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Retina 2 hypertensive changes crvo crao dr.k.n.jha -01.06.16

Retina 2 hypertensive changes crvo crao dr.k.n.jha -01.06.16

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Retina 2 hypertensive changes crvo crao dr.k.n.jha -01.06.16

  1. 1. Retina 2 Professor K N Jha, MS Kirtinath.jha@gmail.com
  2. 2. Learning Aims • Hypertension and the Eye: Clinical features, complications, relationship of retinal changes and prognosis for life • Retinal Vascular occlusions: Clinical features, complications and treatment
  3. 3. Hypertension and the Eye • Retinopathy: FIPTs, microaneurysms, intraretinal microvascular abnormalities (IRMAs), blot haemorrhages, hard exudates, venous beading. and new retinal vessels • Chroidopathy: Elschnig spots, Siegrist streaks • Optic neuropathy: flame-shaped haemorrhages, blurring of the disc margins, florid disc edema with secondary retinal venous stasis, and macular exudates
  4. 4. • Hypertension is also associated with -Intraretinal haemorrhages - Branch retinal artery occlusion(BRAO) - Branch retinal vein occlusion(BRVO) -Central retinal vein occlusion(CRVO) -Retinal arterial macroaneurysms
  5. 5. Focal Intraretinal Periarteriolar Transudate
  6. 6. Elschnig spots
  7. 7. Hypertensive Optic Neuropathy
  8. 8. Hypertensive retinal change: Classification Grade I : Arteriolar narrowing Grade II: Arteriovenous crossing changes Grade III: Hemorrhage and exudates along with the changes in grade I and II plus Grade IV: Hemorrhages, exudates, and papilloedema
  9. 9. Retinal vascular occlusion Arterial Occlusion Venous Occlusion
  10. 10. Arterial Occlusive Disease • Branch Retinal Artery Occlusion(BRAO) • Central Retinal Artery Occlusion(CRAO)
  11. 11. Arterial Occlusive Disease Fundamentals: • Retinal ischemia results from occlusion of common carotid artery to intraretinal arteries
  12. 12. Precapillary Retinal Arterial Obstruction • Leads to NFL infarct(CWS/soft exudates) • They are ¼ dd in size or smaller • Fade in 5-7 weeks • Effect on Va or field will depend on location and size
  13. 13. Etiology: BRAO/CRAO Embolus/thrombosis :from carotids /heart -Cholesterol emboli -Platelet-fibrin thrombus -Calcific emboli -Infective endocarditis, fat emboli etc. In addition in CRAO: -Hemorrhage under plaque -Spasm -Dissecting aneurysm
  14. 14. Other rare causes • Migraine • Trauma • Coagulation disorders • Sickle cell disease • MVP • Oral contraceptive • Toxoplasma/syphilitic retinochoroiditis
  15. 15. Symptoms and signs BRAO • Initially may remain clinically silent • Later: Edematous opacification of retina • Permanent field defect
  16. 16. Management:BRAO • Determine systemic etiology • No ocular therapy • Massage of the globe may be tried
  17. 17. Central Retinal Artery Occlusion • Clinical presentation: Sudden, severe, painless loss of vision Ophthalmoscopic feature: -Retina :edematous and opaque -Foveola: Cherry-red spot -Cholesterol emboli at retinal arterial bifurcation -Arterioles and venules are markedly narrowed -Cattle-truck appearance - Pupil:-RAPD
  18. 18. Central Retinal Artery Occlusion • About 2/3rd of patients have Va of < 3/60 and visual prognosis is poor. • If cilioretinal artery is present central vision may be preserved. • Leading cause of death in these cases is cardiovascular disease.
  19. 19. Investigations -Same as BRAO -Look for evidences of giant cell arteritis -Blood for ESR and C-reactive protein
  20. 20. Management • To be started without delay • They include: • Reduction of IOP by ocular massage • Ant chamber paracentesis • Retrobulbar anaesthesia • Inhalation of 95% O2+ 5% CO2 mixture • Oral acetazolamide and aspirin • Corticosteroid therapy to save the other eye, if giant cell arteritis is diagnosed
  21. 21. Venous Occlusive Disease • Branch Retinal Vein Occlusion(BRVO) • Central Retinal Vein Occlusion(CRVO)
  22. 22. Retinal venous occlusion • Predisposing conditions Systemic -Hypertension -Arteriosclerosis -Cardiovascular disease Ocular -History of glaucoma
