VITREORETINA

dr. Bachtiar Arif Wicaksono, Sp.M

Vitreoretina RSUD DR Moewardi Surakarta / FK UNS
 ANATOMY
• The fundus oculi is the part of the eye
that is visible with ophthalmoscopy
• It includes the retina, its vessels, and
the optic nerve head, or optic disc.
• The retina is a thin, transparent
structure adhering firmly to the optic
nerve head and to the ora serrata
anteriorly
• senses light and sends signals to the
brain
• Visual function :
• detail discrimination
• color perception
• vision in dim illumination
• peripheral vision
 RETINAL LAYERS
• internal limiting membrane (ILM)
• nerve fiber layer (NFL)
• ganglion cell layer (GCL)
• inner plexiform layer (IPL)
• inner nuclear layer (INL)
• outer plexiform layer (OPL)
• outer nuclear layer (ONL)
• external limiting membrane (XLM)
• rod and cone inner and outer
segments (IS/OS)
 RETINAL PIGMEN EPITHELIUM
• The structure of the outer pigmented epithelial layer is relatively simple
compared with that of the overlying inner, or neurosensory, retina.
• Function
• vitamin A metabolism
• maintenance of the outer blood-retina barrier
• phagocytosis of the photoreceptor outer segments
• absorption of light (reduction of scatter)
• heat exchange
• active transport of materials into and out of the RPE
 VITREOUS
• Clear gel-like substance that fills inside eye between
lens-retina
• important to the metabolism of the intraocular
tissues
• lens, ciliary body, and retina
• The vitreous adheres to the retina
• vitreous base, 2.0 mm anterior to the ora serrata
to approximately 4.0 mm posterior
• the disc margin, at the perimacular region, along
the retinal vessels, and at the periphery of the
posterior lens capsule.
• The vitreous becomes more fluid with age and
frequently separates from the inner retina
Diagnostic tools
• Funduscopy : direct, indirect, fundus photograph
• Anatomy evaluation : Optical coherence tomography (OCT)
• Visual function : perimetry, amsler grid
• Vascular evaluation : Fundus fluooresin angiography
VitreoRetina Disease
SIGNS & SYMPTOMS • Age related Macular
Mata tenang Degeneration (AMD)
Visus turun perlahan • Retinal vascular disease
• Diabetic retinopathy
Visus turun mendadak • Hypertensive retinopathy
Metamorfopsia • Retinal vein occlusion
Floaters • Retinal detachment
• Night Blindness
Fotopsia
AGE RELATED MACULAR
DEGENERATION
AMD
• leading cause of severe central visual loss in 1 or both eyes in people over 50 years of age
• estimated 200,000 new cases of wet AMD develop each year.
• Aging affect the outer retina, retinal pigment epithelium (RPE), Bruch membrane, and choriocapillaris
--> formation of lipofuscin granules, and accumulation of residual bodies (drusen)
• Risk Factor
• Age over 50 years
• Smoking
• Hypertension
• Fat
• Classification
• Dry AMD drusen
• Wet AMD drusen, neovascular, hemorhage, OCT intraretinal-subretinal fluid
DRY AMD
MANAGEMENT
• Education : control risk factors
• Micronutrien
• Vitamin (C, E, betacarotene)
• Zinc
• Lutein, zeaxanthin
WET AMD
MANAGEMENT
• Education : control risk factors
• Laser Focal
• Anti-VEGF
Diabetic Retinopathy
 DIABETIC RETINOPATHY
• Caused by high blood sugar from
diabetes that damage vessel leading
to blindness
• Classification :
• Non-proliferative diabetic retinopathy
(NPDR)
presence of intraretinal vascular
changes (intraretinal mycroaneurism,
venous beading, leakage cotton wool
spot, hemorhage dot blood & flame
shape) without the presence of
neovascularization or extraretinal
fibrovascular tissue
• Proliferative diabetic retinopathy (PDR)
presence of intraretinal vascular
changes with neovascularization or
extraretinal fibrovascular tissue
NPDR
PDR
Phatogenesis
Diabetic Macular Edema
