眼科學(xué)課件：03 Retina Disease

1、Depart. Of OphthalmologyDepart. Of Ophthalmology Renji Hospital Renji HospitalEyeball structure and retinaLocated 3mm temporally to the optic papilla, right on the visual axisA concave central retinal depression is called Fovea Centralis macula lutea contains only cones;macula lutea contains only co

2、nes; 1 cone synapes to 1 cone synapes to 1 bipolar cell, which synapes to 1 ganglion cell, 1 bipolar cell, which synapes to 1 ganglion cell, leading to the most sensitive visionleading to the most sensitive visionIn peripheral retina ,600 rods connect to 1 ganglionIn peripheral retina ,600 rods conn

3、ect to 1 ganglionInternal limiting membraneNerve fiber layerGanglion cell layerInner plexiform layerInner nuclear layerOuter plexiform layerOuter nulear layerExternal limiting membranephotoreceptor RPE Bruchs membrane3 neurons: Photoreceptor Bipolar Ganglion cellSupporting tissue: Mller cell rod（sco

4、topic vision） cone（photopic vision）Connecting cell between photoreceptor and ganglionConduct to brain Inner layer central retinal vascular system Outer layer choroid（ciliary vascular system） Macula lutea choriocapillariesInner barrier（bloodretina barrier） dense connection of retinal capillary endoth

5、eliumOuter barrier（choroid-retina barrier） zonula occludens between the RPE RPE- Bruchs membrane- choriocapillaries complexVisual impairmentVisual impairmentMetamorphopsiaMetamorphopsiaFlickeringFlickeringMacropsiaMacropsiaMicropsiaMicropsiaRelated to lesion siteVitreous traction to the retinaRetina

6、 edemafewer cones stimulatedmicropsiaIntracellular edemaIntracellular edemaExtracellular edemaExtracellular edemaCystoid macular edemaCystoid macular edemaRetinal artery occlusion:ischemia leads to edema of bipolar cell,ganglion and RNFLCapillary endothelium injury，and thenexudationHenles fibers are

7、 radially located;This pooling forms a flower-petal pattern Intracellular edemaExtracellular edemaHard exudateCotton-wool spot Leakage of capillary Leakage of capillary absorb absorb deposition of lipid in outer plexiform layer deposition of lipid in outer plexiform layer Also called “soft exudation

8、”Also called “soft exudation”Precapillary arteriole occlusionPrecapillary arteriole occlusion axoplasmic transport blockedaxoplasmic transport blockedorganelles stackorganelles stackCotton-wool spotCotton-wool spotHard exudateHard exudate Deep hemorrhageDeep hemorrhage Superficial hemorrhage Superfi

9、cial hemorrhage Preretinal hemorrhagePreretinal hemorrhageVitreous hemorrhageVitreous hemorrhageBetween outer plexiform layer and inner nuclear layer. Small round, dark redLocated in nerve fiber layerLine, strip, flame-like, bright redCrescent-shaped hematocele with transverse sectionProfuse prereti

10、nalhemorrhage into the vitreous or hemorrhage of retinal neospastic vasculaturePreretinal hemorrhageVitreous hemorrhageDeep hemorrhageSuperficial hemorrhageNeovascularization, NVNeovascularization, NVA large area of retinal ischemia formation of vascular endothelial growth factor neovascularizationN

11、eovascualr membrane, Neovascualr membrane, NVMNVMArise from small veins of optic disc and retina; grow along retinal surface and into the vitreous Retinal neovascularizationNeovacularizaton of optic disc 1. Atherosclerosis, stenosis, occlusion 2. Tortuous vein, dilated vein, bead-like changeA-V cros

12、s signA-V cross signVessel white Vessel white sheathsheathMicroaneurysmMicroaneurysmMicroaneurysm A-V cross signVessel white sheathatrophyatrophyalterationDeath or proliferationPigment lossPigment disorderOsteocyte-like pigment depositionInflammation , metabolic deposit of RPE or Bruchs Inflammation

13、 , metabolic deposit of RPE or Bruchs membrane breakmembrane break CNV reach RPE or subsensory layerCNV reach RPE or subsensory layerRetinoscopyElectroretinographyFluorescein Angiography (FA)OCTVascular diseasesVascular diseasesMacular diseasesMacular diseasesRetinal detachmentRetinal detachmentReti

14、nal degenerationRetinal degenerationRetinal tumorRetinal tumorOcular manifestation of general Ocular manifestation of general diseasesdiseasesRetinal artery occlusionRetinal artery occlusionRetinal venous occlusionRetinal venous occlusionDiabetic retinopathyDiabetic retinopathyVasculitisVasculitisCo

15、ats diseaseCoats disease Common causesCommon causes： atherosclerotic thrombosis of cribriform plate systemic diseases, hemicrania, trauma, blood coagulation disorder, inflammation, infectious disease or connective tissue disease Occasionally seen inOccasionally seen in： retrobulbar injection、retinal

16、 detachment or orbital operationEtiologyEtiology Symptoms SignsSudden painless vision lose of one eyeDirect light reflex disappear, indirect light reflex normalRetinal edema, cherry-red spotcherry-red spotRetina artery narrow, mild hemorrhageNormal eye fundusCRAOFFA of CRAO21s after injection of flu

