This document provides an overview of common retinal diseases, including diabetes mellitus, hypertension, retinal vascular disorders, age-related macular degeneration, and retinal detachment. It describes the pathogenesis, symptoms, classifications, and treatments for each condition. For diabetes mellitus, it discusses diabetic retinopathy in detail, from microaneurysms and neovascularization to laser treatment options. For hypertension, it covers hypertensive changes to the retina and their grading system. Age-related macular degeneration is differentiated as dry or wet forms. Retinal detachment causes and management are also outlined.

1. Common retinal diseases
Dr. Mushawiahti Mustapha
Department. Of Ophthalmology
Universiti Kebangsaan Malaysia

2. Retinal diseases - outline
 Diabetes mellitus
 Hypertension
 Other retinal vascular problem: CRVO/CRAO
 Age related macular degeneration (AMD)
 Retinal Detachment

4. 10 layers of
retina

5. Normal fundus

6. What is Diabetic retinopathy?
 Specific vascular complication
of diabetes mellitus
 Microangiopathy
 Neuropathy
 Nephropathy
 Remains a leading cause of
new blindness

7. Diabetic Retinopathy
 Duration of diabetes,
 after 20 years:have some degree of retinopathy
 nearly all patients with type 1 diabetes mellitus
 more than 60% of patients with type 2 diabetes mellitus
 Other risk factors: pregnancy, hypertension,
renal disease, obesity, hyperlipidaemia,
smoking, anaemia

8. Pathogenesis
 Weak capillary wall →
saccular outpouching of wall
(microaneurysm)-may leak
or thrombosed
 Breakdown of inner BRB
Leakage: capillary changesOcclusion
1. Capillary changes
2. Haematological
changes

9. ↓
→Less O2
→ retinal ischaemia/ hypoxia
↓
Release of VEGF
(Vascular Endothelial Growth Factor)
Occlusion….

10. Symptoms
 Asymptomatic/painless
 Gradual blurring of vision
 diabetic maculopathy
 Sudden blurring of vision
 vitreous haemorrhage
 Painful gradual blurring of vision
 Rubeotic glaucoma

11. Retinal hypoxia Manifested as:
- AV shunt
* intraretinal microvascular
abnormalities (IRMA) -
opening of pre-existing
vascular channel
- Neovascularization
* Attempt to revascularize
hypoxic retina
- Rubeosis iridis, NVD, NVE
- CWS
- microinfarction of NFL
causing axoplasmic
swelling
Cotton wool spot

12. Cotton wool spot
Dot & blot
haemorrhage
Pre-retinal
haemorrhage
Hard exudates

13. Pathogenesis
 Weak capillary wall →
saccular outpouching of wall
(microaneurysm)-may leak
or thrombosed
 Breakdown of inner BRB
Leakage: capillary changesOcclusion
1. Capillary changes
2. Haematological
changes

14. Microvascular leakage
Consequence…
 Intraretinal hemorrhage
(dot and blot)
 Oedema-diffuse or focal
(hard exudate-
lipoprotein and lipid
macrophages
surrounding leaking
microvascular lesion in
circinate pattern)

15. Dot blot
haemorrhage
Hard
exudate

16. Classification – ETDRS
 Non-proliferative DR (NPDR) –
→ mild, moderate, severe
 Proliferative DR (PDR)
With/without
maculopathy

17. Spectrum of disease
Mild/moderate/severe NPDR
↓
PDR
↓
VH
↓
TRD
↓
Rubeotic glaucoma

18. Non-proliferative Diabetic
Retinopathty
 Microaneurysms
 Dot, blot or flame-
shaped
haemorrhages
 Hard exudates
 Retinal oedema
 Intraretinal
microvascular
abnormalities
(IRMA)

19. Proliferative diabetic retinopathy
(PDR)

20. Vitreous haemorrhage

21. Tractional retinal detachment

22. Maculopathy
 Hard exudates and oedema in the macula

23. Treatment
 Laser
photocoagulation
 pan-retinal photocoagulation
(PRP) of peripheral retina
 Macular laser
 Surgery (vitrectomy)

24. How laser is given to patient

25. Left eye – laser spares the macula area

26. Pan-retinal photocoagulation (PRP) for PDR

27. Grid laser for maculopathy

28. Why DR has to be detected
 Diabetes mellitus is the single most
important cause of

29. Causes for the blindness in DR
 Non-resolving vitreous hemorrhage
 Tractional retinal detachment
 Diabetic maculopathy
 Cataract
 Rubeotic Glaucoma

30. How to detect DR?
Using direct ophthalmoscope

31. When to screen for DR
 All NIDDM at the time of diagnosis
(once a year)
 IDDM after at least 5 years of diagnosis
 Diabetic women
 planning for pregnancy
 need to have complete eye examination
before conception
 Once becomes pregnant
 should be examined for retinopathy early in the
first trimester

32. Prevention
 Screening
 Control of blood sugar
 Control of hypertension
 Control of hyperlipidaemia

33. Retinal diseases - outline
 Diabetes mellitus
 Hypertension
 Other retinal vascular problem: CRVO/CRAO
 Age related macular degeneration (AMD)
 Retinal Detachment

34. HYPERTENSION
AND THE EYE

35. HYPERTENSION AND EYE
 The eye is the only place in the body
where the vessels can be directly
observed
 Patients with hypertensive retinopathy
are usually asymptomatic

