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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

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
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

Retinal Diseases Associated with Systemic Diseases


Diabetic retinopathy
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 retinopathy1
Diabetic Retinopathy

  • Classification

    • Non-proliferative (NPDR)

      • Mild

      • Moderate

      • Severe

    • Proliferative (PDR)


Non proliferative diabetic retinopathy npdr
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 npdr1
Non-proliferative Diabetic Retinopathy (NPDR)

  • Dot and blot hemorrhage

  • Hard exudate

  • Cotton-wool spots

  • Venous beading

  • Venous loops




Proliferative diabetic retinopathy pdr
Proliferative Diabetic Retinopathy (PDR)

  • Pathogenesis

    • Retinal ischemia causing neovascularization

  • May be asymptomatic if only neovascularization without hemorrhage


Neovascularization at Disc

(NVD)

Neovascularization elsewhere

(NVE)


Causes of visual loss in dr
Causes of Visual Loss in DR

  • Macular Edema

  • Complications of PDR

    • Vitreous hemorrhage

    • Fibrous tissue proliferation

    • Retinal detachment


Microaneurysms

Circinate exudate

Retinal edema


Vitreous Hemorrhage

Tractional Retinal Detachment

Combined

Retinal Detachment


Diabetic retinopathy2
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 retinopathy3
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
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



Severe hypertensive retinopathy
Severe Hypertensive Retinopathy

Macular star

Disc swelling


Hypertensive retinopathy2
Hypertensive Retinopathy

  • Management

    • Rule out secondary hypertension

    • Control of hypertension



Retinal vascular occlusions
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
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
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



Where is the macula
Where is the macula?

脈絡膜

Choroid

鞏膜

Sclera

視網膜

Retina

角膜

Cornea

黃斑區

Macula

晶體

Lens

Iris

虹膜

視神經

Optic nerve

Cilliary body

睫狀體


Fovea

Macula


Macular diseases1
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
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 amd1
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
Symptoms of AMD – Early

Decrease in color and contrast sensitivity


Symptoms of amd intermediate
Symptoms of AMD – Intermediate

Impairment of central visual function


Symptoms of amd intermediate1
Symptoms of AMD – Intermediate

Metamorphopsia,

distortion of central image


Symptoms of amd late
Symptoms of AMD – Late

Central Scotoma


Hallmark of amd development of drusen
Hallmark of AMDDevelopment of Drusen

Bruch’sMembrane

Drusen


Early dry amd
Early Dry AMD

  • Asymptomatic

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


Intermediate dry amd
Intermediate Dry AMD

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

  • Vision may be impaired


Advanced dry amd
Advanced Dry AMD

  • More severe visual impairment

  • Presence of drusen with degeneration of RPE

  • Geographic atrophy


Dry amd wet amd formation of new vessels
Dry AMD  Wet AMDFormation of New Vessels

ChoroidalNeovascularization


Diagnosis
Diagnosis

  • Vision function testing

    • Visual acuity

    • Amsler grid

  • Ophthalmolscopy

  • Fluorescein angiography


Early diagnosis
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



Fluorescein angiography
Fluorescein angiography

Intravenous injection

Uptake of fluorescein dye at the site of abnormal vessels

- Size, Location, Activity


Management of amd
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
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 v erteporfin
PDT with Verteporfin

Step 2:

Nonthermal Laser

Application

Step 1:

Infusion


Mechanisms of action
Mechanisms of action

  • Chain of reactions  vessel thrombosis

2

Non-thermal Laser

1

Drug infusion


.


High dose areds supplements
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
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
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



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