8. Introduction- retinal disorders
Retinal Disorders. Available [online] at URL: https://medlineplus.gov/retinaldisorders.html. As accessed on June 19, 2018.
Can affect vision and be serious
enough to cause blindness
Common retinal disorders are
o Age related macular degeneration (AMD)
o Diabetic macular degeneration (DME)
o Retinal vein occlusion (RVO)
9. To know more about retinal
disorders, a brief understanding
of structure of eye is important
11. Eye structure
1. Anatomy of the eye. Available [online] at URL: https://www.moorfields.nhs.uk/content/anatomy-eye. As accessed on June 18, 2018. 2. Retinal
Disorders. Available [online] at URL: https://medlineplus.gov/retinaldisorders.html. As accessed on June 19, 2018
Retina1
o Light sensitive layer that lines the
interior of the eye
o Composed of sensitive cells known as
rods and cones
Rods are necessary for seeing in dim
light
Cones function best in bright light and
helps in distinguishing colours
Macula1,2
o Yellow spot on the retina at the back of the eye
(retina) which surrounds the fovea
o Provides sharp vision for
Reading
Driving
Seeing fine detail
12. Eye structure
Anatomy of the eye. Available [online] at URL: https://www.moorfields.nhs.uk/content/anatomy-eye. As accessed on June 18, 2018.
Fovea
o Forms a small indentation at the
centre of the macula
o Area with the greatest
concentration of cone cells
Optic disc
o Visible (when the eye is examined)
portion of the optic nerve, also found on the retina
o Identifies the start of the optic nerve where messages from cone
and rod cells leave the eye via nerve fibres to the optic centre of
the brain
o This area is also known as the 'blind spot’
13. Eye structure
Anatomy of the eye. Available [online] at URL: https://www.moorfields.nhs.uk/content/anatomy-eye. As accessed on June 18, 2018.
Fovea
o Forms a small indentation at the
centre of the macula
o Area with the greatest
concentration of cone cells
Optic disc
o Visible (when the eye is examined)
portion of the optic nerve, also found on the retina
o Identifies the start of the optic nerve where messages from cone
and rod cells leave the eye via nerve fibres to the optic centre of
the brain
o This area is also known as the 'blind spot’
14. Eye structure
1. Anatomy of the eye. Available [online] at URL: https://www.moorfields.nhs.uk/content/anatomy-eye. As accessed on June 18, 2018. 2.
An introduction to eyes and how they work. Available [online] at URL: https://www.medicalnewstoday.com/articles/320608.php. As
accessed on June 19, 208.
Optic nerve1
o Leaves the eye at the optic disc
and transfers all the visual
information to the brain
Vitreous fluid2
o Thick, gel like fluid, found in the
back section of the eye
o Makes up the majority of the
eye's mass
Aqueous fluid2
o More watery than vitreous fluid and circulates through the
front of the eye
16. DME
1. Advocating for Improved Treatment and Outcomes for Diabetic Macular Edema. A Report Based on an International Expert Summit
Convened in Paris, June 2014. 2. Diabetic Macular Oedema. Available [online] at URL: https://www.vsp.com/diabetic-macular-
edema.html . As accessed on June 22, 2018. 3. Diabetic Macular Edema. Available [online] at URL:
http://eyewiki.aao.org/Diabetic_Macular_Edema. As accessed on June 22, 2018.
Leading cause of vision loss in the world, particularly
among working-age adults (20-74 years)1
Common problem in patients with diabetes2,3
Incidence of DME3
o 20% in early onset of diabetes
o 40% in late onset of diabetes
17. How does DME occur?
Healthy eye
Blood vessels leak. Fluid
collects in the retina and
macula. This causes the
macula to swell and bulge
About DME. Available[online] at URL: https://www.lucentis.com/diabetic-macular-edema-information. As accessed on June 22, 2018.
DME
In a healthy retina, the
fovea (the centermost
part of the macula) will
appear indented
19. Types of DME
Diabetic Macular Oedema. Available [online] at URL: https://www.vsp.com/diabetic-macular-edema.html . As accessed on June 22, 2018.
o Abnormalities in the blood vessels in the eye
Focal DME
o Widening/swelling of retinal capillaries (very thin blood
vessels)
Diffuse DME
20. Factors determining
severity of DME
Diabetic Macular Oedema. Available [online] at URL: https://www.vsp.com/diabetic-macular-edema.html . As accessed on June 22, 2018.
