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DISORDERS OF THE VITREOUS AND RETINAL DETACHMENT Dr Russell J Watkins
Vitreous <ul><li>Virtually acellular </li></ul><ul><li>Viscous </li></ul><ul><li>Collagen framework, reinforces with hyalu...
Vitreous <ul><li>Attachments of vitreous </li></ul><ul><ul><li>Vitreous base </li></ul></ul><ul><ul><ul><li>Strong, 3-4mm ...
 
Vitreous <ul><li>Aging changes </li></ul><ul><ul><li>Dissociation of hyaluronate from fibrils </li></ul></ul><ul><ul><li>P...
Vitreous Opacities <ul><li>Muscae volitantes: remnants of hyaloid system </li></ul><ul><li>Syneresis </li></ul><ul><li>Wei...
Vitreous Opacities <ul><li>Synchisis scintillans (settles inferiorly with rest) </li></ul><ul><li>Asteroid hyalosis </li><...
 
Vitreous <ul><li>Vitreous degeneration </li></ul><ul><ul><li>Syneresis </li></ul></ul><ul><ul><ul><li>Vitreous liquefactio...
Posterior Vitreous Detachment <ul><li>Collapse of vitreous gel </li></ul><ul><li>Associated with photopsia & floaters </li...
Posterior Vitreous Detachment <ul><li>PVD with gel collapse </li></ul><ul><ul><li>Without vitreous haemorrhage, 4% develop...
 
 
 
 
Vitreous Haemorrhage <ul><li>Proliferative retinopathies </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Retinal vein ...
Vitreous Haemorrhage <ul><li>Disciform macular degeneration </li></ul><ul><li>Blood dyscrasias </li></ul><ul><li>Subarachn...
 
Retinal Detachment <ul><li>Retinal detachment can be: </li></ul><ul><ul><li>Rhegmatogenous </li></ul></ul><ul><ul><li>Trac...
Rhegmatogenous RD <ul><li>RD occurring in association with hole formation; incidence 1:10,000 per year </li></ul><ul><li>P...
Rhegmatogenous RD <ul><li>Pathogenesis </li></ul><ul><ul><li>Following PVD, dynamic vitreoretinal traction occurs at abnor...
Rhegmatogenous RD <ul><li>Pathogenesis </li></ul><ul><ul><li>Sensory retina detaches from RPE </li></ul></ul><ul><ul><ul><...
Types of Break <ul><li>Horseshoe or U-shaped tear </li></ul><ul><li>Atrophic hole </li></ul><ul><li>Operculated </li></ul>...
Types of Break <ul><li>Giant retinal tear </li></ul><ul><ul><li>90-360° tear; may fold back </li></ul></ul><ul><ul><li>Ass...
Rhegmatogenous RD <ul><li>Symptoms </li></ul><ul><ul><li>Photopsia </li></ul></ul><ul><ul><li>Floaters </li></ul></ul><ul>...
Rhegmatogenous RD <ul><li>Examination </li></ul><ul><ul><li>VA </li></ul></ul><ul><ul><li>Visual fields </li></ul></ul><ul...
 
Rhegmatogenous RD <ul><li>Natural history </li></ul><ul><ul><li>Progression to total detachment </li></ul></ul><ul><ul><li...
Rhegmatogenous RD <ul><li>Principles of treatment </li></ul><ul><ul><li>Localisation & closure of breaks </li></ul></ul><u...
Complications of RD Surgery <ul><li>Anterior or posterior segment ischaemia </li></ul><ul><li>Infection </li></ul><ul><li>...
 
 
 
 
 
 
 
 
 
Vitreoretinal Degenerations <ul><li>Predisposing to RD </li></ul><ul><ul><li>Lattice degeneration - present in 40% of RD <...
 
 
 
Tractional RD <ul><li>Penetrating ocular trauma </li></ul><ul><li>Proliferative retinopathies </li></ul><ul><ul><li>DM </l...
 
 
 
 
Exudative RD <ul><li>Uveitis e.g. Vogt-Koyanagi-Harada syndrome </li></ul><ul><li>Choroidal tumours </li></ul><ul><ul><li>...
 
