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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


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


Neovascularization elsewhere


Causes of visual loss in dr
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 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?
















Optic nerve

Cilliary body




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


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



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



  • 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


Step 1:


Mechanisms of action
Mechanisms of action

  • Chain of reactions  vessel thrombosis


Non-thermal Laser


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