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Mata Tenang Visus Turun

Dr.Michael Indra Lesmana, Sp.M
Don’t forget Basic eye examinations!!
• Visual Acuity
• Pupillary test
• Funduscopy
• Confrontation test
• Amsler grid test
Visual Pathway
• Retina
• Optic Nerve
• Chiasm
• Optic Tract
• Optic Radiations
• Occipital Cortex
Visual Pathway
• Thin, semitransparent, multilayer sheet of neural tissue
• Ends at the Ora Serrata
– Located 6.5 mm behind Schwalbe’s line temporally and 5.7mm nasally
– 0.1 mm thick at the Ora and 0.23 mm thick at the posterior pole
• Closely attached to the RPE, and thus related to Bruch’s Membrane,
the choroid nd the Sclera
– This attachement may be easily separated (as in retinal detachment) to form the
Subretinal Space
– However, at the optic disc and at the ora serrata, the retina and the RPE are firmly
• Macula
– Characteristics:
• Located in the area of the temporal vascular arcade
• Region where more than one layer of ganglion cell nuclei can be found
– Fovea:
• Thinner outer nuclear layer
• 1.5 mm in diameter
• Xanthophyll pigment
– Foveola:
• Central depression within the fovea
• Photoreceptor cells (made up mainly of Cones), glial cells, Mueller cells
• Responsible for the most acute vision
– Foveal Avascular Zone:
• Capillary-free zone
• Important landmark for treatment of subretinal neovascular membrane
• Layers of the Retina:
– Internal limiting membrane
• Abuts the vitreous
– Nerve fiber layer
• axons of the ganglion cells
– Ganglion cell layer
– Inner plexiform layer
• Axons of the bipolar and amacrine cells and dendrites of the ganglion cells and their
– Inner nuclear layer
• Nuclei of bipolar, horizontal, Mueller and amacrine cells
– Outer plexiform layer
• Made up of the connections b/w photoreceptor synaptic bodies and the horizontal and
bipolar cells
• Thicker at the macula (layer of Henle)
– Outer nuclear layer of photoreceptor nuclei
• Rods and cones
– Extenal limiting membrane
– Layer of rods and cones
– Retinal pigment epithelium
• Functions:
– Vitamin A metabolism, maintenance of the outer blood-retinal barrier, phagocytosis of the
photoreceptor outer segments, absorption of light, heat exchange, formation of the basal
lamina,production of mucopolysaccharides, active transport
• Adjacent RPE cells are attached to each other by junctional complexes which provide
both structural and metabolic stability (outer blood-retinal barrier)
– Zonula occludentes and Zonula adherentes
• Thickest at the Papillomacular Bundle and thinnest at the Fovea
Optic Nerve
• not really a peripheral nerve, it is actually a direct
extension of the CNS
• 1.88mm V, 1.77mm H
• Corresponds to the “blind spot” in perimetry
• 1.2 M axons
• 50 mm long
• Blood supply:
– Circle of zinn-haller
• Short PCA
• Choroidal circulation
• Pial vasculature
Optic Nerve
• 4 parts:
– intra-ocular (optic nerve head)
• 1 mm long; 1.5 mm H; 1.8 mm V
• optic disc (visible by fundoscopy)
• non-myelinated axons)
– intra-orbital
• 25 mm in length; 3 to 4.5 mm in diam
• lined by dura, arachnoid and pia mater
• fuses at the apex of the orbit with periosteum and annulus of zinn
– intra-osseous/intra-canalicular
• 9 mm in length
• bordered by the paranasal sinuses
• Firmly anchored to the bone
– Significance: a small mass lesion in the canal can cause compressive optic
neuropathy even before it becomes readiologically visible
– intra-cranial
• 10 mm long, may vary from 3 to 16 mm
• region where the carotid artery bifurcates into ACA and MCA
Visual Field Defects
• location of lesion:
– optic nerve monocular loss of
– vision
– optic chiasm bitemporal
– hemianopsia
– optic tract (incongrous)
– hemianopsia
– temporal lobe “pie in sky”
– parietal lobe “pie in the floor”
– occipital lobe (congrous)
– homonymous
• Diabetic Retinopathy
(Vitreous Haemorrhage, DME, NAAION,
Tractional retinal detachment)
• CSR (Central Serous Retinopathy)
• Optic Neuritis-papilitis, Methanol-toxic optic
Vitreous Haemorrhage Pre-retinal Hge USG/ B-scan