36. Hypertensive changes in the eye
 Acute hypertension (suddden rise of BP)
 Grade III and IV hypertensive retinopathy
 Choroidopathy
 Optic neuropathy
 Chronic hypertension
 Arterial changes

37. Pathophysiology
 Arteriolar narrowing due to
vasoconstriction and arteriolosclerosis
(increase in elastic tissue and
musculature)
 Focal closure of retinal vasculature lead
to microinfarcts (cotton wool spots) and
haemorrhages
 Leakage lead to oedema and exudates
 Disc oedema develops in advanced
stage)

38. Classification
(modified Keith-Wagener-Barker / Scheie)
Grade Haemorr-
hage
Exudate Disc
swelling
AV ratio Light
reflex
AV
crossing
changes
Normal none none none 3:4 Fine
yellow
None
Grade 1 none none none 1:2 Broad
yellow
Mild vein
depression
Grade 2 none none none 1:3 Copper
wiring
A-V
nipping
Grade 3
+ + none 1:4 Silver
wiring
Right angle
Deviation /
Distal
dilatation
Grade 4
+ + + fine
cords
as stage 3 as stage 3

39. Grade 2 hypertensive retinopathy

40. Asymptomatic: poorly controlled
HPT

41. Poor vision:
Grade IV Hypertensive retinopathy

42. Keith, Wagener, and Barker 1939
 The changes seen in groups I and II are
typically chronic
 groups III and IV are seen with more
acute rises in blood pressure.
 Retinal haemorrhages and hard exudates,
cotton wool spots, optic disc swelling

43. Is there a need to refer all
hypertensive patients to
ophthalmologist? No, if there is no visual impairment
 We do not monitor the fundus of HPT
patients
 If BP is high: refer physician

44. Management HT retinopathy
 Referral to physicians for control of the blood
pressure: urgency depends on the stage
 Stage 1 n 2: BP monitoring if on treatment
 Stage 3 n 4: urgent referral

45. Retinal diseases - outline
 Diabetes mellitus
 Hypertension
 Other retinal vascular problem: CRVO/CRAO
 Age related macular degeneration (AMD)
 Retinal Detachment

46. Other retinal vascular disorders
 Retinal vein occlusion
 CRVO
 BRVO
 Retinal artery occlusion
 CRAO
 BRAO

47. CRVO - central retinal vein occlusion

48. BRVO – branch retinal vein occlusion

49. CRAO – central retinal artery occlusion

50. Central retinal artery occlusion
(CRAO)
 Anatomy:
 Internal carotid artery
 Ophthalmic artery
 Central retinal artery
 Mainly supply of blood to
the inner half of
neurosensory retina

51. CRAO – risk factors
 Risk factors:
 Age older than 70 years old
 Atherosclerosis – DM / HPT /
Hypercholesterolaemia / smoking
 Emboli – cholesterol, calcific, fibrin-platelet
 Others – arteritis, thrombophilic disorders,
migraine
 Young: Connective tissue disease, cardiac
valvular disease

52. Retinal diseases - outline
 Diabetes mellitus
 Hypertension
 Other retinal vascular problem: CRVO/CRAO
 Age related macular degeneration (AMD)
 Retinal Detachment

53. AGE RELATED MACULAR
DEGENERATION
(AMD)
DRY (90%) versus WET (10%)

54. ARMD-DRY
 Non-neovascular
 Non-exudative, geographic, or atrophic
AMD
 Neovascular AMD (Wet)
 Exudative, disciform, or serous AMD
Dry Drussen

55. ARMD-WET

58. Symptoms: central visual loss,
metamorphopsia

59. Diagnostic assessment
 Examination
 Visual acuity
 Fundus biomicroscopy via dilated pupil
 Amsler chart
 Color photography
 Fluorescein angiography

61. Detection: The Amsler grid
 Amsler grids can
facilitate early detection
 Signs suggestive of CNV
include:
 Distortion
 Blurring
 Darkening or discoloration
of the grid lines
 Inability to fix on the
central dot

62. Treatment option for CNV
 Argon laser photocoagulation
 Intravitreal anti-VEGF injection
 Photodynamic therapy

63. Visudyne therapy: a two step process
Step 1
Step 2

64. Occlusion of CNV
Reactive oxygen
products
Occlusion of abnormal
vessels
Light-activation of Visudyne
Endothelial cell damage
and thrombus formation

65. Retinal diseases - outline
 Diabetes mellitus
 Hypertension
 Other retinal vascular problem: CRVO/CRAO
 Age related macular degeneration (AMD)
 Retinal Detachment

66. Retinal detachment
 Separation of the neurosensory
layer from the retinal pigment
epithelium (RPE)
1. Rhegmatogenous (RRD)
 Retinal tear / hole
 Risk factors – high myopia, intraocular
surgery, trauma
2. Tractional (TRD)
 Proliferative diabetic retinopathy (PDR)
3. Exudative
 Malignant HPT, tumour, uveitis - VKH

67. RRD – symptoms & signs
 Signs:
 Reduced visual
acuity
 Positive RAPD
 Visual field defect
 Symptoms:
 Photopsia (sensation
of flashing light)
 Floaters
 Reduced vision
 Metamorphopsia –
macula involvement

68. RRD

69. RRD - management
 Urgent / early intervention to flatten the
retina……
 Pars plana vitrectomy (PPV)
 Scleral buckle surgery

70. Acknowledgement
 Dr. Aida Zairani
 Senior lecturer / Ophthalmologist, PPUKM

71. Thank you