17、orescein, a complete absence in filling central retinal artery, except segment of inferior temperal branch and macular branchBRAOBRAOFFATarget: to reestablish retinal Target: to reestablish retinal circulation & functioncirculation & functionTiming: the earlier the betterTiming: the earlier

18、the betterDrugs: vasodilator( tropical or Drugs: vasodilator( tropical or systemic)+ reduce IOP systemic)+ reduce IOP 1. Vasodilator : antispasm or pushing thrombus to the smaller branch2. Reducing IOP:（1）massage （2）anterior chamber paracentesis（3）diamox 500mg st, 250mg bid NaHCO3 500mg bidtid3. Oxy

19、gen inhalation: mixture of 95% oxygen & 5% carbon dioxide 4. Fibrinolytic enzyme: for patients suspect of thrombosis urokinase 5 00010 000U iv qdDepends on site, severity and Depends on site, severity and durationdurationIrreversible after 4 hrs Irreversible after 4 hrs Clinical manifestationCli

20、nical manifestation Non-ischemic typeMild fundus change : retinal hemorrhage and tortuous veinMild VA decreasecapillary nonperfusion rareVisual field defectIschemic typeIschemic type：More commonMore commonExtensive retinal Extensive retinal hemorrhage and tortuous hemorrhage and tortuous veinvein，Mu

21、ltiple cotton-Multiple cotton-wool spots wool spots Severe VA decreaseSevere VA decreaseWidespread capillary Widespread capillary nonperfusionnonperfusion， 60% cases 60% cases present iridal present iridal neovascularizationneovascularizationCRVO Nonischemic CRVO ischemic CRVONon-ischemic typeIschem

22、ic typeVA0.050.05PupilRAPD (-)RAPD (+)FundusMild hemorrhage and edemaExtensive hemorrhage and severe edma, multiple cotton-wool spots FFAcapillary nonperfusion rareWidespread capillary nonperfusionVFCentral visual field defectPeripheral and central visual field defectNVNoneCommonPrognosisGoodPoorBRV

23、OBRVOFFAChinese medicine Chinese medicine Anitplatelet or antithrombotic drugs: unknown therapeutic Anitplatelet or antithrombotic drugs: unknown therapeutic effectseffectsSystemic examination to find out causesSystemic examination to find out causesCorticosteroid if vasculitis existCorticosteroid i

24、f vasculitis existGrid pattern photocoagulation of macula, PRPGrid pattern photocoagulation of macula, PRPLaser induced retina-choroid vascular anastomosisLaser induced retina-choroid vascular anastomosisDiabetic retinopathy is a leading cause of new cases of blindness in working age people worldwid

25、eMany of the complications of diabetic retinopathy can be prevented or delayed by blood glucose control and timely interventionDisease Severity LevelFindings Observable upon Dilated OphthalmoscopyNo apparent retinopathy No abnormalitiesMild NPDRMicroaneurysms onlyModerate NPDRMore than just microane

26、urysms but less than severe NPDRSevere NPDRAny of the following (4-2-1 rule) and no signs of PDR: More than 20 intraretinal hemorrhages in each of four quadrants Definite venous beading in two or more quadrants Prominent IRMA in one or more quadrantsPDROne or both of the following: Neovascularizatio

27、n Vitreous / preretinal hemorrhageVascular Endothelial Growth FactorPromotes vascular growth and permeability Elevated levels of circulating VEGF in conditions with retinal ischemiaMicroanerysmsMicroanerysmsDamage to endothelial cells leads to dilated capillaries and venules These altered vessels al

28、low serum and blood to leak into the retinaRetinal ischemiaMacular edemaVitreous hemorrhageEpiretinal membrane formationRetinal detachmentNeovascular glaucoma Type 1 diabetics Type 1 diabetics First screen 5 years after onset, then annually Type 2 diabetics Type 2 diabetics First screen upon diagnos

29、is and then annuallyNPDR without macular edema NPDR without macular edema ObserveMacular edema Macular edema 1. Focal/Grid laser photocoagulation2. Vitrectomy with membrane peeling3. Intraocular Steroid4. Intraocular VEGF inhibitor*Vitreous Hemorrhage Vitreous Hemorrhage 1. Pan-retinal photocoagulat

30、ion2. Vitrectomy with laser photocoagulation3. Intraocular VEGF inhibitorTraction Retinal Detachment Traction Retinal Detachment 1. Observation if not involving the macula2. Vitrectomy with membrane dissectionEtiologyEtiology Long-term chronic macular light damage, heredity, metabolism, nutrient fac

31、torsMechanismMechanism Decreased phagocytosis of RPE leading to drusen Drusen can cause damage of Bruchs membrane, CNV and fibrocyte proliferation Destruction of choroidal capillary, Bruchs membrane, RPE and photoreceptorVisual acuity decreased VA, metamorphopsia, micropsiaVisual field central scoto

32、maFundus Drydrusen, RPE change Wet-gray-yellow CNV under retina of posterior pole， associated with dark red subretinal hemorrhage, which covers CNV sometimes FFA CNV leakage，bleedingNonexudative AMD: Nonexudative AMD: Drusen, RPE atrophy, Degeneration of photoreceptor, Choroid capillary atrophyExudative AMD: Exudative AMD: Drusen, Damage of Bruchs membr