Retinoschisis <ul><li>Splits or cysts within the neurosensory retina </li></ul><ul><li>Retinoschisis can be </li></ul><ul>...
Senile Retinoschisis <ul><li>Bilateral in 33% </li></ul><ul><li>Usually inferotemporal </li></ul><ul><li>Usually hypermetr...
Senile Retinoschisis <ul><li>Round holes can occur in inner leaf </li></ul><ul><li>Larger holes can occur in outer leaf </...
 
Juvenile Retinoschisis <ul><li>X-linked recessive </li></ul><ul><li>Splits in NFL </li></ul><ul><li>Bilateral </li></ul><u...
Juvenile Retinoschisis <ul><li>Present with </li></ul><ul><ul><li>   vision (may be vitreous haemorrhage) </li></ul></ul>...
 
Secondary Retinoschisis <ul><li>Proliferative retinopathies </li></ul><ul><li>Trauma </li></ul><ul><li>Vitreous traction <...
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VASCULAR AND HEREDITARY RETINAL DISEASE

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Transcript of "VASCULAR AND HEREDITARY RETINAL DISEASE"

  1. 1. DISORDERS OF THE VITREOUS AND RETINAL DETACHMENT Dr Russell J Watkins
  2. 2. Vitreous <ul><li>Virtually acellular </li></ul><ul><li>Viscous </li></ul><ul><li>Collagen framework, reinforces with hyaluronate </li></ul><ul><li>98% water; volume = 4.5ml in emmetropic eye </li></ul><ul><li>Condensations of vitreous </li></ul><ul><ul><li>Anterior hyaloid membrane </li></ul></ul><ul><ul><li>Posterior hyaloid membrane </li></ul></ul><ul><ul><li>Tracts in gel </li></ul></ul><ul><ul><li>Cloquet’s canal </li></ul></ul>
  3. 3. Vitreous <ul><li>Attachments of vitreous </li></ul><ul><ul><li>Vitreous base </li></ul></ul><ul><ul><ul><li>Strong, 3-4mm annular attachment, extending across ora serrata </li></ul></ul></ul><ul><ul><li>Weigert’s ligament </li></ul></ul><ul><ul><ul><li>8-9mm annular attachment to posterior lens surface (anterior end of Cloquet’s) </li></ul></ul></ul><ul><ul><li>Vitreopapillary adhesions </li></ul></ul><ul><ul><ul><li>Posterior end of Cloquet’s canal  Weiss ring </li></ul></ul></ul><ul><ul><li>Vascular adhesions (hence bleeds with PVD) </li></ul></ul><ul><ul><li>Areas of vitreoretinal degeneration </li></ul></ul><ul><ul><ul><li>e.g. lattice degeneration, cystic retinal tufts </li></ul></ul></ul>
  4. 5. Vitreous <ul><li>Aging changes </li></ul><ul><ul><li>Dissociation of hyaluronate from fibrils </li></ul></ul><ul><ul><li>Pooling of hyaluronate </li></ul></ul><ul><ul><li>Fibril degeneration &  elasticity </li></ul></ul><ul><ul><li>Drainage of hyaluronate into retrovitreal space (  posterior vitreous detachment [PVD]) </li></ul></ul>
  5. 6. Vitreous Opacities <ul><li>Muscae volitantes: remnants of hyaloid system </li></ul><ul><li>Syneresis </li></ul><ul><li>Weiss ring </li></ul><ul><li>Haemorrhage </li></ul><ul><li>Tobacco dust: pigment cells </li></ul><ul><li>Inflammatory cells </li></ul><ul><ul><li>Pars planitis </li></ul></ul><ul><ul><li>Chorioretinitis </li></ul></ul><ul><ul><li>AC spillover </li></ul></ul>
  6. 7. Vitreous Opacities <ul><li>Synchisis scintillans (settles inferiorly with rest) </li></ul><ul><li>Asteroid hyalosis </li></ul><ul><ul><li>Seen in 1:200 eyes; more common in DM </li></ul></ul><ul><ul><li>Ca 2+ -soaps, adherent to fibrils </li></ul></ul><ul><ul><li>Does not settle at rest </li></ul></ul><ul><li>Neoplastic cells </li></ul><ul><li>Amyloid </li></ul>
