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RETINARETINADr. Gilbert WS Simanjuntak

Bagian IP Mata FK-UKISMF IP Mata RS PGI Cikini

IntroductionIntroduction

while they were saying among themselves it COULD NOT be done,

BEHOLD IT WAS DONEHelen Keller

RetinaRetina

Thin, semitransparent, multilayered sheet of neural tissueLines the inner aspect of the posterior two-thirds of the wall of the globeAnterior ending point: ora serrataThe retina and and retinal pigment epithelium are easily separated: subretinal space

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Ten layers of retina, starting from inner aspect:1. Internal limiting membrane2. Nerve fiber layer3. Ganglion cell layer4. Inner plexiform layer5. Inner nuclear layer (bipolar, amacrine,y ( p

horizontal cell bodies)6. Outer plexiform layer7. Outer nuclear layer of photoreceptor cell nuclei8. External limiting membrane9. Photoreceptor layer10. Retinal pigment epithelium

Sepuluh Lapisan RetinaSepuluh Lapisan Retina

1. Lp. Epitel pigmen2. Lp. Batang dan kerucut3. Membran limitans eksterna 4. Lp. Nukleus luar5. Lp. Pleksiform luar

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5. Lp. Pleksiform luar6. Lp. Nukleus dalam7. Lp. Pleksiform dalam8. Lp. Sel ganglion9. Lp. Serabut saraf10.Membran limitans interna

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SelBipolar

Sel Amakrin

Thickness:• 0.1 mm at the ora serrata• 0.23 mm at the posterior pole

Area 1.5 mm in diameter, yellowish pigmentation l i f h f l l iresulting from the presence of luteal pigment

(xanthophyll): macula

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Blood supply from two sources:• Outer third (outer plexiform and outer nuclear layers,

the photoreceptors, and the RPE): choriocapillaris• Inner two-thirds: branches of the central retinal artery

Fovea supplied entirely by the choriocapillarisFovea supplied entirely by the choriocapillarisRetinal blood vessels – non fenestrated endothelium: inner blood-retinal barrierRPE: outer retinal-blood barrier

The VitreousThe Vitreous

A clear, avascular, gelatinous body• 99% water• 1% collagen and hyaluronic acid

Comprises two-thirds of the volume and weight of the eyethe eyeOuter surface: the hyaloid membraneVitreous base: firm attachment throughout life to the pars plana epithelium and the retina immediately behind the ora serrataAlso attach to the lens capsule and optic disc

ExaminationExamination

Slitlamp/biomicroscope examination (+60D, +78D, +90D):• Anterior segment (rubeosis iridis, cataract, etc)• PVD (Weiss ring)• S neresis• Syneresis• Vitreous hemorrhage• Fibrovascular proliferation

Non-contact vs contact lens• Pupil dilation, topical anestetics, viscous solution• Image resolution

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Direct/Indirect Ophthalmoscope

B-scan Ultrasonography• diagnostic and prognostic, especially in media haze

(corneal scar, small pupil/posterior synechiae, dense cataract or vitreous opacification)

Fundus Fluorescein AngiographyElectrophysiology Testing

Vitreous DisordersVitreous DisordersVitreous floatersAsteroid hyalosis: little/no effect upon visionAcute vitreous collaps: syneresis, photopsia• It should be assumed that patients with new floaters

or photopsia have retinal tears or detachment until d th i b th h i ti ithproved otherwise by thorough examination with an

indirect ophthalmoscopeProlifrative vitreoretinopathyVitreous loss due to traumaVitritisVitrectomy

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Intraocular TumorsIntraocular Tumors

Retinal angioma• Vision affected by uxudation or bleeding from the

tumor vessels• Photocoagulation diathermy or cryotherapy are• Photocoagulation, diathermy or cryotherapy are

treatment modalities

Retinoblastoma• Life-endangering of childhood• The normal retinoblastoma gen, present in every

individual, is a supresor gene or anti-oncogene• Exophytic and/or exophytic extend through the optic• Exophytic and/or exophytic, extend through the optic

nerve to the brain• Large tumor: enucleation; small: radiotherapy,

cryotherapy, photocoagulation and/or chemotherapy

LymphomaMalignant/choroidal melanomaHemangiomaMetastase tumor from kidney, lung and breastMetastase tumor from kidney, lung and breast

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Retinal Vascular DiseaseRetinal Vascular Disease1. Diabetic Retinopathy1. Diabetic Retinopathy

One of the leading causes of blindness in the western worldChronic hyperglycemia is the major determinant

Y tie t ith t e 1 DM DR d e t• Young patient with type-1 DM, DR does not occur for at least 3-5 years after the onset of the disease

• Type-2 DM, DR occur at a longer periodDiabetic retinopathy is worsening in pregnant women

