Retina

Anatomy of the Retina

The Ten Layers of the 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

Examinations
Visual Acuity
Dark Adaptation
Color vision (Ishihara)
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

External Light

Fundus Reflex

Lens Opacity

INDIRECT
OPHTHALMOSCOPY

DIRECT

INDIRECT

BIOM

Specific Examinations
Fundus

fluorescein angiography (FFA)

Ultrasonography (USG)
Electroretinography

Fundus
Fluorescein
Angiography
(FFA)

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 Detachment
=

ablatio retina
separatio retinae

A condition

where the sensoric retinal

layer seperates from the retinal pigment
epithelium layer (RPE)

Retinal Detachment
Classification based on pathogenesis :
Rhegmatogenous RD
Break/tear in the retina (degeneration/
trauma)
fluid from the vitreus
cavity enters
sub-retina
retina
detached
Nonrhegmatogenous RD
Process behind retina (tumor/
inflammation)
subretinal fluid
retina detached
Tractional RD
Fibrosis in vitreus (bleeding/inflammation)
retinal traction
retina detached

Retinal Detachment
Subjective symptoms
Photopsia,

due to retinal traction, vitreous bleeding

Dark

shadow/curtain

starts peripherally

Reduced

floaters

Vision

macular involvement or vitreous bleeding

Metamorphopsia

macular involvement (detached)

Retinal Detachment
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

Retinal Tears
Cryo/ Laser
Prophylaxis

Retinal Detachment

Retinal Detachment
Therapy
Rhegmatogenous

Tractional
Nonrhegmatogenous
Surgical

objectives

close the tear

remove subretinal fluid
remove vitreous traction

Surgery
(Retinal repositioning)

towards primary d.

Retinal Artery Occlusion

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

Retinal Artery 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
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

consult Internal
Medicine

Retinal Venous Occlusion

Similar

to RAO, painless sudden loss of

vision as presenting symptom
Two types:
central

occlusion behind lamina cribrosa

branch

(CRVO)
(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 :

Prognosis :

NVG seldom
nasal branch --> no visual disturbance
without NVG --> edema, hemorrhage, exudate
slowly absorbed

Therapy :

medical therapy of no benefit

laser photocoagulation
look for cause --> consult Internal Medicine

Diabetic Retinopathy
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
> 30 years

50% retinopathy
80% more

Diabetic Retinopathy

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 Retinopathy
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 Retinopathy

Complications

vitreous

hemorrhage
tractional retinal detachment
Classification

nonproliferative

(background) = NPDR
proliferative = PDR
diabetic macular edema = DME

Diabetic Retinopathy
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 Retinopathy
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 Retinopathy

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 Retinopathy
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 Retinopathy

Changes

due to arteriosclerosis

changes

in arteriole light reflex

changes in a-v crossing
SCHEIE
5

classification(1953)

stages of hypertension and 5 stages of

arteriosclerosis are used

Attenuation
Focal Spasm
Venous Indentation

Hypertensive
Retinopathy

Hypertensive
Retinopathy

CWS
Hemorrhage

Papil Edema

SCHEIE classification
Hypertension

Arteriosclerosis

Grade

Attenuation Focal Hemorrhage Exudate Papil

Spasm
Edema

Light
reflex

3:4

1:1

(-)

(-)

(-)

Yellow line

1:2

1:1

(-)

(-)

(-)

Widened

V.Inden

1:3

2:3

(-)

(-)

(-)

Copper

V.Inden

1:4

1:3

(+)

(+)

(-)

Silver

Dist dilat

soft
thread

distal
occl.

(+)

(+)

(+)

Fibrous
thread

Similar to
3

A-v crossing

SCHEIE Classification
Hypertension
0
Grade 1
Grade 2
Grade 3
Grade 4

Arteriosclerosis
0
Grade 1
Grade 2
Grade 3
Grade 4

Hipertensive Retinopathy

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 Xlinked this occurs usually earlier (reading
disturbance at age 20, blindness at age 40)
often accompanied by hearing disturbance

Retinitis Pigmentosa

Funduscopy :

Perimetry :

attenuation of retinal vessels

in the midperiphery bone-specule pigmentation esp.
along vessels; retina slightly dirty grey in color
annular scotoma

Therapy :

untreatable
low vision aids (LVA)
genetic counseling

Retinitis Pigmentosa