Medical retina and macular diseases
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Medical Retina and Macular Diseases. Dr. Timothy Y. Y. Lai MBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth) Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong. Medical Retina.

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Medical Retina and Macular Diseases

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Medical Retina and Macular Diseases

Dr. Timothy Y. Y. Lai


Department of Ophthalmology and Visual Sciences

The Chinese University of Hong Kong

Medical Retina

  • A specialty that deals with the investigation and non-surgical treatment of retinal disorders

  • Retinal diseases associated with systemic diseases

    • Diabetic Retinopathy

    • Hypertensive Retinopathy

  • Vascular retinopathies

  • Medical macular diseases

    • Age-related Macular Degeneration

Retinal Diseases Associated with Systemic Diseases

Diabetic Retinopathy

  • One of the leading causes of blindness

  • Risk factors

    • Duration of diabetes

      • 80% of type I and 70% of type II diabetics have retinopathy after 15 yrs

    • Type of diabetes mellitus

    • Control of hyperglycemia

    • Hypertension

    • Associated renal disease

    • Pregnancy

Diabetic Retinopathy

  • Classification

    • Non-proliferative (NPDR)

      • Mild

      • Moderate

      • Severe

    • Proliferative (PDR)

Non-proliferative Diabetic Retinopathy (NPDR)

  • Pathogenesis

    • Microvascular disease causing capillary damage

    • Leakage of blood constituents into the retina

      • Retinal hemorrhages

      • Retinal edema

      • Lipid exudation

Non-proliferative Diabetic Retinopathy (NPDR)

  • Dot and blot hemorrhage

  • Hard exudate

  • Cotton-wool spots

  • Venous beading

  • Venous loops

Non-proliferative Diabetic Retinopathy (NPDR)

Progression from NPDR to PDR

Proliferative Diabetic Retinopathy (PDR)

  • Pathogenesis

    • Retinal ischemia causing neovascularization

  • May be asymptomatic if only neovascularization without hemorrhage

Neovascularization at Disc


Neovascularization elsewhere


Causes of Visual Loss in DR

  • Macular Edema

  • Complications of PDR

    • Vitreous hemorrhage

    • Fibrous tissue proliferation

    • Retinal detachment


Circinate exudate

Retinal edema

Vitreous Hemorrhage

Tractional Retinal Detachment


Retinal Detachment

Diabetic Retinopathy

  • Treatment

    • Laser photocoagulation

      • Focal or grid: for macular edema

      • Pan-retinal photocoagulation: for PDR

    • Control of systemic disease

      • Hyperglycemia

      • Hypertension

      • Renal disease

    • Vitreous surgery

Laser Photocoagulation

Outpatient procedure

Topical Anesthesia

Multiple Sessions

In PDR, laser should be performed before

vitreous hemorrhage and retinal detachment develops

Diabetic Retinopathy

  • Early identification of the disease and prompt referral to the ophthalmologist

  • Dilate your patients for examination with ophthalmoscope regularly

  • Prompt treatment reduces risk of visual loss by 50%

  • Patients may be asymptomatic but still have advanced PDR

Hypertensive Retinopathy

  • Focal or generalized narrowing of retinal arteries associated with hypertension

  • Clinical features

    • Cotton-wool spots

    • Hard exudates

    • Macular star

    • Macular edema

    • Retinal hemorrhage

    • Optic disc swelling

Hypertensive Retinopathy

Severe Hypertensive Retinopathy

Macular star

Disc swelling

Hypertensive Retinopathy

  • Management

    • Rule out secondary hypertension

    • Control of hypertension

Vascular Retinopathies

Retinal Vascular Occlusions

  • Venous occlusion more common than arterial occlusion

  • Pathogenesis

    • Arterial occlusion – embolus

      • Central retinal artery occlusion (CRAO)

      • Branch retinal artery occlusion (BRAO)

    • Venous occlusion – abnormal blood flow

      • Central Retinal Vein Occlusion (CRVO)

      • Branch Retinal Vein Occlusion (BRVO)

Retinal Arterial Occlusions

  • Symptoms

    • Sudden, painless, marked loss of vision

    • Immediate treatment within 24-48 hours may be beneficial in some patients

  • Systemic Associations

    • Cardiovascular disease

    • Carotid artery disease

    • Temporal arteritis / inflammatory arteritis

    • Coagulopathies

Central Retinal Artery Occlusion

Afferent Pupillary Defect

Cherry Red Spot

Retinal Edema

Branch Retinal Artery Occlusion

Retinal Venous Occlusions

  • Symptoms

    • Sudden painless loss of vision

    • Various extent of visual loss

  • Systemic Associations

    • Diabetes Mellitus

    • Hypertension

    • Hematological diseases

    • Vasculitis

Central Retinal Vein Occlusion

Branch Retinal Vein Occlusion

Neovascular glaucoma

Macular edema

Laser photocoagulation

Macular Diseases

Where is the macula?
