  7. 9. Vitreous <ul><li>Vitreous degeneration </li></ul><ul><ul><li>Syneresis </li></ul></ul><ul><ul><ul><li>Vitreous liquefaction, fibril aggregation & condensation </li></ul></ul></ul><ul><ul><ul><li>Associated with floaters </li></ul></ul></ul><ul><ul><ul><li>Caused by myopia, senescence, trauma, inflammations, hereditary causes </li></ul></ul></ul><ul><ul><li>Posterior vitreous detachment </li></ul></ul>
  8. 10. Posterior Vitreous Detachment <ul><li>Collapse of vitreous gel </li></ul><ul><li>Associated with photopsia & floaters </li></ul><ul><li>Causes </li></ul><ul><ul><li>Senile </li></ul></ul><ul><ul><li>Myopic </li></ul></ul><ul><ul><li>Post-inflammatory </li></ul></ul><ul><ul><li>Post vitreous haemorrhage </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><li>Read Chignell et al (2000) Optometry in Practice 2(1);97 et seq </li></ul>
  9. 11. Posterior Vitreous Detachment <ul><li>PVD with gel collapse </li></ul><ul><ul><li>Without vitreous haemorrhage, 4% develop retinal breaks </li></ul></ul><ul><ul><li>With vitreous haemorrhage, 20% develop breaks </li></ul></ul><ul><li>PVD without gel collapse </li></ul><ul><ul><li>Associated with future retinal hole or vitreous haemorrhage </li></ul></ul><ul><ul><li>Scaffold for proliferative new vessels </li></ul></ul>
  10. 16. Vitreous Haemorrhage <ul><li>Proliferative retinopathies </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Retinal vein occlusion </li></ul></ul><ul><ul><li>Sickle cell retinopathy </li></ul></ul><ul><ul><li>ROP </li></ul></ul><ul><ul><li>Eale’s disease </li></ul></ul><ul><li>PVD </li></ul><ul><li>Trauma </li></ul>
  11. 17. Vitreous Haemorrhage <ul><li>Disciform macular degeneration </li></ul><ul><li>Blood dyscrasias </li></ul><ul><li>Subarachnoid haemorrhage (Terson’s syndrome) </li></ul><ul><li>Complications of vitreous haemorrhage </li></ul><ul><ul><li>Syneresis; Fibrosis  traction RD; Haemosiderosis; Haemolytic (ghost cell) glaucoma; Synchisis scintillans; Ochre membrane </li></ul></ul>
  12. 19. Retinal Detachment <ul><li>Retinal detachment can be: </li></ul><ul><ul><li>Rhegmatogenous </li></ul></ul><ul><ul><li>Tractional </li></ul></ul><ul><ul><li>Exudative </li></ul></ul>
  13. 20. Rhegmatogenous RD <ul><li>RD occurring in association with hole formation; incidence 1:10,000 per year </li></ul><ul><li>Predisposing conditions </li></ul><ul><ul><li>Acute PVD </li></ul></ul><ul><ul><li>Myopia (esp. High myopia) </li></ul></ul><ul><ul><li> Age </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Aphakia (1% of ICCE; 0.1% of ECCE with intact PC) </li></ul></ul><ul><ul><li>Vitreoretinal degenerations </li></ul></ul>
  14. 21. Rhegmatogenous RD <ul><li>Pathogenesis </li></ul><ul><ul><li>Following PVD, dynamic vitreoretinal traction occurs at abnormal adhesions </li></ul></ul><ul><ul><ul><li>This can  vitreous haemorrhage </li></ul></ul></ul><ul><ul><li>Traction  energy transmission to retina </li></ul></ul><ul><ul><li>To relieve traction, a break forms </li></ul></ul><ul><ul><li>RD caused by collection of subretinal fluid </li></ul></ul>
