This document provides information on vascular disorders of the retina. It begins with the anatomy and blood supply of the retina. It then discusses diabetic retinopathy in detail, including pathogenesis, signs, diagnosis and treatment. It also briefly covers hypertensive retinopathy and retinal vein occlusion, describing their pathophysiology, classification systems, clinical presentation and management. The document focuses primarily on providing an overview of diabetic retinopathy and its various stages and complications.

2. VASCULAR DISORDERS OF
RETINA
BY:
HARIS KHAN
ROLL # 100

3. ANATOMY OF RETINA
The retina is a thin,
semitransparent, multilayered
sheet of neural tissue that lines
the inner aspect of the posterior
two-thirds of the wall of the
globe.

4. LANDMARKS OF RETINA
1. Optic Disc
2. Retinal Blood
Vessels
3. Area centralis with
fovea and foveola
4. Peripheral retina
and ora serrata
5. Thickest near the
optic disc
6. Thin towards the
peripheral

5. MICROSCOPIC STRUCTURE

6. BLOOD SUPPLY OF THE RETINA:
•Outer 4 layers of retina is supplied by (till outer nuclear layer)
choriocapillaries.
•The inner six layers gets its supply from central retinal artery which
is a branch of ophthalmic artery.
•The outer plexiform layer gets partly by both the above arteries.
•The fovea is avascular and is mainly supplied by choriocapillaries.
•The inner portion of the retina is perfused by branches of the central
retinal artery.
•In 30% of eyes ,a cilioretinal artery,branching from the ciliary
circulation ,supplies part of inner retina mainly The Macula Region.
•The retinal blood vessels maintain the inner blood-retinal barrier.This
physiological barrier is due to single layer of non-fenestrated
endothelial cells,whose tight junctions are impervious to tracer
substances such as fluorescein.

8. •Retinal blood vessels lack an internal elastic lamina & a
continuous layer of smooth muscle cells.
•The retinal arteries are end arteries & have no
anastomoses.The only place where the retinal system
anastomoses is in the neighbourhood of lamina cribrosa.
•The veins of the retina unite to form Central retinal vein at the
disc, which follows the corresponding artery.
•The terminal fundus arterioles bend sharply and dip almost
vertically into the retina.
•In most of the Extramacular fundus- two retianal capillary
networks- a superficial and a deep.
•In parafoveal zone it is well developed and in 3 layers.
•A capillary free zone of 500miceo metre diameter in foveal
zone- FAZ.

9. VASCULAR DISORDERS OF
RETINA
1.DIABETIC RETINOPATHY
2.HYPERTENSIVE RETINOPATHY
3.RETINAL VEIN OCCLUSION
4.RETINAL ARTERY OCCLUSION
5.RETINOPATHY OF PREMATURITY

10. DIABETIC RETINOPATHY
• Diabetic retinopathy is a disorder of the retinal
vessels that eventually develops to some
degree in nearly all patients with long-
standing diabetes mellitus.
• Most Common cause of bilateral severe visual
loss in working age group in US

11. RISK FACTORS
• Age at diagnosis of diabetes
• Duration
• Poor control of diabetes
• Pregnancy
• Hypertension
• Nephropathy
• Hyperlipidemia
• Obesity
• Anemia
• Smoking
• Cataract surgery

12. PATHOGENESIS
MICROVASCULAR LEAKAGE
1. LOSS OF PERICYTES
2. MICRO ANEURYSM
3. BLOOD RETINAL BARRIER
BREAKDOWN
IT CAUSES
1. RETINAL OEDEMA
2. HARD EXUDATE
3. RETINAL HEMORRHAGES
• SUPERFICIAL(FLAME
SHAPED)
• DEEP(DOT AND BLOT)
MICROVASCULAR OCCLUSION
1. THICKENING OF BASEMENT
MEMBRANE
2. ENDOTHELIAL DAMAGE
3. STICKNESS AND AGGREGATION OF
PLATELETS
4. FIBRINOLYTIC SYSTEM IS DEFECTIVE
5. RED CELL AGGREGATION
6. DEFECTIVE OXYGEN TRANSPORT
IT CAUSES
1. RETINAL ISCAEMIA(COTTON WOOL
SPOTS)
2. NEOVASCULARIZATION ON THE
SURFACE OF RETINA,OPTIC NERVE
HEAD AND IRIS(RUBEOSIS IRIDIS)
3. ARTERIO VENOUS SHUNTS

