What is chorocapillaries?
The capillary lamina of choroid or choriocapillaris is a layer of capillaries that is immediately adjacent to Bruch’s membrane in the choroid.
what is atrophy?
Atrophy is the partial or complete wasting away of a part of the body.
what is Bruch’s membrane?
PHOTORECEPTOR-> RPE -> BRUCH’s MEMBRANE -> CHOROID
The retinal pigment epithelium transports metabolic waste from the photoreceptors across Bruch’s membrane to the choroid.
Bruch’s membrane consists of five layers (from inside to outside):
the basement membrane of the retinal pigment epithelium
the inner collagenous zone
a central band of elastic fibers
the outer collagenous zone
the basement membrane of the choriocapillaris
Changes that are seen in highly myopic eyes?
lupakan pilihan mama, fiancee ana takkan pergi london.
- lacquer cracks : spontaneous rupture of the bruchs memb
- progressive chorioretinal atrophy: chorioretinal is a structure of retina and choroid thus chorioretinal atrophy refers to damage of both of the structures, due to the progressive enlargement of the globe.
- macular haemorrhage: due to the lacquer cracks or CNV
- fuch’s spot: circular pigmented lesion around the macula
- peripapillary atrophy: stretching of the posterior pole drag the choroid and the RPE
- tilted disc: oblique insertion of the optic nerve
- posterior staphyloma : abnormal protrusion of the uveal tissue.
- lattice degeneration: atrophy of the retina that leads to retinal detachment
what is subretinal neovascularisation?
pathological process consisting of formation of new blood vessels in the choroid.
What are the symptoms of subretinal neovascularization?
- painless
- sudden drop of central vision
- metamorphopsia
- central scotoma
- colo disturbance
What are the signs of subretinal neovascularisation?
- subretinal fluid
- subretinal haemorrhage
- CMO; cystoid macular oedema
- retinal elevation and thickening
- retinal scars and fibrosis- hard exudates formation
What are the causes of subretinal neovascularisation?
- persumed ocular histoplasmosis syndrome (POHS)
- myopic macular degeneration
- wet AMD
- chronic uveitis
- angioid streaks
current or latest treatment for subretinal neovascularisation?
historically:
- Argon laser
- PDT
current:
- anti-VEGF-bind to the VEGF molecules in the retina thus blocking the ability to cause abnormal blood vessel growth under the retina by the intra-vitreal injection
- macugen: every 6 weeks, min 2 years; lucentis starts with 4 weekly intervals followed by further injection based on consultant’s assessment
- submacular surgery to remove the CNV
CASE STUDY:
- 8 year old child
- aching LE
- vision markedly reduced
- fundus: grey inflammatory patch at the posterior pole.
discuss possible cause,management, most likely cause.
possible cause:
VOGT-KOYANAGI HARADA (not because usually 20-50y’old
POSTERIOR UVEITIS (causes; SIT)
-systemic disease: syphilis, TB, sarcoidosis, toxocariasis, toxoplasmosis
-infection: bacterial, viral fungal (persumed ocular hostoplasmosis syndrome)
-trauma: IOFB, perforating injury
managements:
- NSAIDS, steroids, and immunosuppression
- mydriatic to pro to comfort and prevent posterior synechiae
- enucleation
most likely cause: choroiditis
GREY/YELLOW PATCH AT EARLY STAGE AND PIGMENTED BORDERS WITH CHORIORETINAL ATROPHY LATER.
what are the causes of headaches that affecting the vision?
- closed angle glaucoma
- papilloedema
- temporal artritis (GCA)
- migraine
- herpes zoster
what are the characteristics of papilloedema?
- throbbing unilateral HA; often severe
- nausea and vomiting
- raised intracarnial pressure eg. midbrain tumours
- fleeting loss of vision (few seconds up to 30x/day)
- VA,VF, and RAPD text appear normal unless late stage.
- HA worse with coughing and change of posture
What are the symptoms of temporal arteritis?
- > 60yrs
- unilateral or bilateral temporal head pain
- temporal pain, jaw pain, flu like symptoms
- transient diplopia (ischaemic EOMs)
- AION or CRA sudden painless of vision
what are the characteristics of common migraine?