  23. 23. Retinal venous occlusion • In young people -Infective periphlebitis -Facial erysipelas -Orbital cellulitis
  24. 24. Pathology • Common adventitia • Thickening of the arterial wall • Turbulence in blood flow, endothelial damage • Thrombotic occlusion
  25. 25. Pathophysiology of venous occlusion Venous Occlusion Stagnation Increased extravascular pressure Hypoxia Oedema and haemorrhage Sec art narrowing
  26. 26. Symptoms BRVO Depends on whether central vision (macula) is involved or not
  27. 27. Branch Retinal Venous Occlusion
  28. 28. BRVO:Visual Prognosis Depends on • Capillary damage and macular ischemia • Macular edema • Retinal neovascularisation 40 %. • 50-60 % will maintain 6/12 after 1yr. • Secondary glaucoma, rarely.
  29. 29. Management • FFA • BRVO study • Photocoagulation Focal for macular edema PRP for retinal neovascularisation
  30. 30. CRVO:Types • Non-ischemic • Ischemic (diagnosis by FFA) • Papillophlebitis (combined inflammatory and occlusive mechanism)
  31. 31. CRVO Clinical features: Symptoms: transient blurring of vision
  32. 32. Ophthalmoscopic Features • Dilatation and tortuosity of affected vein • Superficial hemorrhages • Retinal edema • Cotton wool spots(soft exudates) • Macular edema in case of macular involvement • Fluorescein fundus angiography
  33. 33. Vascular sheathing and collaterals Hard exudates
  34. 34. Evaluation Visual acuity and RAPD IOP Gonioscopy Look for iris neovascularisation FFA to determine whether the condition is ischemic or no-ischemic Exclude carotid occlusive disease
  35. 35. Management • CRVO study • Associated medical condition • Glaucoma • Panretinal photocoagulation for iris vascularization
  36. 36. Hyperviscosity retinopathy • Generally bilateral • They are related to disproteinemias e.g. Waldenstrom macroglobulinemia or,multiple myeloma
  37. 37. Macular edema • Laser photocoagulation :No benefit may benefit in young in improving Va Corticosteroid and aspirin:efficacy is unproven Systemic anticoagulation: not recommended Intravitreal triamcinolone acetonide
  38. 38. Iris neovascularisation • Predictive factor:Poor visual acuity • Risk factors:Retinal non-perfusion ,intraretinal blood • Panretinal photocoagulation when iris neovascularisation occurs • Prophylactic Panretinal photocoagulation if close follow-up of patient is not possible
  39. 39. BRVO:Visual Prognosis Depends on • Extent of capillary damage and macular ischemia • Integrity of parafoveal capillaries • Macular edema, retinal hemorrhage,parafoveal retinal capillary occlusion • Retinal neovascularisation
  40. 40. Management • Photocoagulation • Pars plana vitrectomy • Intravitreal trimcinolone
  41. 41. Photocoagulation • Indications: -Chronic macular edema with intact perifoveal retinal capillary perfusion -Posterior segment neovascularisation -Iris neovascularisation
  42. 42. Photocoagulation • Visual acuity 6/12 to 6/60 • Argon Laser grid pattern photocoagulation is applied in areas of capillary leakage identified by FFA
  43. 43. Panretinal photocoagulation • For areas of retinal capillary non-perfusion • Disc neovascularisation
  44. 44. Peripheral retinal cryoablation • In those cases where hazy media due to vitreous haemorrhage do not permit photocoagulation
  45. 45. Vitrectomy and/or RD Surgery • For non-resolving vitreous hemorrhage • Retinal detachment
  46. 46. Points To Remember • Retinal Vascular Occlusions cause sudden painless diminution of vision. • Arterial occlusions result from atheromatous plaque, emboli, or vasculitis. • Venous occlusions in elderly result from arteriosclerosis • Macular ischemia/edema, vitreous hemorrhage or neovascularisation result in visual loss.
  47. 47. Points To Remember • Visual loss in arterial occlusion is irreversible. • Macular edema is treated with laser, intravitreal steroid/ anti-VEGF agents. • Prognosis of Venous occlusions depend upon the clinical features and the course.

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