Type of diabetes
Degree of diabetic
retinopathy
Severe hypertension
Duration of diabetes
21. Factors determining
severity of DME
Diabetic Macular Oedema. Available [online] at URL: https://www.vsp.com/diabetic-macular-edema.html . As accessed on June 22, 2018.
Hyperlipidemia, or high fat
levels in the blood
Fluid retention (Water
content in the body)
Hypoalbuminemia, or
low protein in body fluids
22. Signs and symptoms
Diabetic Macular Edema. Available [online] at URL: https://www.vsp.com/diabetic-macular-edema.html. As accessed on June 22, 2018.
Double vision
Blurry vision
Eventually blindness if it
goes untreated
Floaters
23. Diagnosis
Diabetic Macular Edema. Available[online] at URL: https://www.webmd.com/diabetes/diabetic-macular-edema#1 . As accessed on June 19, 2018
Detailed
history
Visual
acuity test
Dilated
eye exam
Fluorescein
angiography (FA)
Optical
coherence
tomography
(OCT)
24. Diagnosis
Raman R and Bhende M. Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2.
Proper history taking is essential during assessment
of DME
Duration of diabetes Past glycemic control
(hemoglobin A1c)
History related to drugs
causing macular edema
25. Diagnosis
Raman R and Bhende M. Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2.
Proper history taking is essential during assessment
of DME
Medications
o Insulin
o Oral hypoglycemics
o Antihypertensives
o Lipid-lowering drugs
Systemic history
o Renal disease
o Cardiovascular events
o Hypertension
o Lipid levels
o Pregnancy
26. Diagnosis
Raman R and Bhende M. Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2.
Visual acuity
o Eye chart to measure near and
distance vision
Dilated eye exam
o Doctor instil drops in eyes to widen or dilate
the pupils
o Provides a better view of the back of the eye
o Using a special magnifying lens, retina and
optic nerve are examined
27. Fluorescein angiography
Diabetic Macular Edema. . Available[online] at URL: https://www.webmd.com/diabetes/diabetic-macular-edema#1 . As
accessed on June 19, 2018
o Injection of dye through patient’s
peripheral veins(arm or hand)
o A series of photographs are taken
after injection of dye
o Helps to identify areas of leakage
28. Optical coherence
tomography (OCT)
Raman R and Bhende M. Sci J Med & Vis Res Foun June 2015 | volume XXXIII | number 2.
o Newer, non-invasive technique similar
to ultrasound - except that instead of
sound waves light rays are used
o Provides a detailed, highly magnified,
cross-section view of a patient’s
macula
o Eyes are dilated, patient is asked to
place head on a chin rest and images
are obtained
Light beam is painless
29. Management of DME
Diabetic Macular Edema. Available [online] at URL: http://eyewiki.aao.org/Diabetic_Macular_Edema. As accessed on June 22, 2018.
Combined
therapy (Laser+
Pharmacological)
Surgical
therapy
Pharmacological
Laser therapy
Non-
pharmacological
30. Non pharmacological
Diabetic Macular Edema. Available [online] at URL: http://eyewiki.aao.org/Diabetic_Macular_Edema. As accessed on June 22, 2018.
Diet
modification
Weight loss
Strict control
o Diabetes
o Hypertension
o Hypercholesterolemia
Exercise
31. Pharmacological
Facts About Age-Related Macular Degeneration. Available[online] at URL: https://nei.nih.gov/health/maculardegen/armd_facts. As
accessed on June 19, 2018. Diabetic Macular Edema. Available [online] at URL: http://eyewiki.aao.org/Diabetic_Macular_Edema. As
accessed on June 22, 2018.
