This document provides an overview of vitreoretinal pathology, including techniques for indirect ophthalmoscopy, treatment of retinal breaks and detachments, and features of pathological myopia. Key topics covered include examining the fundus using indirect ophthalmoscopy, assessing and managing retinal breaks and detachments, and ocular and systemic associations of high myopia such as Stickler syndrome, Marfan syndrome, and Ehlers-Danlos syndrome.
5. ► Observe external cues:
► High myopic glasses: myopic
degeneration, staphyloma, laser for retinal
tear
► Hearing aid: RP
► Etc.
INDIRECT
OPHTHALMOSCOPY
6. ► Lie patient on couch
► Make sure enough room to move around
patient
INDIRECT
OPHTHALMOSCOPY
7. ► Adjust everything:
► Headband
► IPD: adjust by shining light on back of
hand
► Dim room lights
► Make sure you use the 28D or 20D lens
the right way up
INDIRECT
OPHTHALMOSCOPY
8. ► Look at the fundus:
► Move lens away from eye until stereoscopic
image obtained (5cm for 20D lens)
► Tilt lens to reduce reflections
INDIRECT
OPHTHALMOSCOPY
9. ► Examine:
► Optic Disc
► Retinal Vessels
► Macula
► Peripheral retina in all cardinal positions
INDIRECT
OPHTHALMOSCOPY
10. ► Indent:
► To view between equator (14mm
from limbus) and pars plana (Spiral of
Tillaux)
INDIRECT
OPHTHALMOSCOPY
16. http://www.volk.com/main/compare/indirectbio.html
Lens Magnifica Field of Image Principal
tion view use
+14 BIO 4x 40o Inverted, Fundus
Reversed, lesion
Real
+20 BIO 3x 45o Routine
examinati
on
+30 BIO 2x 50o Child,
small
pupil,
media
opacity
INDIRECT
OPHTHALMOSCOPY
20. ► Treat all symptomatic tears/holes
► Notes to VR Consultant
► If low risk, discharge with Retinal Detachment
Warning
► If treatment not complete, ring me and I will
complete treatment within a week
► My job is twofold:
► Laser up to ora
► Look for other breaks
RETINAL TEARS
21. ► Anything that doesn’t need lasering?
RETINAL TEARS
22. ► Tear more dangerous than Hole
► Pigmentation is reassuring
► Symptomatic breaks more dangerous than incidental finding
► Worrying factors:
► Cataract surgery esp. with vitreous loss
► Myope
► FHx RD
► Marfan, Stickler, Ehlers-Danlos
RETINAL TEARS
27. ► What the Vitreoretinal Surgeon wants to know:
► History (symptoms, duration, VF defect, trauma), vision, POH,
Myopia, Systemic Conditions (connective tissue disease,
suitability for GA), FHx RD, Tobacco dust, extent of RD (clock
hours, how close to macula, shallow, bullous, dome), Is the
retina translucent? Are there lines of pigment around the
detachment? Does the fellow eye have Retinoschisis? If mac-
on, keep NBM for now (just in case). DO NOT promise
immediate surgery!!!
RETINAL DETACHMENT
39. ► 1. NBM
► 2. DO NOT promise immediate surgery. Consent "Right/Left Retinal
Detachment Repair".
► 3. Admit to D4
► 4. Is patient happy for LA instead of GA?
► 5. Nurses to phone Nucleus Theatres to see what's on the emergency list.
► 6. Inform on-call theatre staff and ask if surgery next morning (07:30) is an
option.
► 7. Take 2 patient stickers to Nucleus Theatres and book the case for tonight
AND tomorrow morning.
WHAT TO DO WHILE
WAITING
40.
41. ► Dialysis, trauma related, young patient, avulsion of vitreous base may give
bucket-handle. If no RD, laser. If RD, usualy progress slowly due to healthy
vitreous gel in young individuals.
50. ► Grade A (minimal) PVR: diffuse vitreous haze and
tobacco dust. Pigmented clumps under retina.