  15. 22. Rhegmatogenous RD <ul><li>Pathogenesis </li></ul><ul><ul><li>Sensory retina detaches from RPE </li></ul></ul><ul><ul><ul><li>Pigment cells may be avulsed into vitreous  tobacco dust </li></ul></ul></ul><ul><ul><ul><li>This predisposes to proliferative vitreoretinopathy (PVR) </li></ul></ul></ul><ul><ul><li>Retina becomes opaque due to oedema </li></ul></ul><ul><ul><li> Photoreceptor degeneration </li></ul></ul>
  16. 23. Types of Break <ul><li>Horseshoe or U-shaped tear </li></ul><ul><li>Atrophic hole </li></ul><ul><li>Operculated </li></ul><ul><li>Dialysis </li></ul><ul><ul><li>Involves splitting of vitreous base </li></ul></ul><ul><ul><li>Usually inferotemporal </li></ul></ul><ul><ul><li>Can be spontaneous or traumatic </li></ul></ul><ul><li>Macular hole </li></ul><ul><ul><li>Idiopathic; myopia; Commotio retinae </li></ul></ul>
  17. 24. Types of Break <ul><li>Giant retinal tear </li></ul><ul><ul><li>90-360° tear; may fold back </li></ul></ul><ul><ul><li>Associated with PVR </li></ul></ul><ul><ul><li>Trauma; myopia; Stickler’s syndrome </li></ul></ul><ul><li>Bucket handle tears </li></ul><ul><ul><li>Usually superonasal </li></ul></ul><ul><ul><li>Avulsion of vitreous base </li></ul></ul><ul><ul><li>Always traumatic </li></ul></ul>
  18. 25. Rhegmatogenous RD <ul><li>Symptoms </li></ul><ul><ul><li>Photopsia </li></ul></ul><ul><ul><li>Floaters </li></ul></ul><ul><ul><li>Shadow </li></ul></ul><ul><ul><li>60% of patients with RD have ALL symptoms </li></ul></ul>
  19. 26. Rhegmatogenous RD <ul><li>Examination </li></ul><ul><ul><li>VA </li></ul></ul><ul><ul><li>Visual fields </li></ul></ul><ul><ul><li>Peripheral retinal evaluation </li></ul></ul><ul><ul><ul><li>BIO + 3-mirror </li></ul></ul></ul><ul><ul><li>Tobacco dust </li></ul></ul><ul><ul><li>Mild anterior uveitis </li></ul></ul><ul><ul><li>Low IOP </li></ul></ul>
  20. 28. Rhegmatogenous RD <ul><li>Natural history </li></ul><ul><ul><li>Progression to total detachment </li></ul></ul><ul><ul><li>Spontaneous reattachment (can happen) </li></ul></ul><ul><ul><li>Retinal & RPE atrophy </li></ul></ul><ul><ul><li>“ High water mark” - RPE hyperplasia </li></ul></ul><ul><ul><li>Viscous subretinal fluid </li></ul></ul><ul><ul><li>Intraretinal cyst formation </li></ul></ul><ul><ul><li>PVR </li></ul></ul><ul><ul><li>Rubeosis iridis </li></ul></ul><ul><ul><li>Phthisis bulbi </li></ul></ul>
  21. 29. Rhegmatogenous RD <ul><li>Principles of treatment </li></ul><ul><ul><li>Localisation & closure of breaks </li></ul></ul><ul><ul><li>Relief of vitreoretinal traction </li></ul></ul><ul><ul><ul><li>Buckling or vitrectomy </li></ul></ul></ul><ul><ul><li>Neuroretinal-rpe adhesion </li></ul></ul><ul><ul><ul><li>Photocoagulation or cryotherapy </li></ul></ul></ul><ul><ul><li>Internal tamponade </li></ul></ul><ul><ul><ul><li>Air; longer acting gases [SF 6 , C 3 F 8 ]; Silicone oil </li></ul></ul></ul>
  22. 30. Complications of RD Surgery <ul><li>Anterior or posterior segment ischaemia </li></ul><ul><li>Infection </li></ul><ul><li>Perforation or erosion of plomb into eye </li></ul><ul><li>Extrusion of plomb </li></ul><ul><li>Muscle imbalance </li></ul><ul><li>Refractive changes </li></ul><ul><li>Macular pucker </li></ul><ul><li>Cataract </li></ul><ul><li>Glaucoma </li></ul><ul><li>Redetachment </li></ul>