13. SIGNS
1. BACKGROUND DIABETIC RETINOPATHY
2. PREPROLIFERATIVE STAGE
3. PROLIFERATIVE STAGE
4. DIABETIC MACULOPATHY
5. ADVANCED STAGE

14. BACKGROUND DIABETIC
RETINOPATHY
1. MICROANEURYSMS

15. MICRO ANEURYSMS

16. 2. HAEMORRHAGES
1. FLAMED SHAPED
HAEMORRHAGES
2. DOT AND BLOT
HAEMORRAGES

17. 3. HARD EXUDATES
• LOCATED
BETWEEN INNER
PLEXIFORM AND
INNER LAYER OF
RETIINA
• COMPOSED OF
PLASMA PROTEINS
AND LIPID
• YELLOW WAXY
APPEARANCE WITH
DISTINCT MARGINS

18. 4. RETINAL
EDEMA
IT CAUSES
THICKENING OF
RETINA AND GIVES
CYSTOID
APPEARANCE TO
RETINA

19. PREPROLIFERATIVE CHANGES
1. VASCULAR CHANGES
• VENOUS CHANGES IN THE FORM OF
BEADING,LOOPING AND SAUSAGE LIKE
SEGMENTATION
• ARTERIOLES BECOME NARROW

20. Retinal arteriole obliterationVenous Segmentation
Venous BeadingVenous Loop

21. 2. COTTON WOOL
SPOTS
APPEAR AS
WHITISH,GREY
AREAS WITH
INDISTINCT
MARGINS

22. 3.DARK BLOT
HAEMORRHAGE
THEY REPRESENT
HAEMORRHAGIC
RETINAL
INFARCTS

23. INTRA RETINAL MICROVASCULAR
ABNORMALITIES

24. PROLIFERATIVE DIABETIC RETINOPATHY
NEO
VASCULARIZATION
: DISC
NEW VESSELS
GROW OR
PROLIFERATE ON
THE OPTIC NERVE
HEAD

25. 2. NEO
VASCULARIZATION
ELSEWHERE:
NEW VESSELS
PROLIFERATE
ALONG COURSE
OF INTERNAL
TEMPORAL
VASCULAR
ARCADES OR
OTHER AREAS OF
RETINA

26. ADVANCED DIABETIC EYE DISEASE
• Pre retinal
hemorrhage
• Vitreous
hemorrhage
• Traction RD
• Rubeosis
Iridis
• Neovascular
Glaucoma

27. DIABETIC MACULOPATHY
CAUSES
1. OEDEMA
2. HARD EXUDATE
3. MACULAR
HAEMORRHAGE
4. MACULAR ISCHAEMIA
5. PRE MACULAR
MEMBRANE
FORMATION
6. MACULAR TRACTION
OR DETACHMENT
CLINICAL TYPES
1. FOCAL EXUDATIVE
2. DIFFUSED EXUDATIVE
3. ISCHAEMIC
4. MIXED MACULOPATHY

28. DIAGNOSIS
1. FUNDUS EXAMINATION WITH
• DIRECT OPHTHALMOSCOPE
• INDIRECT OPHTHALMOSCOPE
• SLIT LAMP BIMICROSCOPY WITH CONTACT LENS
AND NON CONTACT LENS
2. FUNDUS FLUORESCEIN ANGIOGRAPHY FOR
ASSESSMENT OF:
• LEAKING AREAS
• OCCLUSION AREAS
3. OPTICAL COHERENCE TOMOGRAPHY IS USEFUL
TO ASSESS RETINAL OEDEMA

29. TREATMENT
MEDICAL
1. CONTROL OF RISK FACTORS
• DIABETES MELLITUS
• HYPERTENSION,ANAEMIS,NEPHROPATHY,HYPERLIPI
DEMIA
2. ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR
3. INTRAVITREAL STEROIDS ARE USEFUL TO REDUCE
THE MACULAR OEDEMA (INTRAVITREAL INJECTION OF
TRIAMCINOLONE)

