RETINA

• dr boyke sisprihattono, spm

A N AT O M Y O F T H E R E T I N A
T H E T E N L AY E R S O F T H E
RETINA
1. Pigment epithelium layer
2. Layer of rods and cones
3. External limiting membrane
4. Outer nuclear layer
5. Outer plexiform layer
6. Inner nuclear layer
7. Inner plexiform layer
8. Ganglion cell layer
9. Nerve fibre layer
10.Internal limiting membrane
SYMPTOMS IN RETINAL
DISEASES
✹ Night blindness
✹ Peripheral visual disturbance
✹ Central visual disturbance
✹ Color visual disturbance
✹ Metamorphopsia
✹ Micropsia
✹ Macropsia
✹ Photopsia
✹ Muscae volitantes (floaters)
✹ Without symptoms
E X A M I N AT I O N S

✹ Visual Acuity
✹ Color vision (Ishihara)
✹ Macular Function tests (Interferometry,Purkinje,etc.)
✹ Dark Adaptation
✹ Visual field :
• confrontation test
• Goldmann perimetry
• Bjerrum tangent screen
• Octopus perimetry
✹ Ophthalmoscopy
• direct ophthalmoscopy
• indirect ophthalmoscopy
• biomicroscopy + contact lens/Hruby lens/+90 D lens
 DIRECT
OPHTHALMOSCOPY
INDIRECT
OPHTHAL-
MOSCOPY
DIRECT

INDIRECT
ULTRASONOGRAPHY
of the NORMAL EYE
 DISEASES OF THE RETINA

✹ Congenital anomalies

✹ Trauma

✹ Inflammation

✹ Retinal detachment

✹ Vascular disorders

✹ Degeneration

✹ Neoplasma
 RETINAL DISEASES TO BE
DISCUSSED
✹ Retinal detachment (ablatio retina)

✹ Retinal artery occlusion

✹ Retinal vein occlusion

✹ Diabetic retinopathy

✹ Hypertensive retinopathy

✹ Retinitis pigmentosa
 RETINAL D E TA C H M E N T

✹ = ablatio retina

separatio retinae

✹ A condition where the sensoric retinal layer seperates from

the retinal pigment epithelium layer (RPE)
 RETINAL D E TA C H M E N T

Classification based on pathogenesis :

❑ Rhegmatogenous RD
Break/tear in the retina (degeneration/trauma)
fluid from the vitreus cavity enters subretina caused
retina detached
❑ Nonrhegmatogenous RD
Process behind retina (tumor/inflammation)
subretinal fluid caused retina detached
❑ Tractional RD
Fibrosis in vitreus (bleeding/inflammation) caused
retinal traction
 RETINAL D E TA C H M E N T

Subjective symptoms
• Photopsia, floaters
• due to retinal traction, vitreous bleeding
• Dark shadow/curtain
• starts peripherally
• Reduced Vision
• macular involvement or vitreous bleeding
• Metamorphopsia
• macular involvement (detached)
 RETINAL D E TA C H M E N T

✹ Objective signs
• Low IOP
• Relatively calm anterior segment
• Funduscopy
• Detached retina greyish in color, elevated towards the
vitreous cavity, vessels also elevated, surface often multi-
lobulated
al Tears

Cryo/ Laser
Prophylaxis
Retinal Detachment
RETINAL D E TA C H M E N T

✹ Therapy Surgery
• Rhegmatogenous (Retinal repositioning

• Tractional
• Nonrhegmatogenous : towards to primary causa
• Surgical objectives
• close the tear
• remove subretinal fluid
• remove vitreous traction
R E T I N A L A R T E RY O C C L U S I O N

✹ A condition where the retinal artery is occluded by an

embolus

✹ Symptom: sudden visual loss without pain

✹ Two types :
• Central (CRAO) - occlusion behind the lamina
cribrosa
• Branch (BRAO) - occlusion in front of lamina
cribrosa
 R E TI N A L A R T ERY OCCLUSION

Causes :

✹ Arteriosclerosis

✹ Hypertension

✹ Carotid arterial disease

✹ Diabetes mellitus

✹ Valvular heart disease

✹ Others: oral contraception, trauma, coagulopathy, toxoplasmosis, etc.