  23. 40. Vitreoretinal Degenerations <ul><li>Predisposing to RD </li></ul><ul><ul><li>Lattice degeneration - present in 40% of RD </li></ul></ul><ul><ul><li>Snail track degeneration </li></ul></ul><ul><ul><li>“ White without pressure” </li></ul></ul><ul><li>Benign </li></ul><ul><ul><li>“ White with pressure”; Pigment clumping; Diffuse chorioretinal atrophy; Peripheral microcystoid changes; Snowflake degeneration; Pavingstone degeneration; Honeycomb degeneration; Drusen; Oral pigmentary degeneration </li></ul></ul>
  24. 44. Tractional RD <ul><li>Penetrating ocular trauma </li></ul><ul><li>Proliferative retinopathies </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Sickle cell retinopathy </li></ul></ul><ul><ul><li>ROP </li></ul></ul><ul><ul><li>Retinal vein occlusion </li></ul></ul><ul><ul><li>Eale’s disease </li></ul></ul><ul><li>Persistent hyperplastic primary vitreous </li></ul><ul><li>Toxocariasis </li></ul><ul><li>Pars planitis </li></ul>
  25. 49. Exudative RD <ul><li>Uveitis e.g. Vogt-Koyanagi-Harada syndrome </li></ul><ul><li>Choroidal tumours </li></ul><ul><ul><li>Malignant melanoma </li></ul></ul><ul><ul><li>Metastatic </li></ul></ul><ul><li>Low blood protein levels </li></ul><ul><li>Hypertension </li></ul><ul><li>Eclampsia </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Choroidal effusion syndrome </li></ul>
  26. 51. Retinoschisis <ul><li>Splits or cysts within the neurosensory retina </li></ul><ul><li>Retinoschisis can be </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><ul><li>Senile (level of OPL) </li></ul></ul></ul><ul><ul><ul><li>Juvenile/congenital (level of RNFL) </li></ul></ul></ul><ul><ul><li>Secondary to other conditions </li></ul></ul>
  27. 52. Senile Retinoschisis <ul><li>Bilateral in 33% </li></ul><ul><li>Usually inferotemporal </li></ul><ul><li>Usually hypermetropic </li></ul><ul><li>Dome elevation of inner retinal layers </li></ul><ul><li>White dots (snowflakes) on inner limiting membrane </li></ul><ul><li>Inner leaf has beaten metal appearance </li></ul><ul><li>Sheathing of peripheral vessels </li></ul>
  28. 53. Senile Retinoschisis <ul><li>Round holes can occur in inner leaf </li></ul><ul><li>Larger holes can occur in outer leaf </li></ul><ul><li>1% progress to rhegmatogenous RD </li></ul><ul><li>Peripheral field defect though often asymptomatic </li></ul><ul><li>Need periodic observation with visual fields </li></ul>
  29. 55. Juvenile Retinoschisis <ul><li>X-linked recessive </li></ul><ul><li>Splits in NFL </li></ul><ul><li>Bilateral </li></ul><ul><li>Foveal (cystoid changes BUT not CMO) or peripheral </li></ul><ul><li>Associated with Favre-Goldmann & Wagner’s diseases </li></ul><ul><li>Poor visual prognosis </li></ul><ul><li>Predisposes to RD, esp inferotemporally </li></ul>
  30. 56. Juvenile Retinoschisis <ul><li>Present with </li></ul><ul><ul><li> vision (may be vitreous haemorrhage) </li></ul></ul><ul><ul><li>Maybe asymptomatic </li></ul></ul><ul><ul><li>Even though congenital, may not be detected for years </li></ul></ul>
  31. 58. Secondary Retinoschisis <ul><li>Proliferative retinopathies </li></ul><ul><li>Trauma </li></ul><ul><li>Vitreous traction </li></ul>
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