• Retinal edema threatening or
involving the fovea often results
in central vision los
• It is an important consequence
of abnormal retinal vascular
permeability in diabetic
retinopathy
• The diagnosis of DME is made
when macular thickening is noted
by funduscopy or optical
coherence tomography (OCT)
MANAGEMENT
• Education manage risk factor
• Multidiscipline evaluation
• PDR  laser panretinal photocoagulation (reduce retinal ischemic
area then reducing VEGF)
• DME  intravitreal injection anti-VEGF,corticosteroid
• Surgery  non clearing vitreous hemorhage, macular threatening
tractional retinal detachment
Hypertensive Retinopathy
Hypertensive Retinopathy
• Hypertension affects focal arteriolar narrowing
and arterial venous nicking are related to
vascular sclerosis
• Uncontrolled systemic hypertension leads to
nonperfusion at various retinal levels and to
neuronal loss and related scotomata
• Hypertension may be complicated by branch
retinal artery occlusion (BRAO), branch retinal
vein occlusion (BRVO), central retinal vein
occlusion (CRVO)
• Modified Scheie Classification of
"Hypertensive Retinopathy":
 Central Retinal Vein Occlusion
• Characteristic fundus appearance
• Dilated and tortuous retinal veins, swollen optic
disc, intraretinal hemorrhages, retinal edema
• CRVO is now classified by 2 ends of the spectrum of
disease:
• Nonischemic (mild) CRVO
• characterized : good visual acuity, a mild or no
afferent pupillary defect, and mild visual field
changes
• Ophthalmoscopy : mild dilation and dot- and
flame-shaped hemorrhages in all quadrants of the
retina
• Macular edema with mild optic disc swelling may
or may not be present.
• Ischemic (severe) CRVO
• usually associated with poor vision, afferent
pupillary defect, dense central scotoma
• Ophthalmoscopy : venous dilation, more
extensive 4-quadrant hemorrhage, retinal edema,
neovascularization on retina & iris
• Poor prognosis
Management & Evaluation
• Systemic medical evaluation
Hypertension, diabetes mellitus, elevated cholesterol levels, and hyperhomocysteinemia, as well as a history
of smoking
• Manage Complication
• Anterior segment neovascularization and neovascular glaucoma laser panretinal photocoagulation, and
glaucoma medication or surgery
• Vitreous Hemorhage  vitrectomy + endolaser
• Macular edema  anti VEGF
RETINAL DETACHMENT
Retinal Detachment
Retinal detachments are classified as
• Rhegmatogenous
The most common type, vitreous liquefaction followed by traction in vitreoretinal interface resulting retinal
break. Liquefied vitreous passing through a retinal break into interspace between the sensory retina and the
RPE
• Tractional
Less common, tractional detachments are caused by proliferative membranes that contract and elevate the
retina
• Exudative
Rare,caused by retinal or choroidal diseases in which fluid leaks beneath the sensory retina and
accumulates.
Rhegmatogenous Retinal Detachment
Rhegmatogenous Tractional Exudative
Traction Tissue (+) Traction Tissue (-)
Break (+) Break (-) Break (-)
Management
• Rhegmatogenous : vitrectomy emergency
• Tractional : systemic & risk factor evaluation, vitrectomy if threatening
macula
• Exudative : systemic & risk factor evaluation
Night Blindness
• Night Vision Problem may be associated with:
• Cataract
• Fuchs' Dystrophy
• LASIK
• Nystagmus
• Retinitis Pigmentosa
• Vitamin A Deficiency
Retinitis Pigmentosa
• defined as a group of hereditary disorders
that diffusely involve photoreceptor and
pigment epithelial function
• characterized by progressive visual field
loss
• Typical fundus findings
• arteriolar narrowing
• variable waxy pallor of the disc
• bone spicule-like pigment changes
THANK YOU