30. LASER PHOTOCOAGULATION
OBJECTIVES
1. TO DESTROY THE HYPOXIC
RETINA ,STOP THE RELEASE
OF VASOFORMATIVE
SUBSTANCE AND CAUSE
INVOLUTION OF NEW VESSEL
2. TO DESTROY THE LEAKAGE
AREAS AND ENHANCE THE
ABSORPTION OF OEDEMA
AND EXUDATE
TYPES
1. FOCAL TREATMENT
FOR FOCAL MACULAR
OEDEMA
2. GIRD TREATMENT
FOR DIFFUSE
MACULAR OEDEMA
3. PANRETINAL
PHOTOCOAGULATION

32. SURGERY
PARS PLANA VITRECTOMY IS
INDICATED FOR:
1. DENSE PERSISTENT
VITREOUS HAEMORRHAGE
2. TRACTIONAL RETINAL
DETACHMENT
3. EPIRETINAL MEMBRANES

33. HYPERTENSIVE RETINOPATHY
DEFINITION
HYPERTENSIVE RETINOPATHY IS A RETINAL
VASCULAR DAMAGE CAUSED BY
HYPERTENSION.

34. Pathophysiology
Systermic
chronic
hypertension
Arteriosclerosis
and
atherosclerosis
predominates
Narrowing of
retinal arterioles
Retinal
Ischaemia
Hypoxia
Increased
capillary
permeability
Focal Retinal Oedema, retinal
haemorrhage,cotton wool spots, hard
exudates

36. 1. The cardinal funduscopic feature of malignant hypertension is disk swelling, which appears as
blurring and elevation of disk margins. The top image also shows a characteristic star-shaped
macular lesion caused by leaking retinal vessels; the bottom image also shows a characteristic
flame-shaped hemorrhage and dilated veins.
2. Moderate hypertensive retinopathy is characterized by thinned, straight arteries; intraretinal
hemorrhages; and yellow hard exudates (top). Cotton-wool spots (bottom) are an additional
feature of moderate hypertensive retinopathy. They are caused by focal axonal swelling of the
retinal nerve fiber layer as a result of small-vessel occlusion.

37. Retinal arteriolar narrowing due to thickening and opacification of arteriolar
walls (copper wiring) caused by hypertensive arteriosclerosis. Image also
shows macular edema.

38. Classification
• Keith-Wagener-Barker classification
Grade Description
Grade 1 Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild,
asymptomatic hypertension
Grade 2 Definite narrowing, focal constriction, sclerosis, and AV nicking; blood
pressure is higher and sustained; few, if any, symptoms referable to blood
pressure
Grade 3 Retinopathy (cotton-wool patches, arteriolosclerosis, hemorrhages); blood
pressure is higher and more sustained; headaches, vertigo, and
nervousness; mild impairment of cardiac, cerebral, and renal function
Grade 4 Neuroretinal edema, including papilledema; Siegrist streaks, Elschnig
spots; blood pressure persistently elevated; headaches, asthenia, loss of
weight, dyspnea, and visual disturbances; impairment of cardiac, cerebral,
and renal function

39. Modified Scheie classification
Grade 0 - No changes
Grade 1 - Barely detectable arterial narrowing
Grade 2 - Obvious arterial narrowing with focal irregularities
Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates
Grade 4 - Grade 3 plus disc swelling

41. Retinal Vein Occlusion
• Definition:
o It is a common vascular disorder characterized by retinal vein
occlusion resulting in edema and hemorrhages on retina in the
affected region with potential blinding complications
• Types:
o Central retinal vein occlusion
o Branch Retinal vein occlusion
• Etiology and Risk Factors:
o Age of age of above 50 years
o Systemic diseases like hyperlipidemia, Diabetes, Chronic Renal
Failure
o Chronic Open Angle Glaucoma

42. Retinal Vein Occlusion
• Clinical Presentation:
o Sudden painless loss of vision
o Persistent decreased central vision
• Clinical Examination:
o Visual Acuity- Severe visual loss, up to 20/200
o Intra Ocular Pressure- Raised
o Fundus Examination- dilated, tortuous veins, retinal and macular
edema, flame shaped hemorrhages, and cotton wool spots

43. Central retinal vein occlusion
Clinical manifestation
• Non-ischemic type
– Mild fundus change :
retinal hemorrhage and
tortuous vein
– Mild VA decrease
– capillary nonperfusion rare
– Visual field defect (retinal
hemorrhage)

44. • Ischemic type：
– More common
– Extensive retinal
hemorrhage and
tortuous vein，Multiple
cotton-wool spots
– Severe VA decrease
– Widespread capillary
nonperfusion， 60%
cases present iridal
neovascularization.

