macula and choroid Flashcards
what are maculopathies ?
conditions that affect the macula and the choroid
what are the different types of maculopathies ?
- acquired
- hereditary
what are hereditary conditions ?
- macular dystrophies
what are acquired conditions ?
- AMD
- central serous retinopathy (CSR)
- macular hole
- cystoid macula oedema (CMO)
- myopic maculopathy
- choroidal neovascularisation
- epiretinal membrane (ERM)
- diabetic maculopathy
- drug-induced maculopathies
what are the symptoms common to all maculopathies ?
. reduced vision especially at near
. positive scotoma - smudge or a visible blur at centre of vision
. distortion ( metamorphopisa)
- complain that straight lines appear wobbly or that door frames look crooked
what are rare symptoms of maculopathies?
- micropsia (rare) . increased spacing of foveal cones e.g. caused space occupying lesion - macropsia (rare) . reduced spacing of foveal cones e.g. caused oedema
. the patient will complain of distortion in central vision
what investigation to carry for diagnosis for maculopathies ?
- BCVA
- near vision both monocularly and binocularly - Amsler grid - to record and measure distortion
- pupils light reaction
- expect to be normal
- differentiates from optic nerve lesions - dilated fundus examination using SL-BIO which helps look at subtle changes
- OCT - visualise the inner layer
- fundus autofluorescence
- HES- fluoroscein angiography
what are the characteristics of fundus autofluorescence imaging ?
. blood vessels are fluorescing
. optic nerve head is fluorescing
what are the characteristics of fluorescein angiography ?
. fluorescein is injected to a vein and the fluorescein flows around the vasculature and series of photographs are taken and blood vessels are filled with fluorescence
what is central serous retinopathy (CSR)?
- a type of maculopathy
- also called central serous choroidal retinopathy
- exudative detachment of sensory retina in macula area
- subtle pigmentary changes and shallow area of sub-retinal fluid
- common cause of centra vision loss ( 4th most common retinopathy after AMD, DR and RVO)
what is the pathogenesis of central serous retinopathy ?
- poorly understood
- due to multiple leaks in extrafoveal RPE
. FA ‘’ smoke stack’’ or ‘‘ink blot’’ appearance
. active choroidal leakage
-ICG - impaired choroidal circulation
what is the epidemiology of central serous retinopathy ?
. incidence 10 per 100,000 in M . M to F 6:1 to 10:1 ratio . 25-50 year age group . unilateral (80%) . 30% recur - in ipsilateral or contralateral eye
what are the risk factors of central serous retinopathy ?
. type A personality
. elevated testosterone levels
. systemic steroid use
what are the symptoms of central serous retinopathy ?
. sudden onset reduced VA/blurring
- VA 6/9 to 6/18
- possible hyperopic shift due to elevation of retina
. positive scotoma - interruption to central vision
. metamorphopsia- distortion
. micropsia
what is the clincal presentation of acute central serous retinopathy ?
.detachment of sensory retina with serous fluid between RPE and photoreceptor outer segs - oval/round elevation - shallow . absent/attenuated foveal reflex . pigment changes . PED
. 30% Px will have recurrence within a year
. multiple recurrence lead to chronic central serous retinopathy
what is the clinical presentation of chronic central serous retinopathy ?
. RPE atrophy
. risk of CNV
how to differentiate between chronic CSCR and wet AMD?
- patients with CSCR are younger than patients with wet AMD
- CSR resolves on its own accord
- wet AMD progresses
- differentiation with wet AMD based on age of onset and progression
what is the optometric management of CSR ?
. reassure patient . CSR tends to resolve spontaneously within 2-3 months . VA recovers approx 90% of patients . subtle metamorphopsia may persist . refer to ophthalmologist
what is the ophthalmological management of CSR ?
. confirmation of diagnosis . observation . tapering of systemic steroids . PDT or focal laser - hastens resolution but does not affect visual outcome . Anti-VEGF? . guarded prognosis if recurrent/chronic
what are the different types of macular holes dependent on ?
- refers to extent of retina that is involved
what is a full thickness macular hole?
- this is a hole that goes from the internal limiting membrane all the way through to the RPE
what are the clinical features of full thickness macular hole?
. edge of hole
- pseudocysts ( small intra retinal spaced )
- edge of fovea is thickerthan normal
. ‘punched out’ circle appearance at macula
. pseudocysts at edge
. pigment changes at base of hole
. edges may appear sl.raised
what is partial thickness macular hole or lamellar macular hole?
- photoreceptors are intact
- loss of layers of retina
- irregular foveal contour
- retinal cells are still attached to the posterior vitreous face known as operculum
what is an operculum ?
retinal cells are still attached to the posterior vitreous face known as operculum
what are the causes of macular hole ?
- traction
- this is where retina is lifted from RPE pump
- causes macular oedema - idiopathic
- trauma to eye
- inflammation
what is the prevalence of macular hole ?
. 1 in 3,300
. 6th and 7th decades
. typically female
. bilateral in 10-30% of cases
what are the symptoms of macular hole ?