- no visual aura 60% of all migraine
- dull ache progresses to throbbing pain of increasing intensity
- frequency duration and severity vary
- HA last longer minimum four hours to 48 hours
- attacks more frequent than classic
- often marked mood change, frequent yawning, poor concentration
what are the phenomenon associated with migraine?
peningnya PADON
- ophthalmic: commonly scotoma
- neurological: pareses, dysphasia
- abdominal: nausea and vomiting
- dermatological: skin pallor and flushing
- psychic: memory, aggression, and depression
CASE STUDY:
- 68 yo lady
- severe HA
- reduction of vision in LE
- fumdus examination reveals blurred disc margin on LE
discuss possible causes of headache, management, most likely cause.
interpretation of the clinical findings:
blurred disc margin:
-indicates swollen disc (which one of the changes that occur to the optic disc besides optico-ciliary shunt and optic atrophy)
-three causes of swollen disc ; papilloedema,papillitis and neuroretinitis, anterior ischeamic neuropathy (AION associated with GCA)
severe headaches with reduction of vision indicates 5 possible causes:
1) papilloedema
- the optic nerve head appears swelling bilaterally (which make it less likely for this case)
- VF: enlarged blind spot
- fundus appearance: hyperaemic disc, mild venous engorgement, indistinct disc margin, CWS, macular star, exudates.
- treatments: maintain normal ICP
2) closed angle glaucoma
3) migraine: common migraine shows symptom of unilateral dull ache, progression if throbbing pain of increasing intensity.
4) herpes zoster
5) temporal artritis (GCA)
- in this case temporal artritis (GCA) fits the criteria of headaches and loss of vision. one of the causes of the appearance of unilateral swollen disc is AION (insufficient blood supply by short posterior ciliary artery to the ONH) which usually associated with GCA. thus rule out the diagnosis of papilloedema since ONH of papilloedema appears swollen bilaterally. however, a good H&S will helps to make tentative diagnosis since GCA usually occurs with weight loss, scalp tenderness, jaw claudiclating, myelgia.
we must not ignore the possibility of papillitis (inflammation of ONH) that may cause hyperaemic and swollen disc as well. corticosteroids may help the inflammation. clinical findings show RAPD and central/paracentral scotoma lead to blindness.
CASE STUDY:
- 55 yo male
- diagnosed with hypertension a week ago
- BP: 220/100mmHG
- current meds: atenolol
possible ocular findings?
side effect of the meds?
-hypertension above 160/95mmHG
- ocular findings (4 phase):
i) vasoconstrictive phase: autoregulation, blood pressure increased, constriction of the vessels
ii) exudative phase: blood retinal barrier disrupted that leads to haemorrhage, exudates, and CWS.
iii) sclerotic phase:hardening and loss of muscle cells
iv) complication of sclerotic phase: microanwurysms, macroaneurysyms, CRAO, CRVO, epiretinal membrane formation - ocular presentation:
i) major important changes to fundus: - retinal oedema due to breakdown of blood retinal barrier
- hard exudates with macular star
- disc swelling
- IRMA due to capillary occlusions
ii) retinal haemorrhage
iii) lid or conjunctival redness, inflammed, subconjunctival haemorrhage and dry eyes.
iv) pareis of EOM
v) photophobia, ocular pain
optometrist role:
- referral for HBP
- referral by fundus sign alone
- retinal vasculature
CASE STUDY:
- 25 yo myope
- 3 day history of left sided ocular pain
- LE reduced vision( since 3 days ago)
- VA 6/18
- CLs wearer since last year, not used sterile solution to clean the CLs
possible findings:
possible findings:
- acanthaemoeba keratitis
- bacterial keratitis
- herpes simplex keratitis
CASE STUDY:
- 50 year old male
- 2 week history of photobia, RE vision loss
- eyes inflamed during this period
- VA reduced to 6/12
- IOP 24mmHG
- posterior synechiae present in LE with similar symptom and resolve after treatment 12 months ago.
Possible diagnosis:
IRITIS:
-redness form the limbus
-edge of the cornea appears cloudey and smokey
-hypopuon settling at the bottom
-keratic percipitate looks like drops of fat
-iris poterior synechiae
treatments: topical steroid for a short time or systemic steroid
short term usage:
- increased IOP
- retarded wound healing
- immunosuppression
- hide side of infection
long term usage: steroid cataract, steroid glaucoma, corneal thinning (risk of perforation).
4 ocular condition associated with syhphilis?
- sclera: scleritis
- choroid-unifocal choroiditis
- choroid+retina: chorioretinitis
- uvea: interstitial uveitis, anterior uveitis
- 3rd & 6th nerve palsy
- papilloedema
- madarosis
- conjunctival ulcers
list 4 causes of the inflammation of the sclera?
- episcleritis
- anterior scleritis
- posterior scleritis
4 unwanted side effeccts of the paneetinal of photocoagulation?
3 losses
- loss of VA
- loss of CV
- loss of VF
- nyctalopia
- photophobia
3 condition which retinal neovascularisation occur?
- wet AMD
- proliferative DR
- sickle cell disease
- CRVO
- ROP
what are 4 types of lens opacity?
- nuclear sclerosis
- posterior subcapsular
- anterior subcapsular
- corticol
- Christmas tree
