Vitreoretinal pathology (shared using VisualBee)

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  • Resource: Practical Ophthalmology (A manual for beginning residents) Fred M Wilson II, MD – Executive Editor
  • Some people remove their glasses as having the eyepieces closer to their eyes gives a greater field of view.The image is at 33cm. With presbyopia, this may become difficult to see. So, some people will need more plus correction. There is already a +2 correction in the BIO.
  • Start with the superior retina.
  • CMV Retinitis
  • Vitreoretinal pathology (shared using VisualBee)

    1. 1. VITREORETINALPATHOLOGYMr A Manna –http://about.me/ashmannaVitreoretinal ASTO – WolverhamptonEye Infirmary28 August 2012
    2. 2. CONTENTS► Indirect Ophthalmoscopy ► Technique► Retinal Breaks ► Treatment► Retinal Detachment ► Assessment► Pathological Myopia ► Ocular and systemic features
    3. 3. INDIRECTOPHTHALMOSCOPY
    4. 4. ► Introduce yourself.INDIRECTOPHTHALMOSCOPY
    5. 5. ► Observe external cues: ► High myopic glasses: myopic degeneration, staphyloma, laser for retinal tear ► Hearing aid: RP ► Etc.INDIRECTOPHTHALMOSCOPY
    6. 6. ► Lie patient on couch ► Make sure enough room to move around patientINDIRECTOPHTHALMOSCOPY
    7. 7. ► Adjust everything: ► Headband ► IPD: adjust by shining light on back of hand ► Dim room lights ► Make sure you use the 28D or 20D lens the right way upINDIRECTOPHTHALMOSCOPY
    8. 8. ► Look at the fundus: ► Move lens away from eye until stereoscopic image obtained (5cm for 20D lens) ► Tilt lens to reduce reflectionsINDIRECTOPHTHALMOSCOPY
    9. 9. ► Examine: ► Optic Disc ► Retinal Vessels ► Macula ► Peripheral retina in all cardinal positionsINDIRECTOPHTHALMOSCOPY
    10. 10. ► Indent: ► To view between equator (14mm from limbus) and pars plana (Spiral of Tillaux)INDIRECTOPHTHALMOSCOPY
    11. 11. ► Draw: (useful to have notes upside down) ► Red: retinal arterioles, retinal haemorrhage, microaneurysms, neovascularisation, retinal break ► Blue: retinal venules, detached retina, outline of retinal break or hole ► Yellow: exudate, oedema ► Green: vitreous opacity (e.g. haemorrhage) ► Brown: pigmentation, detached choroid ► Black: ora serrata, drusen, hyperpigmentationINDIRECTOPHTHALMOSCOPY
    12. 12. http://www.volk.com/main/compare/indirectbio.htmlLens Magnifica Field of Image Principal tion view use+14 BIO 4x 40o Inverted, Fundus Reversed, lesion Real+20 BIO 3x 45o Routine examinati on+30 BIO 2x 50o Child, small pupil, media opacityINDIRECTOPHTHALMOSCOPY
    13. 13. Done!INDIRECTOPHTHALMOSCOPY
    14. 14. ► What to treat?RETINAL TEARS
    15. 15. ► Treat all symptomatic tears/holes► Notes to VR Consultant► If low risk, discharge with Retinal Detachment Warning► If treatment not complete, ring me and I will complete treatment within a week ► My job is twofold: ► Laser up to ora ► Look for other breaksRETINAL TEARS
    16. 16. ► Anything that doesn’t need lasering?RETINAL TEARS
    17. 17. ► Tear more dangerous than Hole► Pigmentation is reassuring► Symptomatic breaks more dangerous than incidental finding► Worrying factors: ► Cataract surgery esp. with vitreous loss ► Myope ► FHx RD ► Marfan, Stickler, Ehlers-DanlosRETINAL TEARS
    18. 18. RETINAL DETACHMENT
    19. 19. ► What the Vitreoretinal Surgeon wants to know:► History (symptoms, duration, VF defect, trauma), vision, POH, Myopia, Systemic Conditions (connective tissue disease, suitability for GA), FHx RD, Tobacco dust, extent of RD (clock hours, how close to macula, shallow, bullous, dome), Is the retina translucent? Are there lines of pigment around the detachment? Does the fellow eye have Retinoschisis? If mac- on, keep NBM for now (just in case). DO NOT promise immediate surgery!!!RETINAL DETACHMENT
    20. 20. HIGH MYOPIA
    21. 21. ► 1. NBM► 2. DO NOT promise immediate surgery. Consent "Right/Left Retinal Detachment Repair".► 3. Admit to D4► 4. Is patient happy for LA instead of GA?► 5. Nurses to phone Nucleus Theatres to see whats on the emergency list.► 6. Inform on-call theatre staff and ask if surgery next morning (07:30) is an option.► 7. Take 2 patient stickers to Nucleus Theatres and book the case for tonight AND tomorrow morning. WHAT TO DO WHILE WAITING
    22. 22. ► Dialysis, trauma related, young patient, avulsion of vitreous base may give bucket-handle. If no RD, laser. If RD, usualy progress slowly due to healthy vitreous gel in young individuals.
    23. 23. Don’t miss the elephant in the room
    24. 24. ► Convex, smooth (not corrugated)► Mobile, with ‘shifting fluid’ phenomenon► Systemic disease: Harada disease, toxaemia of pregnancyEXUDATIVE RD