- painless loss of vision
- full thickness macular hole the VA is 6/60
- partial macular hole vision may be better
- positive scotoma
- metamorphopsia
what is the treatment of macular hole ?
. self resolving - no treatment required
. not urgent referral
. put px under observation
. new full thickness macular may require surgery
how is the surgery of macular hole carried out ?
- vitrectomy and peel
- post-operative positioning - sitting with face down to allow retina to adhere
- visual outcome depends on presenting VA
- risk of cataract
what is cystoid macular oedema ?
- cystoid macular oedema causes a painless loss of central vision (6/12-6/60)
- result of fluid accumulation ( cysts ) at OPL and INL of fovea
- fluid accumulation is a result of breakdown of blood-retinal barrier
what is the short term result of cystoid macular oedema ?
- may not be serious
- can improve without treatment
what happens if cystoid macular oedema becomes chronic or severe ?
- can be difficult to treat
- may cause permanent drop in central vision
- cysts may coalesce/merge to form a lamellar hole
what are the clinical signs of cystoid macular oedema ?
- loss of foveal depression
- cysts may be visible with an OCT- appear as hyporeflective ( dark ) spaces within the retina
- FA ( fluorescein angiography ) typical ‘flower-patel’ pattern of late hyperfluorescence ( due to dye accumulation with time in the OPL cysts )
what are the causes of cystoid macular oedema ?
- post surgery
- diabetes
- wet AMD - fluid leakage from the blood vessels results in cystic spaces being formed can cause cystoid macular oedema
- retinal vein occlusion
- uveitis
- epiretinal membran
- radiation retinopathy
- choroidal tumours
- retinitis pigmentosa
- prostaglandin analogue eyedrops for glaucoma
- macula telangectasia
- coats disease
what is irvine-gass syndrome ?
- it is cystoid macular oedema which follows cataract surgery
- occurs 1-3 months post-op
- clinically significant CMO affects 10% after routine cataract surgery ( but 25-40% show CMO on FA)
what happens when a patient has cataract surgery ?
- they are invited to an appointment 6-12 weeks after surgery, during which they have an OCT to identify if there is any element of cystoid macular oedema
what happens to diabetic patients post-cataract surgery ?
- in diabetes, post-cataract surgery CMO occurs in 32% without DR ( diabetic retinopathy ) , and 81% of diabetics with DR
- pre-existing diabetic macular oedema should be treated before cataract surgery whenever possible
what is the treatment of Irvine-gass syndrome ?
- topical non-steroidal anti-inflammatory drugs (NSAIDs)
- topical corticosteroids
- anti-VEGF
what does pathological/degenerative myopia cause ?
- degenerative changes in sclera, choroid and RPE
- > -6D
- AL ( axial length) greater than 26mm
- significant cause of visual impairment in working population
how prevalent is pathological/degenerative myopia ?
- 2 to 10% population
- race dependent
what are the systemic associations of high myopia ?
. down syndrome
. marfan syndrome
. prematurity
. ehlers-danlos syndrome
how does myopic fundus look like ?
- pale tessellated ( tigroid) fundus
- diffuse attenuation of RPE ( RPE is thinned ) with increased visibility of choroidal vasculature - focal chorioretinal atrophy
- patchy areas where choroid ( and possibly ) sclera visible due to elongation of globe - anomalous optic nerve head
- small, large or tilted appearance ( edges more blurred on one side ) - peripapillary chorioretinal atrophy
- atrophy surrounding optic nerve head
- common
- includes peripapillary intrachoroidal cavitation = small yellow-orange area inferior to disc
- can cause visual field defect - acquired optic disc pit
- due to expansion of peripapillary area over time - Lacquer cracks
- subretinal haemorrhages ( may develop from lacquer cracks )
- choroidal neovascularisation
- Fuch’s spot
what are lacquer cracks ?
. linear breaks in RPE-bruch’s membrane complex
- fine yellowe lines, criss-crossing
- stretching and degeneration of the choroid from elongation of globe
- associated with CNV( choroidal neovascularisation ) in 82% of eyes
what is the prevalence of choroidal neovascularisation ( CNV) ?
. CNV in 10% highly myopic eyes
- CNV located between neurosensory retina and RPE
- minimal sensory retinal elevation
. typical onset 40-50 years
. better prognosis than with CNV in AMD
. location is mostly subfoveal in 60%
. juxtafoveal ( to the side ) in 30%
what does myopic CNV lead to in the advanced stages ?
. advanced stages: leads to Fuch’s spot
- macular scar with pigment clumping
- raised, follows reabsorption of sub retinal bleed
- treatment : anti-VEGF
what other changes that can occur in myopic eye ?
. staphyloma
- peripapillary or macular ectasia of posterior sclera due to focal thinning
. lattice degeneration
. retinal tears and breaks
. retinal detachment
. macular retinoschisis
- possible in eyes with staphyloma due to macular traction
. macular hole
- spontaneous or after trauma
what are other myopia complications ?
. premature lenticular opacities
- PSC or early onset nuclear sclerosis
. lens dislocation - may be associated with systemic conditions
. primary open angle glaucoma
- increased prevalence