Chief complaint: floaters red or black spot covering vision with no

eye pain, most of cases associated with Diabetes Mellitus,
Hypertension, High myopia and degenerative state.
Photo Fundus OCT Macula-cystoid form OCT-Macula map

Sudden blurring of vision, central scotoma,

abnormality result in amsler grid test, with no foveal
reflex, cystoid form in OCT and pettaloid pattern in
Fluorescein angiography.
Common in diabetic patient.
Anti VEGF intravitreal and Grid laser are treatment
Fluorescein Angiography
Non arteritic anterior ischemic optic
neuropathy (NAAION)

Blurr disc margin, sometime with Alltitudinal scotoma is a

splinter hemorrhage around disc characteristic of NAAION

Systemic diseases induce NAAION including: HPN, DM, Hyperuricemia, Dislipidemia,

Leukemic and other blood abnormality.
Tractional Retinal Detachment

In Diabetic patient
Rhegmatogenous Retinal Detachment

Horseshoe tear Lattice degeneration Retinal dialysis

Occurs in High myopic eye, aging process and post traumatic eye
Tractional Retina Detachment Rhegmatogenous RD
CSR (Central Serous Retinopathy)
• Is an eye disease which causes visual impairment,
often temporary, usually in one eye. When the
disorder is active it is characterized by leakage of
fluid under the retina that has a propensity to
accumulate under the central macula.
• This results in blurred or distorted
vision (metamorphopsia).
• The disease is considered idiopathic but mostly
affects white males in the age group 20 to 50.
• The condition is believed to be exacerbated
by stress or corticosteroid use.

Central Retina Vein Occlusion Branch Retina Vein Occlusion

Subjective & Objective
• Sudden blurring of vision • Sudden blurring of vision
• Full field visual defect • Altitudinal field defect
• Ischemic and non ischemic • Visual acuity may remain
• Usually associate with RAPD good if macula is not
positive affected
• Macular edema
• May develop glaucoma in
90-100 days

Hypertension is major risk factor

Ancillary test and Treatment plan
OCT and FFA Anti VEGF and argon laser
CRAO-cherry red spot BRAO
Blood Supply of the Retina
• Choriocapillaries
– outer third of the retina
• Central Retinal Artery
– inner two thirds of the retina
• An acute, persistent, painless loss of vision in the
range of counting fingers to light perception in
90% of patients.
• Some patients may reveal a history of amaurosis
• Ask about any medical problems that could
predispose to embolus formation (eg, atrial
fibrillation, endocarditis, coagulopathies,
atherosclerotic disease, hypercoagulable state).
• Immediate lowering of intraocular pressure
includes acetazolamide
• Topical medications are used to lower intraocular
• Further treatmentsCarbogen therapy (5% CO2,
95% O2): CO2 dilates retinal arterioles, and
O2increases oxygen delivery to ischemic tissues.
Perform for 10 minutes every 2 hours for 48
• Hyperbaric oxygen therapy
Optic Neuritis- Papilitis
• Optic neuritis is inflammation of the optic
nerve. It is also called papillitis (when the
head of the optic nerve is involved)
and retrobulbar neuritis (when the posterior
of the nerve is involved)
• The most common cause is multiple sclerosis,
which occurs predominantly in women.
Papilitis:hyperemic disc margin Retrobulbar optic neuritis: disc margin
noted reveal normal
ONTT (optic neuritis treatment)
• Intravenous methylprednisolone (250 mg, 6
hourly) for 3 days, followed by oral
prednisolone (1 mg\kg\d) for 11 days.
• May request MRI brain with contrast to rule
out of Multiple sclerosis.
Toxic/Nutritional Optic Atrophy
• Causes:
– Ethambutol, rifampicin, vitamin B12 deficiency,
thiamine deficiency, methanol
• Painless, symmetric, bilateral loss of vision
• Central/cecocentral visual field loss
Clinical classification of optic disc swelling

– papilledema
• strictly refers to edema of the disc secondary to an
increase in intra-cranial pressure
– optic disc edema
• may be secondary to an ischemic, inflammatory, or
infiltrative process
– pseudoedema
• conditions that may present clinically with an
appearance of a swollen disc or blurred disc margin
Optic Atrophy
• The end result of diseases or
injuries to the optic nerve.
• Funduscopy will show a very pale
optic disc
• Common causes
– Long standing papilledema
– Inflammation (optic neuritis)
– Ischemia
– Glaucoma