 RETINAL ARTERIAL OCCLUSION

Symptoms and signs:

✹ Sudden blurred vision (HM - LP)

✹ Calm anterior segment

✹ Funduscopy
• ‘cherry-red spot’ (greyish pale retina except at the
fovea)
• small arteries, uneven caliber
• small veins, segmental
 RETINAL ARTERIAL OCCLUSION

Branch RAO
✹ If macula not involved, vision relatively stable
✹ Retina pale only at the involved area
✹ A/v changes only at the occluded branch
Complications:
✹ Papil atrophy
✹ Glaucoma (NVI + NVG)
Prognosis:
✹ Poor. Visual recovery only if : 1. Occlusion overcome within 1-
2 hours after onset, 2. Occlusion temporary (spasm), 3.
Cilioretinal artery present
 CRAO

BRAO
RETINAL ARTERIAL OCCLUSION

Therapy:

✹ The aim of treatment is to quickly recover the arterial

circulation by lowering the IOP :
• paracentesis (AH aspirated 0.15 - 0.2 cc)
• Acetazolamide (Diamox) 500 mg. i.v.
• digital massage of eyeball
• inhalation of 95% O2 - 5% CO2 mixture

✹ Look for cause and consult Internal Medicine

 RETINAL VENOUS OCCLUSION

✹ Similar to RAO, painless sudden loss of vision as presenting

symptom

✹ Two types:
• central (CRVO)
• occlusion behind lamina cribrosa
• branch (BRVO)
• occlusion in front of lamina cribrosa

✹ RVO 4-5 times more often than RAO

RETINAL VENOUS OCCLUSION

✹ Causes :
• hypertension & arteriosclerosis (60%)
• Common adventitial sheath at a-v crossing.
Sclerosis --> vein compressed --> slowed flow -->
thrombus --> occlusion
• open angle glaucoma (40-70%)
• hyperviscosity (polycythemia, hyperli-pidemia,
leukemia, etc)
• thromblophlebitis
• etc.
RETINAL VENOUS OCCLUSION

✹ Symptoms and signs :

• sudden loss of vision
• calm anterior segment
• funduscopy :
• dilated and tortuous vein
• edema, hemorrhage, soft exudate

✹ Complication :
• NVG
• 30-35% of CRVO, 1-3 months after onset
 CRVO

BRVO
RETINAL VENOUS OCCLUSION

✹ Branch RVO :
• NVG seldom
• nasal branch --> no visual disturbance
✹ Prognosis :
• without NVG --> edema, hemorrhage, exudate slowly
absorbed
✹ Therapy :
• medical therapy of no benefit
• laser photocoagulation
• look for cause --> consult Internal Medicine
 D I A B E T I C R E T I N O PAT H Y

✹ DR is a retinal abnormality in a diabetic due to

microangiopathy

✹ Almost always bilateral although the stages may be different

✹ incidence increased with duration of DM :

• > 20 years 50% retinopathy
• > 30 years 80% more
 DIABETIC R E T I N O PAT H Y

✹ Juvenile onset DM : delayed onset of DR.

✹ Mature onset DM (age > 40 yrs) : onset sooner

✹ Good metabolic control will delay the onset of DR

✹ Main cause of new blindness in the US

 DIABETIC R E T I N O PAT H Y

Signs :
• microaneurysm
• retinal hemorrhage
• hard exudate
• soft exudate
• retinal edema
• collateral vessels (IRMA-IntraRetinal Microvasular
Abnormalities)
• venous beading
• CNPA (Capillary Non Perfusion Area)
• neovascularization & gliosis
 DIABETIC R E T I N O PAT H Y