Intravitreal injections
o Medicines known as anti-VEGF/corticosteroids are injected in
the eyes
o Multiple monthly injections
o Before each injection eyes are numbed and cleaned with
antiseptics
32. Management-
pharmacological
Anti VEGF injections can
help to slow down or hold
back any loss of vision
Anti VEGF therapies
o Anti VEGF stands for "anti vascular endothelial growth factor”
VEGF is a protein that promotes blood vessel growth
o Anti VEGF injections
Reduces new blood vessel growth
Slows down any leakage or swelling these new blood vessels may cause
Anti-VEGF treatment. Available [online] at URL: https://www.rnib.org.uk/eye-health-eye-conditions-z-eye-conditions/anti-vegf-treatment. As
accessed on August 9, 2018.
33. Administration of Anti-VEGF
injection
o Anti-VEGF drugs are given as an injection into the vitreous (the jelly-like
substance inside eye)
o The injection is given
Through the white of eye (the sclera)
Under aseptic precautions
May be given in an operating theatre
o The needle used for the injection is small and short and the injection itself
only takes a few seconds
Anti-VEGF treatment. Available [online] at URL: https://www.rnib.org.uk/eye-health-eye-conditions-z-eye-conditions/anti-vegf-treatment. As
accessed on August 9, 2018.
34. Administration of Anti-VEGF
injection
o Instillation of eye drops which dilate pupil (This
allows ophthalmologist to see the back of eye
more easily)
Anti-VEGF treatment. Available [online] at URL: https://www.rnib.org.uk/eye-health-eye-conditions-z-eye-conditions/anti-vegf-treatment. As
accessed on August 9, 2018.
Basic steps for giving an anti-VEGF injection
o Instillation of local anaesthetic eye drops or a
local anaesthetic injection
Helps to make the injection as pain free as
possible
35. Administration of Anti-VEGF
injection
o The eye and skin around the eye is cleaned to
prevent infection
Anti-VEGF treatment. Available [online] at URL: https://www.rnib.org.uk/eye-health-eye-conditions-z-eye-conditions/anti-vegf-treatment. As
accessed on August 9, 2018.
Basic steps for giving an anti-VEGF injection
o Face and the area around the eye may be
covered by a drape to keep the area sterile
36. Administration of Anti-VEGF
injection
o A small device called a speculum is used to keep
the eye open and prevent blinking
Anti-VEGF treatment. Available [online] at URL: https://www.rnib.org.uk/eye-health-eye-conditions-z-eye-conditions/anti-vegf-treatment. As
accessed on August 9, 2018.
Basic steps for giving an anti-VEGF injection
o The injection is given once the eye is numb
o Following the injection, antibiotic
drops may be given
37. Laser surgery
Diabetic Macular Edema. Available [online] at URL: http://eyewiki.aao.org/Diabetic_Macular_Edema. As accessed on June 22, 2018. Diabetic
Macular Edema. Available [online] at URL: https://www.webmd.com/diabetes/diabetic-macular-edema#2 . As accessed on June 22, 2018.
o Mainstay of treatment
o Involves aiming an intense “hot” laser to seal leaking
blood vessels
38. Combined therapy
Diabetic Macular Edema. Available [online] at URL: http://eyewiki.aao.org/Diabetic_Macular_Edema. As accessed on June 22, 2018.
o In some cases combination therapy is preferred
o Laser + intravitreal injections
39. Surgical therapy
Diabetic Macular Edema. Available [online] at URL: https://www.webmd.com/diabetes/diabetic-macular-edema#2 . As accessed
on June 22, 2018.
o A surgery called vitrectomy is one of the options
o Done in bleeding macula
o Fluid that clouds the vision is replaced with clear solution
40. Prevention of DME
DME. Available[online] at URL: https://www.preventblindness.org/diabetic-macular-edema-dme. As accessed on June 22, 2018.
Tight control of
o Blood sugar
o Blood pressure
o Cholesterol
Comprehensive dilated
eye exam at least once
a year, or more often as
directed by the eye doctor
41. Prevention of DME
DME. Available[online] at URL: https://www.preventblindness.org/diabetic-macular-edema-dme. As accessed on June 22, 2018.
Maintaining
a healthy
lifestyle
Exercising
regularly
Healthy diet
42. Advise on lifestyle
modifications
1. Macular Degeneration. Available [online] at URL: https://patient.info/health/visual-problems/age-related-macular-degeneration . As
accessed on June 22, 2018 . 2. Retinal diseases. Available [online] at URL: https://www.mayoclinic.org/diseases-conditions/retinal-
diseases/diagnosis-treatment/drc-20355827. As accessed on June 22, 2018.