25% of diabetic population have some degree of diabetic retinopathy (DR)5% are affected by more severe disease (proliferative retinopathy)Prevalence increases with the duration of diabetes, consequences of prolonged hyperglycemiaq p g yp g yAfter 20 years of hyperglycemia, develop some degree of DR• nearly all in type I DM → more severe proliferation• 60% in type II DM → older patients, visual loss due

to macular edema

Type-1 should be referred at least 3 year after the onset, type-2 at the time of examination. Diabetic pregnant women should be examined in the first trimester. Any sign of severe NPDR or more should be treated. Re-examined every 3 months until parturition

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Technique :• Spot size 50-100 microns, one spot width apart• Duration <100 ms• Power adequate to obtain definite whitening around

the m.a. or leakage site

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Side effects and complications :• paracentral scotomas• transient increased edema/decreased vision• choroidal neovascularization• photocoagulation scar expansion• inadvertent foveolar burns

Vitrectomy in DMEVitrectomy in DME

A rare, more subtle traction-induced complication with macular edema induced by the contraction of a taut, persistently attached posterior hyaloid• does not respond to focal or grid laser

d t i l l f th t ti• respond to surgical release of the traction• clinically : prominent and thickened posterior

hyaloid, VA <20/80

Smiddy WE, Flynn HW. Surv Ophthalmol 1999

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If new vessels appear to be active and significant vitreous/preretinal hemorrhage are occuring, additional PHC strongly consideredLIO is useful to ‘fill-in’ the far periphery in cases continued NV activity after good PRP

Artery OcclusionsArtery Occlusions

Classifications of Retinal Vein Classifications of Retinal Vein OcclusionsOcclusions

CRVO :• Ischemic• Non-ischemic

HCROHCRO :• Ischemic (hemi-hemorrhagic retinopathy)• Non-ischemic (hemi venous stasis ret.)

BRVO :• Major BRVO• Macular BRVO

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venous obstruction

venous pressure

capillary closure

retinal ischemia

intraretinal h’gesmacular edema

decreased vision

intraocular NV

SystemicSystemic

Hypertension, DM, Cardiovascular disease (CAD), increased hematocrit and plasma viscosityOdds ratio for ischemic :• 4.8 for hypertension• 2.7 for DM• 2.1 for CAD• 2.1 for α1-globulin

ComplicationsComplications

Vitreous hemorrhageNeovascular glaucomaRetinal detachment

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Results : • Intraoperative

decompression achieve in all 15 patients

• 80% VA postoperative ~ preoperative

• 67% VA improved, with i 4 li faverage gain 4 lines of

vision• 20% had worse VA,

average 2 lines

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Macular DiseasesMacular Diseases

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Age Related Macular Degeneration (ARMD)

Treatment:• Anti-VEGF • Transpupillary Thermotherapy• Photodynamic Therapy• Macular Translocation• Submacular Sx

Macular Hole

Treatment:

Vitrectomy + ILM Peeling

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H/O DOV 6 mosPreop-REVA 20/200

Postop-REVA 20/40

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Central Serous Chorioretinopathy (CSR)

Cystoid Macular Edema (CME)

Ind. Oph. Examination Stage 1Retinopathy of Prematurity (ROP)

Stage 2 Stage 3

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Pl DiSt 5

Stage 4a Stage 4b

Plus DiseaseStage 5

RETINAL DETACHMENTRETINAL DETACHMENT

Ablasio Retina Ablasio Retina RegmatogenRegmatogen

Lapisan retina sensorik/neuroretina terpisah dari lapisan EPRlapisan EPRAkibat adanya robekan retinaCairan dari vitreus melalui robekan pindah ke rongga subretina retina terangkatTerapi : operasi

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Aposisi:1. Tekanan hidrostatik

dari TIO2. Perbedaan tekanan

osmotik antara koroiddan rongga subretina

3. Transpor metabolik

Mekanisme Perlekatan Retina NormalMekanisme Perlekatan Retina Normal

ion-ion oleh EPRLain-lain: interdigitasi

vili, MIP

Melepas:4. Gerakan bola mata5. Gravitasi6. Traksi vitreus7. PVD

Laser ProfilaksisLaser Profilaksis

Retina robek, belum terjadi pelepasan retina [1]Bibir robekan dan daerah sekitarnya difotokoagulasi laser [2]

[1] [4]

Terjadi sikatriks korioretina yang tidak dapat dilalui oleh cairan ablasio retina tercegah [3]Dapat juga dengan kriopeksi [4]

[2][3]

Persiapan Daerah Operasi

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Pemasangan Bakel

Sirkumferensial

Sirklase

Bakel silikon:- Strip- Sponge- Tyre

Radial Sleeve

Drainase cairan

subretina

Retinopeksi

Penutupan luka operasi

p- Krio- Diatermi- Laser

F. Indirek ulang

Prabedah Pascabedah

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Color Vision DefectsColor Vision DefectsSpectrum wavelength 400-700 nm is capable of being absorbed by visual pigment of cone photoreceptors (blue, green and red)Congenital: most red-green Acquired: blue yellowAcquired: blue-yellowAffects both eyes equallyProtanopia: red-sensitive pigment lossDeutranopia: green-sensitive pigment lossTritanopia: blue-yellow color blindness

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