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Retinal Vascular Disorders

Retinal vascular disorders refer to diseases that affect the blood vessels in the eye. Common types include retinal artery occlusions, retinal vein occlusions, diabetic retinopathy, hypertensive retinopathy, and retinopathy of prematurity. Retinal vein occlusions are characterized by retinal vein occlusion and vision loss can occur from arterial or vein occlusion. Diabetic retinopathy is a leading cause of blindness and risk increases with duration of diabetes. Hypertensive retinopathy refers to fundus changes seen in patients with high blood pressure.

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117 views52 pages

Retinal Vascular Disorders

Retinal vascular disorders refer to diseases that affect the blood vessels in the eye. Common types include retinal artery occlusions, retinal vein occlusions, diabetic retinopathy, hypertensive retinopathy, and retinopathy of prematurity. Retinal vein occlusions are characterized by retinal vein occlusion and vision loss can occur from arterial or vein occlusion. Diabetic retinopathy is a leading cause of blindness and risk increases with duration of diabetes. Hypertensive retinopathy refers to fundus changes seen in patients with high blood pressure.

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sushma shrestha
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Retinal Vascular Disorders

Presented by: Seema Basnet


Roll no: 34
PBBN 3rd Year
Anatomy of Retina

• 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.
• Thin delicate layer of nervous tissue.
• Surface area of 266mm2
• Extends from optic disc to ora serrata.
• It contains millions of photoreceptors, which are
responsible for picking up light, converting it into
nerve signals, and then transmitting it through the optic
nerve to the brain for processing into images.
Functions of Retina

• To absorb photons of light.


• Translate light into a biochemical message.
• Translate biochemical message into electrical
impulse.
• Transmit electrical impulse to the brain via
ganglion cells.
Retinal Vascular Disorders
Retinal Vascular Disorders refer to a range of eye
diseases that affect the blood vessels in the eye.
Loss of vision can occur from occlusion of a retinal
artery or vein. These conditions are linked to
existing vascular diseases, such as high blood
pressure, high cholesterol and diabetes – conditions
that cause atherosclerosis (thickening of the artery
walls).
Cont….
Common vascular disorders of retina include:
retinal artery occlusions, retinal vein
occlusions, diabetic retinopathy, hypertensive
retinopathy and retinopathy of prematurity.
Retinal Vein Occlusion
Retinal Vein Occlusion (RVO) 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 :
1. Central Retinal Vein Occlusion
2. Branch Retinal Vein Occlusion
Central Retinal Vein Occlusion

Central Retinal Vein Occlusion also known as


CRVO, is a condition in which the main vein
that drains blood from the retina closes off
partially or completely. This can cause blurred
vision and other problems with the eye.
Branch Retinal Vein Occlusion
It is more common than the central retinal vein
occlusion. It may occur at the following sites: main
branch at the disc margin causing hemispheric
occlusion, major branch vein away from the disc,
at A-V crossing quadrantic occlusion and small
macular or peripheral branch occlusion. In branch
vein occlusion edema and hemorrhages are limited
to the area drained by the affected vein. Vision is
affected only when the macular area is involved.
Etiology and Risk Factors
• Age of age above 50 years
• Systemic diseases like hyperlipidemia, Diabetes,
Chronic Renal Failure
• Raised intraocular pressure .Central retinal vein
occlusion is more common in patients with primary
open-angle glaucoma.
• Periphlebitis retinae which can be central or
peripheral.
• Local causes are orbital cellulitis and cavernous
sinus thrombosis.
Cont…
 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.
Cont…
 Investigations :
o Fluorescein Angiography
o ECG
o Blood CP
o ESR
o Blood Glucose level
Cont…

Treatment: Panretinal photocoagulation (PRP)


or cryo-application, if the media is hazy, may
be required to prevent neovascular glaucoma
in patients with widespread capillary
occlusion. Photocoagulation should be carried
out when most of the intraretinal blood is
absorbed, which usually takes about 3-4
months.
Central Retinal Artery Occlusion
A central retinal artery occlusion (CRAO) is a
blockage of the central retinal artery – the main
blood vessels that brings blood and oxygen to
the eye. It occurs due to obstruction at the level
of lamina cribrosa. This is a very serious
condition that requires emergency treatment.
When the main source of oxygen to the eye is
blocked , permanent damage can occur.
Etiology
• Atherosclerosis-related thrombosis at the level of
lamina cribrosa is the most common cause
(75%) of CRAO.
• Embolism
• Raised Intra Ocular Pressure
• Giant Cell Arteritis
• Angiospasm- is a rare cause of retinal artery
occlusion. It is commonly associated with
amaurosis.
Symptom
• Sudden painless vision, lose of one eye
• Repeated transient episode of decreased vision or
blindness.

