Retina
Prof.Andrea Facskó M.D., Ph.D. med. habil.
Head of the Dept. Of Ophthalmology
Cross section
Ophthalmoscop
Fluorescein angiogram (FLAG)
The retina
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Fotoreceptors: rodes (150 mill.) for light perception
cones (7 mill.) for color vision
Macula region: very dens of receptors
Human eye: like a 137 megapixel camera
Human eye+brain: TRIDIMENSINAL view
Human eye:from blue to red from 400 till 700 nm
wave length light can be detected
10 layers of the retina
OCT
/Spectral domain optical coherence tomography/
B scan
C scan
OCT
General remarks
The retina and the optic nerve are parts of the central nervous
system
The retina
 transparent
 red color (from the blood in the
choroidal vessels)
 choroidal vascular network is
normally invisible
 arteries (arterioles) are end-arteries
(without anastomoses)
 veins are dark red (the ratio of vein to
artery diameters is 2:3)
 capillaries are normally not visible
Diseases of the retina
1.
Local circulatory disturbances
a)
Central retinal artery occlusion (emergency situation) (CAO)
(ischemic infarct of the retina)
Symptoms: sudden painless loss of vision
Etiology:
embolus from an arteriosclerotic aorta or carotid
artery
transient ischemic attack in the brain
embolus from the valves of the heart
a myxoma of the atrium
fat - because of severe crushing injuries to the chest
or abdomen
temporal arteritis
increased blood viscosity or dysproteinemia
systemic circulatory disturbances with severe
hypotension
severe migraine, nicotine abuse, oral contraceptives
Ophthalmoscopic picture:
 the disc: pale with blurred outlines
 milky white ischemic edema of the posterior pole
 in the fovea : cherry red spot
 the retinal arterioles: extremely thin
Therapy: paracentesis, injection of vasodilators
retrobulbar
Prognosis:poor
Central arterial occlusion
Branch artery occlusion: a sector-shaped, milky
white retinal opacity can be seen,corresponding to the
area supplied by the corresponding arterial
branch
Diseases of the retina
1. Local circulatory disturbances
b) Occlusion of the central retinal vein (CVO)
(red infarct of the retina)
Symptoms: painless reduction of visual
acuity,visual field defect
Etiology : arteriosclerosis
cardiovascular, hypertension
disturbances of coagulation
diabetes
systemic diseases of the blood vessels
Predisposition factors:
certain toxic substances (nicotine)
areas, where the venous passages are narrow
Ophthalmoscopic picture:
optic nerve head: hyperemic,edematous,
contains hemorrhages
retinal veins: dark red, tortuous, dilated
dot and flame-shaped retinal hemorrhages
macular edema, (later secondary alterations:
macular star, white deposits,
cystoid macular edema)
Therapy: unsatisfactory
The underlying systemic disorder must be treated
accompanying macular edema: systemic
corticosteroid
Venal occlusion
Complications: neovascular glaucoma
therapy: photocoagulation
Prognosis depends on the condition of the central
retinal artery:
Venous stasis retinopathy : central retinal artery is
not affected, visual field is full. The prognosis is good
Hemorrhagic retinopathy : simultaneous,often
transient occlusion of the central retinal artery.
Visual field is constricted,visual acuity reduced.
The prognosis is poor
Branch vein occlusion: Hemorrhagic infarct
corresponding to the sector which is drained
by the corresponding, specific vein.
Predisposing areas: arterio-venous
crossings
Vascular retinopathy
Diseases of the retina
2. Retinal changes in systemic vascular diseases
(status of retinal vessels allows a conclusions as to the
status of the cerebral vessels)
a. Arteriosclerosis
Ophthalmoscopic picture:
optic nerve head: pale, sharply outlined
the wall of the arterioles becomes less transparent (reflex stripes
appear)
uneven vessel width: hyalinized irregular thickening of the vessel
wall
general and segmental attenuation of the blood columns
Gunn’s sign: at the arteriovenous crossing the
hardened artery obscures the underlying veins
b.
Circinate retinopathy
Symptoms: visual disturbances
Etiology: arteriosclerosis, diabetes
Ophthalmoscopic picture: wreath-like arrangement of
white ,hard exudates
Ophthalmoscopic picture:
a.: Anterior Ischemic Optic Neuropathy (AION)
optic nerve head is swollen and shows
superficial hemorrhageslater:flat atrophic excavation
highly attenuated retinal arterioles
b.: normal ophthalmoscopic finding: Posterior
Ischemic Optic Neuropathy (PION)
Therapy: high doses of corticosteroid
Prognosis: poor
CARDIOVASCULAR , HYPERTENSION
General remarks
Benign hypertension: organs remain normal,
systolic blood pressure may rise up to 160 mmHg,
diastolic up to 90 mmHg
Malignant hypertension: a primary idiopathic
hypertension or secondary to a cardiovascular, endocrin
or neurogenic condition
In cases of renal ischemia the ocular changes occur
mainly with chronic glomerulonephrosis or with
secondary nephrosclerosis.
Ophthalmoscopic picture:
Benign hypertension (stages I-II )
Stage I.
deep red color of the entire fundus
optic nerve head: normal
arterioles: tortuous, widened, copper wire reflex,
thickened vessel wall, Gunn-sign’s,
blunt angle of the branching arterioles,
veins: normal/irregular caliber, tortuous venules
Stage II.
optic nerve head: normal
arterioles: increasing sclerosis,
attenuation, streching,
irregular caliber
widened light reflexes
hard exudates, small multiple
retinal hemorrhages
Hypertesion angiopathy
b.: Malignant hypertension (stages III-IV)
Stage III.
optic nerve head: ischemic papilledema
arterioles: silver wire with increased
reflexes from the
attenuated blood vessels, markedly
thinned blood column
cotton-wool patches (ischemic local
retinal edema)
flame-shaped superficial hemorrhages
Malignant hypertonic angiopathy
Stage IV.
optic nerve head: advanced ischemic edema
arterioles: general attenuation, irregular
caliber,white sheating
silver-wire reflexes, crossing phenomena
cotton wool spots, macular star
hard fatty exudates
flame shaped and dot like hemorrhages,
general ischemic pallor
Immediate medical treatment is required!