45. BRANCH RETINAL
VEIN OCCLUSION
• MORE COMMON THAN
CRVO
• OEDEMA AND
HAEMORRHAGE
LIMITED TO THE
AFFECTED VEIN
• VISSION AFFECTED
ONLY MACULAR AREA
IS INVOLVED
• SECONDARY
GLAUCOMA OCCURS
RARELY
• PROGNOSIS IS
REASONABLY GOOD

46. Retinal Vein Occlusion
• Investigations:
o Fluorescein Angiography
o ECG
o Blood CP
o ESR
o Blood Glucose level
• Complications:
o Chronic Macular Edema
o Conversion from Non-Ischemic to Ischemic type
o Retinal Neovascularization
o Neovascular Glaucoma

47. Retinal Vein Occlusion
• Treatment:
o Macular Laser Photocoagulation
o Intra Vitreal injections anti-VEGF and steroids
o Intra Vitreal triamcinolone injections

48. Retinal Artery Occlusion
• Definition:
o Vascular disorder of retina resulting in sudden painless loss of
vision, with antecedent transient visual loss
• Types:
o Central Retinal Artery Occlusion
o Branch Retinal Artery Occlusion
• Etiology:
o Thrombosis due to atherosclerosis
o Embolism
o Raised Intra Ocular Pressure
o Giant Cell Arteritis
o Angiospasm- Retinal Migraine

49. Clinical manifestation
Symptoms
Signs
Sudden painless vision
lose of one eye
Direct light reflex disappear,
indirect light reflex normal
Retinal edema、cherry-red spot
Retina artery narrow，mild hemorrhage

50. CENTRAL
RETINAL
ARTERY
OCCLUSION
• RETINAL OEDEMA
• CHERRY RED
SPOTS
• RETINAL ARTERY
NARROW
• MILD
HAEMORRHAGE
• WHITISH
APPEARANCE OF
RETINA

51. BRANCH
RETINAL
ARTERY
OCCLUSION
• DUE TO LODGMENT OF
EMBOLI AT
BIFURCATION OF
RETINAL ARTERY
• RETINAL DISTAL TO
OCCLUSION BECOMES
OEDEMATIOUS WITH
NARROWED
ARTERIOLES
• INVOLVED AREA
ATROPHIED CAUSING
SECTORIAL VISUAL
FIELD DEFFECT
PERMANANTLY.

52. Retinal Artery Occlusion
• Treatment:
o Intraocular pressure lowered immediately by anterior chamber
paracentasis or I.V Acetazolamide
o Inhaled oxygen and carbon dioxide mixture to improve oxygen
delivery to retina
o Thrombolytic therapy

53. Retinopathy Of Prematurity
• Definition:
o It is a bilateral vasoproliferative retinopathy occurring in
premature infants with low birth weight and exposed to high
concentration of oxygen
• Etiology and Risk Factors:
o Low birth weight
o Exposure to high concentrations of oxygen
o Premature birth
• Pathology:
o THE TEMPORAL RETINAL VASCULARIZATION IS
COMPLETED 1 MONTH AFTER BIRTH
o TOXIC LEVEL OF OXYGEN INTERFERES WITH
REVASCULARIZATION BY DAMAGING THE ENDOTHELIUM
AND OBLITERATING NEWLY FORMED CAPILLARIES.

54. Retinopathy Of Prematurity
Stage 1- Changes at junction of vascular and
avascular retina as demarcation line

55. Retinopathy Of Prematurity
Stage 2- Formation of distinct ridge

56. Retinopathy Of Prematurity
Stage 3- Extra retinal fibrovascular proliferation

57. Retinopathy Of Prematurity
Stage 4- Severe retinal detachment

58. Retinopathy Of Prematurity
Stage 5- Total retinal detachment seen as whitish mass
(leukocoria) behind iris

59. Retinopathy Of Prematurity
• Treatment:
o Peripheral retinal laser in stage 2
o Ablation of avascular retina in stage 3
o Vitreotomy in stage 4 & 5