Stop smoking1 Eat a healthy
balanced diet1
Safety whilst
driving1 Use magnifiers2
Change computer
display2
Use of brighter
lights at home2
43. Advise on lifestyle
modifications
1. Macular Degeneration. Available [online] at URL: https://patient.info/health/visual-problems/age-related-macular-degeneration . As
accessed on June 22, 2018 . 2. Retinal diseases. Available [online] at URL: https://www.mayoclinic.org/diseases-conditions/retinal-
diseases/diagnosis-treatment/drc-20355827. As accessed on June 22, 2018.
Use electronic reading aids2
o Try talking watches, clocks and
calculators, large-print books, tablet
computers, and audio books
Special appliances made for low vision2
o Some clocks, radios, telephones and
other appliances have extra-large
numbers
Retinal disorders affect this vital tissue. They can affect your vision, and some can be serious enough to cause blindness. Examples are
Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones. The human eye contains about 125 million rods, which are necessary for seeing in dim light. Cones, on the other hand, function best in bright light. There are between 6 and 7 million cones in the eye and they are essential for receiving a sharp accurate image and for distinguishing colours. The retina works much in the same way as film in a camera.
Macula: a yellow spot on the retina at the back of the eye which surrounds the fovea. In the center of this nerve tissue is the macula. It provides the sharp, central vision needed for reading, driving and seeing fine detail.
Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells. When the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately registered by the brain.
Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies the start of the optic nerve where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the brain. This area is also known as the 'blind spot’.
Optic nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
Sclera: the white part of the eye, a tough covering with which the cornea forms the external protective coat of the eye.
Rod cells are one of the two types of light-sensitive cells in the retina of the eye. There are about 125 million rods, which are necessary for seeing in dim light.
Cone cells are the second type of light sensitive cells in the retina of the eye. The human retina contains between six and seven million cones; they function best in bright light and are essential for acute vision (receiving a sharp accurate image). It is thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue. Other colours are seen as combinations of these primary colours.
Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones. The human eye contains about 125 million rods, which are necessary for seeing in dim light. Cones, on the other hand, function best in bright light. There are between 6 and 7 million cones in the eye and they are essential for receiving a sharp accurate image and for distinguishing colours. The retina works much in the same way as film in a camera.
Macula: a yellow spot on the retina at the back of the eye which surrounds the fovea.
Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells. When the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately registered by the brain.
Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies the start of the optic nerve where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the brain. This area is also known as the 'blind spot’.
Optic nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
Sclera: the white part of the eye, a tough covering with which the cornea forms the external protective coat of the eye.
Rod cells are one of the two types of light-sensitive cells in the retina of the eye. There are about 125 million rods, which are necessary for seeing in dim light.
Cone cells are the second type of light sensitive cells in the retina of the eye. The human retina contains between six and seven million cones; they function best in bright light and are essential for acute vision (receiving a sharp accurate image). It is thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue. Other colours are seen as combinations of these primary colours.
Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones. The human eye contains about 125 million rods, which are necessary for seeing in dim light. Cones, on the other hand, function best in bright light. There are between 6 and 7 million cones in the eye and they are essential for receiving a sharp accurate image and for distinguishing colours. The retina works much in the same way as film in a camera.
Macula: a yellow spot on the retina at the back of the eye which surrounds the fovea.
Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells. When the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately registered by the brain.
Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies the start of the optic nerve where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the brain. This area is also known as the 'blind spot’.
Optic nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
Sclera: the white part of the eye, a tough covering with which the cornea forms the external protective coat of the eye.
Rod cells are one of the two types of light-sensitive cells in the retina of the eye. There are about 125 million rods, which are necessary for seeing in dim light.
Cone cells are the second type of light sensitive cells in the retina of the eye. The human retina contains between six and seven million cones; they function best in bright light and are essential for acute vision (receiving a sharp accurate image). It is thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue. Other colours are seen as combinations of these primary colours.
Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones. The human eye contains about 125 million rods, which are necessary for seeing in dim light. Cones, on the other hand, function best in bright light. There are between 6 and 7 million cones in the eye and they are essential for receiving a sharp accurate image and for distinguishing colours. The retina works much in the same way as film in a camera.
