause of neovascularisation in the eye
VEGF (veso-endothelial growth factor) present
Tx
Anti VEGF injected (anti-inflammatory)
Neo in eye
Retinia disc choroid - iris
7. Intraretinal Microvasular Abnormalities (IRMA)
Location
Occurs in areas of retinal hypoxia (usually deeper part) in intraretinal
vessels (very small vessels)
DDX
Easily mistaken for neovascularisation vessels or collateral, but
DEEPER
Fluorescein angiography > IRMAs leak in late phase of angiogram
Clinical
Poor prognosis
Aetiology
Response to hypoxia
8. Collaterals
Aetiology
Def
Function
DDX
Morph
Joins
Serous
11.
Choroidal neovascular membrane (CNVM)
Pathophysiol
Due to neovascularisation of choroid
ogy
Underlying blood vessel formation is like a fibrous meshwork and is
obscured
Clinical
Ocular emergency
CNVM tend to grow rapidly and are unpredictable
May recur at later stage
Morph
Greenish-grey membrane
Slight elevation to area involved
Layers
Choroid Bruchs RPE sensory retina
involved
Tendency to underlie macula
Complication
Serous RP detachment
s
Serous sensory retinal detachment
Retinal haemorrhage
DDX
Between serous detachments
Serous are paler, more defined by their definite borders and balloon
out acuity more affected
Use 90D to see
Tx
Urgent referral
Try to determine aetiology and location
Fluorescein angiography and laser treatment indicated
Photocoagulation
Aetiology
ARMD
Presumed
ocular
histoplasmos
is
Pathological
myopia
Angioid
Streaks
Argon
Krypton
Yag
Visuodyme
Anti-VEGF
The Macula
A. Anatomy Review
Posterior
Size: 3 to 4DD
pole
Area is defined where ganglion cells are greater than one cell layer
in thickness
Normally extends from temporal edge of ONH, bounded by vascular
arcades
Macula
Size: 5mm
Affects central 5deg of vision
Region bounded by Xanthophyll and contains more than 1 layer of
ganglion cells
Unique part of retina due to elongated RPE cells
Avascular
Choroid underneath is extremely vascular and appears darker
Central pit accentuates foveal slopes
Fovea
Depression in inner retinal surface at centre of macula
Forms foveal reflex due to concave mirror effect (Loss of reflex is
significant)
Affects central 1-deg of vision
Size: 1.5mm
Foveal
Important landmark in laser Tx
avascular
Extends to 1/3DD in size
zone
Darker, and RPE is taller with presence of xanthophyll
300 microns devoid of capillaries
Foveola
Forms central floor of fovea
Diameter = 0.35mm
Contains no ganglion cells
Only cones and their nuclei
Very thin
Central depression = umbo
B. Details of anatomy of macula
Retinal
Only outer layers present: ILM OPL ONL ELM Photoreceptors
Layers
(outer seg) RPE layer
OPL has huge cystic spaces (carries receptor cell axons) > increase
in extracellular space at macula
Function of RPE layer is to keep this area relatively dry > pumps out
Fe and water from subretinal space
Pathology > fluid tends to accumulate
NFL of Henle = radial arrangement of axons > forms stellate pattern
of fluid and exudate if RPE is compromised
RPE
RPE-Bruchs very tightly attached and affects each other
Bruchs
If integrity is lost, waste products from photoreceptor cells collects
choriocapilla
(RPE cant phagocytose it)
ris
Bruchs
angiograph
y
Fundus
photograph
y
Colour
vision
10
Contrast
sensitivity
Dx
Documentation
Objective monitoring
Good test for acquired colour defects
Blue/Yellow loss indicates macular disease
Tritan defect = diabetes with oedema
Red/Green defects = ONH disease
Impression of quality of vision
Higher frequency CS decrease in certain macular pathologies
Risk
Clinical
Epidemiolog
y
Causes