You are on page 1of 61

Vitreo - Retina

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

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Vitreous
Abnormality
Floater / turbidity (Thin dense)
Degeneration
Haemorrhage
Infection / inflammation (vitritis)
Flashes
Traction to retina

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
PVD and retinal break

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retina

Normal retina
Optic disc
Superior temporal arcades
Inferior temporal arcades
Macula
Fovea

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Anatomy

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Anatomy
Retina layers

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Vision
Biochemistry of Vision:
Visual proteins : based on Vitamin A
Stimulation by light : a biochemical cascade
Electrophysiological changes
transmitted and modified through the layers of the retina the
ganglion cells the optic nerve
Central Vision:
The foveola : the most detailed vision
High density of cones
Reduction in the inner layers
reduce obstruction to light
High (near 1:1) ratio of cones to ganglion cells

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Vision
Retinal Pigment Epithelium:
The RPE
special metabolic and ionic conditions
the rods and cones for normal vision

Aging changes
Age Related Macular Degeneration
Highly vascular portion of the uvea
Supplies the outer retina

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Examination
Physical examiantion
Slit Lamp Biomicrosopic with
Condensing Lens
Goldman three mirror
Ophthalmoscope
Direct
Indirect
Additional examination
Fundus Photo Color
Fundus Fluorescein angiography
Ultrasonography

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Goldman Three Mirror Condensing Lens

Slit lamp Biomicroscopic


Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Indirect Ophthalmoscope

Direct Ophthalmoscope

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Fundus Fluorescein angiography

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Optical coherence tomography

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Ultrasonography

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retinal Abnormality
Dystrophy
Degeneration
Infection / Inflammation
Vascular
Detachment
Tumor

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Dystrophy
Retinitis Pigmentosa
Stargardt Disease

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retinitis Pigmentosa
Hereditary degeneration
Fotoreceptor
Dysfunction, loss and atrophy optic nerve.
Autosomal recessive
Autosomal dominant
x-linked rescessive
1/3 no family history

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retinitis Pigmentosa
Symptom :
Niktalopia
Constricted visual field
Sign :
Bone spicule like
pigmentation in fundus
Arteriolar narrowing
Treatment
Low vision aid
No direct medical treatment
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Stargardt disease

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Degeneration
Myopic degeneration
Age related macular degeneration

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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
Attention to complications that may occur.
Scleral buckling

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Myopic degeneration

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
ARMD
The most common cause of central vision loss
> 50 years of age (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).

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Dry ARMD
Dry ARMD / non-eksudatif (90%)
Drusen (yellowish deposits of debris in retina)
Geographic Atrophic
Treatment
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
vision worsens
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Wet ARMD
Wet ARMD (10%)
More progressive
Choroidal neovascularization
Treatment
Laser photocoagulation (> 200 um)
Photodynamic therapy
Macular translocation
Sub macular surgery

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Dry ARMD

Wet ARMD

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Infection / Inflammation
Chorioretinitis toxoplasma (toxoplasmosis)
intracellular protozoan Toxoplasma gondii.
Mammal and bird hosts.
(intermediate host is the cat).
The most frequent causes of retinochoroiditis
75 % the world's general population
possessing some seropositive findings.

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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.

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Funduscopically,
active toxoplasmosis :
white-yellow chorioretinal lesions
vitreous cells.
inactive lesions in the fellow eye.

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Treatment
Eradicate the parasite
Suppress the inflammatory response.
Classic treatment regimen:
Pyrimethamine
75 mg loading dose, followed by 25mg PO BID
administration
Sulfadiazine
2 g loading dose, then 1g PO QID for 4 to 6 weeks
Concurrent folinic acid
3 mg to 5 mg PO twice weekly
Minimize bone marrow
pyrimethamine toxicity
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Treatment
Alternative treatments
Clindamycin
Tetracycline
Trimethoprim
Sulfamethoxazole,
Oral steroid 20 to 80 mg PO
Daily 4 or 6 weeks. (after antibiotic treatment)

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Active toxoplasmosis

Inactive toxoplasmosis

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retinal vascular disease
Diabetic retinopathy
Hypertensive retinopathy
Oklusi pembuluh darah retina
Retinopati pada prematur
etc

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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
Macular Edema
Leakage plasma constituent and fluid in the macula

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Diabetic Retinopathy
Treatment
NPDR
Glucose
systemic abnormality control
Hypertension
Dislipidemia, etc
Edema makula
Focal or grid laser photocoagulation
Anti-VEGF
Steroid intra vitreal or sub tenon
PDR
Pan Retina photocoagulation
Vitrectomy
Anti-VEGF

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
NPDR

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
PDR

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Hypertensive retinopathy
WHO definition
Systolic blood pressure >140 mm Hg
Diastolic blood pressure > 90 mm Hg
HTN can affect
the choroid, retina, and optic nerve
Hypertension can cause:
Cotton Wool Spots
Nerve Fiber Layer micro-infarcts to disruption of
axoplasmic transport
Dot / Blot and flame shaped hemorrhages

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
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)

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Hypertensive Retinopathy

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

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Grade III

Grade IV

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Retinal vessel occlusion
Vena
Central (CRVO)
Cabang (BRVO)
Arteri
Central (CRAO)
Cabang (BRAO)

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
CRAO
Symptom
Acut severe loss of vision
Amaurosis fugax penglihatan kabur hilang timbul
Sign
RAPD
Pale / ischaemic retina
Cerry red spot
4-6 weeks : optic disc pale
Risk factor
Hypertension
Dislipidemia
Hemorrhelogy abnormality
GCA
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Treatment
No effective therapy
90 minutes irreversible
Ocular massage
Paracintesis
Carbogen inhalasion

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
CRAO
Pale / ischaemic retina
Cerry red spot

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
CRVO
Symptom
Acut severe loss of vision
Pain less
Sign
RAPD
Retinal and vitrous hemorrhage
Macular edema and NVG
Optic disc edema
Risk factor
Hypertension
Dislipidemia
Hemorrhelogy abnormality
GCA Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
CRVO
Treatment
No effective therapy
Laser photocoagulation

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
CRVO

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
ROP (Retinopathy of Prematurity)
A disease that occurs in premature infant and affect the blood vessel of
the developing retina
Vascular shunts
Neovascularization
Tractional retinal detachment
A major cause of Blindness and Visual Impairment in premature
infant.
Fortunately
Regression : 80 %
Progression : 20 %
25 % poor visual outcome despite current treatment
Screening at first 1 month
NORMAL VASCULAR DEVELOPMENT
IN UTERO ENVIRONMENT

1 2 months
After birth
8 months
4 months

Avascular zone Hypoxia Physiologic VEGF


Retinopathy of Prematurity

Avascular zone

Hyperoxia

Down regulated
VEGF

Decrease normal
Vascularization

Hypoxia

Up regulated
VEGF

Neovascularization
Stage 1, distinct demarcation line

Stage 2, ridge between the avascular


and vascularized retina
Stage 3, ridge with extraretinal proliferation

Stage 4, subtotal retinal detachment


4a. macula involvement (-)
4b. macula involvement (+)
ROP
Treatment
Threshold :

Laser photocoagulation, cryotherapy or anti-

VEGF
Retinal detachment
Vitrektomi
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 RD
Treatment : Vitrectomy
Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Rhegmatogen RD

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Tractional RD

Exudative RD

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Tumor
Retinoblastoma
Hemangioma choroid
Tumor sub division

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital
Thank you

Ophthalmology Department
Faculty of Medicine Diponegoro University
Kariadi General Hospital