    25. 25. ► Causes: ► Choroidal tumours: melanomas, haemangiomas, metastases ► Inflammation: Harada, scleritis ► Bullous CSR: rare ► Iatrogenic: RD surgery, PRP ► CNVM ► Hypertensive choroidopathy: toxaemia of pregnancy ► Idiopathic: Uveal effusion syndromeEXUDATIVE RD
    26. 26. ► Grade A (minimal) PVR: diffuse vitreous haze and tobacco dust. Pigmented clumps under retina.► Grade B (moderate) PVR: wrinkling of inner retinal surface, tortuosity of blood vessels, retinal stiffness, decreased mobility of vitreous gel, rolled edges of retinal breaks► Grade C (marked) PVR: full thickness rigid retinal folds. Heavy vitreous condensation and strands. Described as Anterior/Posterior + Clock hours.PVR IN LONGSTANDING RDS
    27. 27. HIGH MYOPIA
    28. 28. ► Refractive error > -6D and axial length > 26mm► 0.5% of population► Maculopathy commonest cause of visual lossHIGH MYOPIA
    29. 29. Pale tessellate (tigroid) appearance due to diffuse attenuation of the RPE withvisibility of large choroidal vessels.
    30. 30. Focal chorioretinal atrophy characterised by visibility of the larger choroidalvessels and eventually the sclera
    31. 31. ‘Lacquer cracks’ consist of ruptures in the RPE-Bruch membrane-choriocapillariscomplex characterised by fine, irregular, yelow lines, often branching and criss-crossing at the posterior pole
    32. 32. Fuchs spot is a raised, circular, pigmented lesion that may develop after amacular haemorrhage has absorbed
    33. 33. Subretinal ‘coin’ haemorrhages, which may be intermittent, may develop fromlacquer cracks in the absence of CNV
    34. 34. Staphylomas are due to expansion of the globe and scleral thinning. They maybe peripapillary or involve the posterior pole and be associated with macularhole formation.
    35. 35. ► Foveal retinoschisis: in the absence of macular hole.► Peripapillary detachment: asymptomatic, innocuous, yellow-orange elevation of the RPE and sensory retina at the inferior border of the myopic conus.HIGH MYOPIA
    36. 36. ► Associations: ► Cataract ► POAG ► Pigmentary glaucoma ► ROP can be related to subsequent high myopia ► Amblyopia uncommon, but can be there due to anisometropia ► Systemic: ► Stickler ► Marfan ► Ehlers-Danlos ► Pierre-RobinHIGH MYOPIA
    37. 37. ► Associations: ► Cataract ► POAG ► Pigmentary glaucoma ► ROP can be related to subsequent high myopia ► Amblyopia uncommon, but can be there due to anisometropia Systemic: ► Stickler Syndrome ► Stickler Hereditary arthro-ophthalmopathy ► Marfan Abnormal vitreous ► Ehlers-Danlos High myopia ► Pierre-Robin Orofacial abnormality Deafness Arthropathy Mitral valve prolapse AD inheritance with variable expressivityHIGH MYOPIA Commonest inherited cause of retinal detachment in children.
    38. 38. ► Associations: ► Cataract ► POAG ► Pigmentary glaucoma ► ROP can be related to subsequent high myopia ► Amblyopia uncommon, but can be there due to anisometropia Systemic: ► Marfan Syndrome ► Stickler Connective tissue disorder – mutation of fibrillin ► Marfan gene on chromosome 15q. ► Ehlers-Danlos Tall, thin, long limbs compared with trunk ► Pierre-Robin Arachnodactyly, joint hypermobility Gothic palate Dilatation of ascending aorta, aortic incompetence, heart failure, mitral valve disease, aortic dissectionHIGH MYOPIA Ectopia lentis, myopia, RD AD inheritance with variable expressivity.
    39. 39. ► Associations: ► Cataract ► POAG ► Pigmentary glaucoma ► ROP can be related to subsequent high myopia ► Amblyopia uncommon, but can be there due to anisometropia Systemic: ► Ehlers-Danlos syndrome type 6 ► Stickler 9 subtypes, but only type 4 and 6 affect the ► Marfan eye. ► Ehlers-Danlos Rare, usually AR disorder of collagen caused by ► Pierre-Robin deficiency of procollagen lysyl hydroxylase. Thin hyperelastic skin. Hypermobile joints. Cardiovascular disease: bleeding diathesis,HIGH MYOPIA dissecting aneurysms, spontaneous rupture of large blood vessels, mitral valve prolapse Ocular fragility with increased vulnerability to mild trauma, high myopia, retinal detachment, keratoconus
    40. 40. ► Associations: ► Cataract ► POAG ► Pigmentary glaucoma ► ROP can be related to subsequent high myopia ► Amblyopia uncommon, but can be there due to anisometropia Systemic: ► Pierre-Robin syndrome ► Stickler ► Marfan Micrognathia, small tongue, cleft soft palate, ► Ehlers-Danlos high-arched palate. ► Pierre-Robin Jaw that is very small with small (receding) chin Jaw that is far back in the throat Repeated ear infections Small opening in the roof of the mouth, whichHIGH MYOPIA causes choking Teeth that appear when the baby is born (natal teeth) Tongue that is large compared to the jaw

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