Optic nerve

Cilliary body




Macular Diseases

  • Common surgical macular diseases

    • Macular hole

    • Epiretinal membrane

  • Common medical macular diseases

    • Age-related macular degeneration (AMD)

    • Myopic maculopathy

    • Central serous chorioretinopathy (CSC)

Age-related Macular Degeneration (AMD)

  • Leading cause of severe vision loss in people > 50 years in the western world

  • Visual loss due to drusens / RPE degeneration or development choroidal neovascularization (CNV)

Age-related Macular Degeneration (AMD)

  • Two forms

    • Dry (non-neovascular) AMD(80% to 90%)

    • Wet (neovascular) AMD(10% to 20%)

  • 90% of vision loss is caused by wet form of AMD

Symptoms of AMD – Early

Decrease in color and contrast sensitivity

Symptoms of AMD – Intermediate

Impairment of central visual function

Symptoms of AMD – Intermediate


distortion of central image

Symptoms of AMD – Late

Central Scotoma

Hallmark of AMDDevelopment of Drusen



Early Dry AMD

  • Asymptomatic

  • Examination reveals several small drusen or a few medium-sized drusen (63-124m)

Intermediate Dry AMD

  • Many medium-sized drusen or 1 large drusen (>125m)

  • Vision may be impaired

Advanced Dry AMD

  • More severe visual impairment

  • Presence of drusen with degeneration of RPE

  • Geographic atrophy

Dry AMD  Wet AMDFormation of New Vessels



  • Vision function testing

    • Visual acuity

    • Amsler grid

  • Ophthalmolscopy

  • Fluorescein angiography

Early Diagnosis

  • Amsler Grid

  • Adequate lighting

  • Wear reading glasses

  • Hold the Amsler grid at normal reading distance (about 30cm)

  • Cover one eye at a time

  • Stare at the center dot

  • Ask the following questions:

  • Are any of the lines wavy, missing, blurry, or discolored?

  • Are any of the boxes different in size or shape from the others?

5mm squares

10 cm x 10 cm

Self monitoring with Amsler Grid

Normal Abnormal

Fluorescein angiography

Intravenous injection

Uptake of fluorescein dye at the site of abnormal vessels

- Size, Location, Activity

Management of AMD

  • Treatment for neovascular AMD

    • Laser photocoagulation

    • Submacular surgery

    • Photodynamic therapy (PDT) with Verteporfin

    • Anti-angiogenesis therapy (Anti-VEGF)

  • Prevent progression to advanced AMD

    • Antioxidants

    • Quit smoking

  • Low-vision aids

Laser Photocoagulation

  • Non-selective thermal laser photocoagulation

    • Destroy CNV

    • Irreversible damage to the overlying retina and RPE

    • Side effects of immediate scotoma or drop in central vision

    • CNV persist or recur in 50% of patients

PDT with Verteporfin

Step 2:

Nonthermal Laser


Step 1:


Mechanisms of action

  • Chain of reactions  vessel thrombosis


Non-thermal Laser


Drug infusion


High dose AREDS supplements

  • Beta-carotene

  • Vitamin A

  • Vitamin C

  • Vitamin E

  • Zinc

  • Copper

  • Decrease risk of progression from dry to wet AMD

Smoking and AMD

  • Most important risk factors for AMD

  • Smokers have 300% to 400% more risk in developing AMD than non-smokers

  • Even passive smoking increase the risk of AMD by 30% to 40%

Prevention is better than cure

  • Increasing prevalence of AMD due to aging and western life-style

  • Recognize and correct risk factors

    • Quit smoking

    • Healthy diet

  • Self screening testin high-risk group

  • Regular dilated fundus examination to evaluate AMD findings

    Early diagnosis is the key to save vision

Thank You

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