✹ Complications :
• vitreous hemorrhage
• tractional retinal detachment

✹ Classification :
• nonproliferative (“background”) = NPDR
• proliferative = PDR
• diabetic macular edema = DME
 DIABETIC R E T I N O PAT H Y

✹ NPDR
• early : signs 1 to 8
• severe = preproliferative

✹ PDR
• early : + sign 9
• severe : + complications
 Mild NPDR

Photo

FFA
Severe NPDR

Venous Beading
 NVD

PDR

Severe PDR
 DIABETIC R E T I N O PAT H Y

Therapy
• metabolic control
• laser photocoagulation
• indicated in
• severe NPDR
• early PDR
• DME
• vitrectomy and retinal repositioning
• in Vitreous Hemorrhage and Retinal Detachment
complications
PRP PRP

FOCAL
PARS PLANA VITRECTOMY
HYPERTENSIVE R E T I N O PAT H Y

• Changes in the retina of a hypertensive patient is due

to hypertension and arteriosclerosis
• changes due to hypertension :
• arteriole attenuation
• focal constriction/spasm
• hemorrhage and exudate
• papil edema
• changes due to arteriosclerosis :
• changes in arteriole light reflex
• changes in a-v crossing
 HIPERTENSIVE R E T I N O PAT H Y

Changes due to hypertension :

• arteriole attenuation
• normal A:V ratio 2:3 or 3:4
• attenuation < 3:4 (e.g. 1:2, 1:3)
• focal constriction
• hemorrhage
• hard exudate
• soft exudate
• papil edema
 HIPERTENSIVE R E T I N O PAT H Y

✹ Changes due to arteriosclerosis

• changes in arteriole light reflex
• changes in a-v crossing

✹ SCHEIE classification(1953)
• 5 stages of hypertension and 5 stages of
arteriosclerosis are used
 Attenuation
Focal Spasm
Venous Indentation

Hypertensive
Retinopathy
 Hypertensive
CWS
Retinopathy
Hemorrhage

Papil Edema
 HIPERTENSIVE R E T I N O PAT H Y

✹ Therapy :
• toward the hypertension
• hypertensive signs may disappear; sclerotic signs
persist
• papil edema, focal constriction quickly disappear
• hemorrhage, soft exudate disappear within several weeks-
months
• hard exudate disappear within 4-6 months or more
 RETINITIS PIGMENTOSA

✹ A hereditary disease in which a pigmentary degeneration of

the retina occurs

✹ Characteristically there is a progressive degeneration of the

photoreceptors and RPE

✹ most severe if X-linked recessive, least severe if autosomal

dominant
 RETINITIS PIGMENTOSA

Subjective symptoms :
• Nightblindness
• Gradual reduction of visual acuity up to less than 6/60
within 4 - 10 years. In X-linked this occurs usually earlier
(reading disturbance at age 20, blindness at age 40)
• often accompanied by hearing disturbance
 RETINITIS PIGMENTOSA

✹ Funduscopy :
• attenuation of retinal vessels
• in the midperiphery bone-specule pigmentation esp. along
vessels; retina slightly dirty grey in color
✹ Perimetry :
• annular scotoma
✹ Therapy :
• untreatable
• low vision aids (LVA)
• genetic counseling
Retinitis Pigmentosa
R O P ( R E T I N O PAT H Y O F P R E M AT U R I T Y )

• Potentially blinding disease caused by abnormal

development of retinal blood vessels in premature infants.
When a baby is born prematurely, the retinal blood vessels
can grow abnormally

• Gestational age : 30 weeks or less

• Birth weight : 1500 gr or less; or 1500 - 2000 gr with an

oxygen supplementation
D I A G N O S I S : F U N D U S E X A M I N AT I O N
 MANAGEMENT

• Observation

• Laser ablation

• Vitrectomy/scleral buckle
Prematurity is a risk factor for the development of :

• amblyopia (lazy eye)
• eye misalignment (strabismus)
• the need for glasses (even at a young age) 
• cortical visual impairment
THANK YOU