Stage:IV severe angiopathy
Retinal changes in diabetes
General remarks:
Benign variety (background retinopathy, limited to
the retina) and
malign stage (proliferative retinopathy).
Insulin dependent juvenile diabetes has a higher
tendency to be complicated by proliferative retinopathy,
than adult-onset diabetes.
Diabetes mellitus is one of the most frequent cause
of blindness!
Ophthalmoscopic picture:
a.: Background retinopathy
Juvenile form: capillary aneurisms, ischemic areas,
proliferation, hypertrophy of the retinal venules
with a formation of a rete mirabile,
saccular dilatation of venous branches
Senile form: microaneurisms, dot- and blot-like hemorrhages
deep yellow hard exudates, fatty deposits
(arranged in the shape of wreath) cotton wool spots wessels
are of varying caliber and of thickened walls
Therapy: laser photocoagulation
Prognosis: good
Diabetic retinopathy, background
Diabetic retinopathy, background
FLAG:
b.: Proliferative retinopathy
 newly-formed blood wessels sprout in front of the
retina
 growing on the back surface of the detached vitreous
 hemorrhages in and beneath the vitreous
 membrane formation
 traction retinal detachment
Therapy: vitrectomy
Prognosis: poor
Proliferative diabetic retinopathy
Proliferative diabetic retinopathy
Proliferative diabetic retinopathy
Kimmelstiel-Wilson disease: proliferative diabetic
retinopathy associated with cardiovascular
hypertension and diabetic nephrosclerosis.
Ophthalmoscopic picture:
edema of the optic nerve head and the retina,
macular star, attenuated arterioles, cotton wool spots,
retinal hemorrhages
Retinopathy of Prematurity / Retrolental fibroplasia
(ROP)
disruption of normal development of the retinal
vasculature in preterm infants with birth weight
less than 2500 gr
Symptoms: leucocoria, strabismus, high myopia
Etiology:preterm birth and exposure to oxygen
Classification of retinopathy of prematurity
Stage I.
demarcation border between vascularized
and nonvascularized retina
Stage II. formation of a ridge (development of
intraretinal proliferative tissue)
Stage III. ridge with extraretinal proliferation
Stage IV. subtotal retinal detachment
Stage V. total retinal detachment
Treatment: cryotherapy, laser photocoagulation,
vitrectomy
Prophylaxis: partial pressure of oxygen shoud be kept as
low as possible ophthalmoscopic screening
Early detection is particularly important!
ROP
ROP
ROP
Hematologic disease
Hemoglobinopathies
Pernicious anemia
Secondary anemia
Leukemia
Hodgkin’s disease
Polycytemia
Dysproteinemia
Macroglobulinemia
DISEASES OF THE MACULA
(AQUIRED OR INHERITED)
Senile (age-related) macular degeneration
(AMD)
Symptoms: deterioration of central vision, good
peripheral vision
Etiology: degenerative changes or familial disease
Ophthalmoscopic picture:
a.: dry form of macula degeneration
atrophic pale area in the center, foveal reflex is missing
irregular areas of pigmentation, partial atrophy of the
pigment epithelium
drusen (excrescences of the pigment epithelium)
Age related macular degeneration AMD non exud.
AMD
b.: wet form of macular degeneration
(disciform macular degeneration, Kuhnt- Junius)
serous than hemorrhagic subretinal fluid
subretinal neovascularisation
hemorrhagic detachment of the RPR)
scar formation (gray-white)
circinate retinopathy
Age related macular degeneration AMD exud.
Secondary maculopathies
phototoxic effect of artificial light
(operations)
intensive light (at the eclipse of
the sun)
drug toxicity (cloroquine)
Hereditary macular degenerations (dystrophies)
1.
Stargardt’s disease
Symptoms: progrediating decrease of visual acuity
Ophthalmoscopic picture:
a.: early atrophic ,sharply delineated area
b.: yellowish circumscribed foci in the
macular area and retinal periphery
(Stargardt’s fundus flavimaculatus)
2. Vitelliform macular degeneration (Best )
Symptoms: visual loss, photophobia
Ophthalmoscopic picture:
stages:
1: egg yolk (lipofuscin deposit int he RPE)
2.: hypopyon like(deposit liquified and show a
horisontal level)
3.: scrambled egg (the cyst bursts)
4.: scar formation
3. Cone dystrophy
4. Rod monochromatism
5.: X-linked juvenile retinoschisis
Hereditary retinal degenerations
(progressive,noninflammatory retinal diseases)
1. Retinitis pigmentosa (RP)
Etiology: inherited disease
Symptoms: night blindness, loss of peripheral vision,
central visual loss
Ophthalmoscopic picture:
pale, waxy-yellow optic nerve head
attenuated retinal arterioles (thickened wall)
black or brown bone corpuscle-like
pigmentation
(sometimes:cystoid maculaedema, bull’s eye
lesion or macular hole)
Therapy : -
Tumors of the retina
Retinoblastoma (10% are hereditary! , Both eyes!)
Signs: amaurotic cat’s eye: yellow-white or gray reflex in
pupil
strabismus
greatly reduced vision
Differential diagnosis:
persistence and hyperplasia of the primary vitreous
retrolental fibroplasia
Coats’ disease
Toxocara canis infestation
metastatic ophthalmia
congenital cataract
the
Thanks for the attention!