Macula: a yellow spot on the retina at the back of the eye which surrounds the fovea.
Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells. When the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately registered by the brain.
Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies the start of the optic nerve where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the brain. This area is also known as the 'blind spot’.
Optic nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
Sclera: the white part of the eye, a tough covering with which the cornea forms the external protective coat of the eye.
Rod cells are one of the two types of light-sensitive cells in the retina of the eye. There are about 125 million rods, which are necessary for seeing in dim light.
Cone cells are the second type of light sensitive cells in the retina of the eye. The human retina contains between six and seven million cones; they function best in bright light and are essential for acute vision (receiving a sharp accurate image). It is thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue. Other colours are seen as combinations of these primary colours.
Diabetic Macular Edema (DME) is an accumulation of fluid in the macula—part of the retina that controls our most detailed vision abilities—due to leaking blood vessels. In order to develop DME, you must first have diabetic retinopathy. Diabetic retinopathy is a disease that damages the blood vessels in the retina, resulting in vision impairment. Left untreated, these blood vessels begin to build up pressure in the eye and leak fluid, causing DME. DME usually takes on two forms:
Focal DME, which occurs because of abnormalities in the blood vessels in the eye.
Diffuse DME, which occurs because of widening/swelling retinal capillaries (very thin blood vessels).
Focal DME, which occurs because of abnormalities in the blood vessels in the eye.
Diffuse DME, which occurs because of widening/swelling retinal capillaries (very thin blood vessels).
The severity of diabetic macular Oedema is dependent upon several factors:
Degree of diabetic retinopathy
Length of time the patient has had diabetes
Type of diabetes
Severe hypertension, very high blood pressure
Fluid retention
Hypoalbuminemia, or low protein in body fluids
Hyperlipidemia, or high fat levels in the blood
The severity of diabetic macular Oedema is dependent upon several factors:
Degree of diabetic retinopathy
Length of time the patient has had diabetes
Type of diabetes
Severe hypertension, very high blood pressure
Fluid retention
Hypoalbuminemia, or low protein in body fluids
Hyperlipidemia, or high fat levels in the blood
History regarding duration of diabetes, past glycemic control (hemoglobin A1c), Medications (especially insulin, oral hypoglycemics, antihypertensives, and lipid-lowering drugs), systemic history (e.g., renal disease, cardiovascular events, systemic hypertension, serum lipid levels, pregnancy). • History related to drugs causing macular edema (Thiazolidinediones, fingolimod (used in MS), tamoxifen, taxanes, niacin, interferons and prostaglandin analogs).2–8
History regarding duration of diabetes, past glycemic control (hemoglobin A1c), Medications (especially insulin, oral hypoglycemics, antihypertensives, and lipid-lowering drugs), systemic history (e.g., renal disease, cardiovascular events, systemic hypertension, serum lipid levels, pregnancy). • History related to drugs causing macular edema (Thiazolidinediones, fingolimod (used in MS), tamoxifen, taxanes, niacin, interferons and prostaglandin analogs).2–8
Visual acuity test. This eye chart measures how well you see at distances.
Dilated eye exam. Your eye care professional places drops in your eyes to widen or dilate the pupils. This provides a better view of the back of your eye. Using a special magnifying lens, he or she then looks at your retina and optic nerve for signs of AMD and other eye problems.
OCT is a newer, non-invasive, quick exam that has gained universal acceptance during the last decade and is now used by many ophthalmologists to visualize the retinal microarchitecture. Using reflected light rays, OCT provides a detailed, highly magnified, cross-section view of a patient’s macula. Sometimes, it will uncover tiny areas of fluid or retinal irregularity not readily apparent to a retina specialist during a microscopic exam.
The standard of treatment for CSME since 1985 has been focal laser photocoagulation since the results of Early Treatment for Diabetic Retinopathy study (ETDRS) were published. In severe cases, you may also have laser photocoagulation. A doctor will use a tiny laser on your eye to seal leaking blood vessels. You may need more than one treatment to control the problem. It's usually not painful, but you may have slight stinging feeling when the laser touches you.