Signs :
o Direct light reflex disappear
o Indirect light reflex normal
o Retinal edema, cherry-red spot
o Retinal hemorrhage
o Retinal artery narrowing
Clinical Examination
• Visual Acuity- Severely reduced, between
counting finger and light perception.
• Direct Pupillary Light reflex- Absent
• Fundus Examination- Whitish appearance of
retina vessels, retinal arteries, segmented
blood column in retinal vessels, cherry red
spot at macula, pale appearance of optic disc.
Branch Retinal Artery Occlusion
When the blockage occurs in one the branches
of the central retinal artery , it is called a
branch retinal artery occlusion (BRAO). Some
patients with branch retinal artery occlusion
(BRAO) are symptom free, whereas others
complain of a sudden loss of vision if the
macular area is involved.
Treatment
 Immediate lowering of intraocular pressure by intravenous
mannitol and intermittent ocular massage. It may aid the
arterial perfusion and also help in dislodging the embolus.
Even paracentesis of anterior chamber has been
recommended for this purpose.
 Vasodilators and inhalation of a mixture of 5% carbon-
dioxide and 95% oxygen may help by relieving element of
angiospasm.
 Anticoagulants may be helpful in some cases.
 Intravenous steriods are indicated in patients with giant cell
arteritis.
Hypertensive Retinopathy
It refers to fundus changes occurring in patients
suffering from systemic hypertension.
Incidence:
o The second most common retinal vascular disease.
o Systemic hypertension (>160/90mmHg ) 10-15% in
the UK >40 age group.
o Malignant hypertension (240/140mmHg) 0.5-0.75%
o Hypertensive Retinopathy 4-10%
Risk Factors
• Age
• Family History
• Medications
• Obesity
• Smoking
• Stress
• Alcohol consumption
• Lack of exercise
Pathogenesis
Three factors which play role in the
pathogenesis of hypertensive retinopathy are:
1. Vasoconstriction: Primary response of the
retinal arterioles to raised blood pressure is
narrowing (vasoconstriction) and is related to
the severity of hypertension. It occurs in pure
form in young individuals, but is affected by
the pre-existing involutional sclerosis in older
patients.
Cont…

2. Arteriosclerotic changes: which manifests as


changes in arteriolar reflex and A-V nipping
result from thickening of the vessel wall and
are a reflection of the duration of hypertension.
In older patients arterioscelrotic changes may
pre-exist due to involutional sclerosis.
Cont…

3. Increased Vascular permeability: results


from hypoxia and is responsible for
hemorrhages, exudates and focal retinal
edema.
Classification
Management
Treatment of the underlying systemic condition
can halt the progression but arteriolar narrowing
and AV nicking usually are progression.
Hypertension emergencies : sodium
nitroprusside , nitroglycerin, calcium channel
blockers, beta blockers and angiotensin-
converting enzyme inhibitors.
Blood pressure should be lowered in a
controlled fashion.
Diabetic Retinopathy

It refers to retinal changes seen in patients with


diabetes mellitus. With increase in the life
expectancy of diabetic, the incidence of
diabetic retinopathy (DR) has increased. In
western countries, it is the leading cause of
blindness.
Risk Factors

• Duration of diabetes is the most important determining


factor. Roughly 50% of patients develop DR after 10
years, 70% after 20 years and 90% after 30 years of onset
of the disease.
• Sex: Incidence is more in females than males(4:3).
• Poor metabolic control is less important than duration, but
is nevertheless relevant to the development and
progression of DR.
• Heredity: It is transmitted as a recessive trait without sex
linkage. The effect of heredity is more on the proliferative
retinopathy.
Cont…

• Hypertension , when associated, may also


accentuate the changes of diabetic retinopathy.
• Other risk factors include smoking, obesity
and hyperlipidemia.
Investigations
• Urine examination
• Blood sugar estimation
• Fundus fluorescein angiography should be
carried out to elucidate areas of
neovascularisation, leakage and capillary
nonperfusion.
Medical Treatment
 Control of risk factors: Diabetes Mellitus,
Hypertension, Anemia, Nephropathy and
Hyperlipidemia
 Antivascular endothelial growth factor
 Intra vitreal steriods are useful to reduce the
macular edema (Intra vitreal injection of
triamcinolone) .
Laser Photocoagulation
It remains the mainstay in the treatment of diabetic
retinopathy and maculopathy. That destroy the
hypoxic retina, stop the release of vasoformative
substance and cause involution of new vessel and the
leakage areas and enhance the absorption of edema
and exudate.
Types:
1. Focal treatment for focal macular edema
2. Grid treatment for diffuse macular edema
3. Panretinal photocoagulation
Surgical Treatment

It is required in advanced cases of Proliferative


diabetic retinopathy. Pars plana vitrectomy is
indicated for dense persistent viterous
hemorrhage , tractional retinal detachment and
epiretinal membranes. Associated retinal
detachment also needs surgical repair.
Retinopathy of Prematurity

It is a bilateral vaso-proliferation occurring in


premature infants with low birth weight and
exposed to high concentration of oxygen.

Etiology and Risk factors:


• Low birth weight
• Exposure to high concentrations of oxygen
• Premature birth
Pathology

• The temporal retinal vascularization is


completed 1 month after birth.
• Toxic level of oxygen interferes with
revascularization by damaging the
endothelium and obliterating newly formed
capillaries.
Stages
Treatment

• Peripheral retinal laser in stage 2.


• Ablation of avascular retina in stage 3
• Vitreotomy in stage 4 and 5
Cont…
 Complications:
o Chronic Macular Edema
o Retinal Neovascularization
o Neovascular Glaucoma
Reference
• Khurana A.K. Comprehensive Opthalmology; 4th
edition; New Delhi, New Age International (P) Ltd
(2007).
• Sihota R & Tandon R. Prason’s Disease of the Eye ;22nd
edition ; New Delhi, Reed Elsevier India Private
Limited (2015).
• Williams L & Wilkins. Brunner & Siddarth’s Textbook
of Medical Surgical Nursing; 12th edition;(2010).
• Jack J Kanski & Bowling B. Clinical Opthalmology A
Systematic Approach; 7th edition; Elsevier India Private
Limited (2011).

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