► Grade B (moderate) PVR: wrinkling of inner retinal
surface, tortuosity of blood vessels, retinal
stiffness, decreased mobility of vitreous gel, rolled
edges of retinal breaks
► Grade C (marked) PVR: full thickness rigid retinal
folds. Heavy vitreous condensation and strands.
Described as Anterior/Posterior + Clock hours.
PVR IN LONGSTANDING RDS
52. ► Refractive error > -6D and axial length > 26mm
► 0.5% of population
► Maculopathy commonest cause of visual loss
HIGH MYOPIA
53. Pale tessellate (tigroid) appearance due to diffuse attenuation of the RPE with
visibility of large choroidal vessels.
54. Focal chorioretinal atrophy characterised by visibility of the larger choroidal
vessels and eventually the sclera
55. ‘Lacquer cracks’ consist of ruptures in the RPE-Bruch membrane-choriocapillaris
complex characterised by fine, irregular, yelow lines, often branching and criss-
crossing at the posterior pole
56. Fuchs spot is a raised, circular, pigmented lesion that may develop after a
macular haemorrhage has absorbed
58. Staphylomas are due to expansion of the globe and scleral thinning. They may
be peripapillary or involve the posterior pole and be associated with macular
hole formation.
59. ► Foveal retinoschisis: in the absence of macular hole.
► Peripapillary detachment: asymptomatic, innocuous,
yellow-orange elevation of the RPE and sensory
retina at the inferior border of the myopic conus.
HIGH MYOPIA
60. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
► Systemic:
► Stickler
► Marfan
► Ehlers-Danlos
► Pierre-Robin
HIGH MYOPIA
61. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Stickler Syndrome
► Stickler Hereditary arthro-ophthalmopathy
► Marfan Abnormal vitreous
► Ehlers-Danlos High myopia
► Pierre-Robin Orofacial abnormality
Deafness
Arthropathy
Mitral valve prolapse
AD inheritance with variable expressivity
HIGH MYOPIA Commonest inherited cause of retinal
detachment in children.
62. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Marfan Syndrome
► Stickler Connective tissue disorder – mutation of fibrillin
► Marfan gene on chromosome 15q.
► Ehlers-Danlos Tall, thin, long limbs compared with trunk
► Pierre-Robin Arachnodactyly, joint hypermobility
Gothic palate
Dilatation of ascending aorta, aortic
incompetence, heart failure, mitral valve
disease, aortic dissection
HIGH MYOPIA Ectopia lentis, myopia, RD
AD inheritance with variable expressivity.
63. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Ehlers-Danlos syndrome type 6
► Stickler 9 subtypes, but only type 4 and 6 affect the
► Marfan eye.
► Ehlers-Danlos Rare, usually AR disorder of collagen caused by
► Pierre-Robin deficiency of procollagen lysyl hydroxylase.
Thin hyperelastic skin.
Hypermobile joints.
Cardiovascular disease: bleeding diathesis,
HIGH MYOPIA dissecting aneurysms, spontaneous rupture of
large blood vessels, mitral valve prolapse
Ocular fragility with increased vulnerability to
mild trauma, high myopia, retinal detachment,
keratoconus
64. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Pierre-Robin syndrome
► Stickler
► Marfan Micrognathia, small tongue, cleft soft palate,
► Ehlers-Danlos high-arched palate.
► Pierre-Robin
Jaw that is very small with small (receding) chin
Jaw that is far back in the throat
Repeated ear infections
Small opening in the roof of the mouth, which
HIGH MYOPIA causes choking
Teeth that appear when the baby is born (natal
teeth)
Tongue that is large compared to the jaw
Notas del editor
Resource: Practical Ophthalmology (A manual for beginning residents) Fred M Wilson II, MD – Executive Editor
Some people remove their glasses as having the eyepieces closer to their eyes gives a greater field of view.The image is at 33cm. With presbyopia, this may become difficult to see. So, some people will need more plus correction. There is already a +2 correction in the BIO.