1. I N T R O D U C T I O N , ANATOMY REVIEW AND DIAGNOSTICS P O S T E R I O R S E G M E N T

2. WELCOME 3. S Y L L A B U S 8072 Ocular Disease IV P O S T E D O N B L A C K B O A R D A N D W E B S I T E : M A Y C H A N G E C O U R S E W E B S I T E H T T P : / / W W W . Y O U N G E Y E S . I N F O P A P E R S A N D C A S E R E P O R T S C A N B E U P D A T E D W E E K L Y P O P Q U I Z G U E S T L E C T U R E R S C O N T A C T I N F O R M A T I O N G R A D I N G 4. N O R M A L H E A L T H / D I S E A S E / T R A U M A N B E O P A R T 2 5. L E A R N I N G O B J E C T I V E S Recognize normal anatomical structures discussed in the lecture and their physiological variations. Recognize the location, depth and extent of pathological lesions. Identify and interpret the findings of diagnostic tests discussed in the course. List indications, contraindications and side effects of Diagnostic tests 6. V I T R E O U S A N A T O M Y Ultrastructure of posterior vitreous cortex in humans. Scanning electron microscopy demonstrates the dense packing of collagen fibrils in the vitreous cortex. To some extent this arrangement is exaggerated by the dehydration that occurs during specimen preparation for scanning electron microscopy (bar = 10 [a 5]mm). (Sebag J: The Vitreous--Structure, Function and Pathobiology. New York, Springer-Verlag, 1989) 7. V I T R E O U S A N A T O M Y Eye (2008) 22, 12141222; doi:10.1038/eye.2008.21; published online 29 February 2008 Adult vitreous structure and postnatal changes M M Le Goff1 and P N Bishop1 Eye (2008) 22, 12141222; doi:10.1038/eye.2008.21; published online 29 February 2008 Adult vitreous structure and postnatal changes M M Le Goff1 and P N Bishop1 8. V I T R E O U S A N A T O M Y Lens Attachment of vitreous 9. Patellar Fossa 10. V I T R E O U S B A S E A N A T O M Y Dissection of Human Vitreous Body Elements for Proteomic Analysis Jessica M. Skeie1, Vinit B. Mahajan1 Department of Ophthalmology and Visual Sciences, Omics Laboratory, University of Iowa 11. V I T R E O U S B A S E A N A T O M Y 12. P R O M I N E N T V I T R E O U S B A S E A N A T O M Y 13. V I T R E O U S A T T A C H M E N T S A N A T O M Y Major Blood Vessels premacular bursa, or precortical vitreous pocket (Area of Martegiani) (ciliobursal canal) Annular Gap (Space of Garnier) 14. N E U R O S E N S O R Y R E T I N A A N A T O M Y F a = umbo; b = foveola; c = fovea; d = parafovea; e = perifovea 15. B E Y O N D P O S T E R I O R P O L E A N A T O M Y www.oculist.net 16. O R A S E R R A T A A N A T O M Y Meridional folds possible site for break Dentate Processes Oral bay 17. C R O S S - S E C T I O N R E T I N A A N A T O M Y MLM=middle limiting membrane inner/outer segment junction 18. inner/outer segment junction 19. C R O S S - S E C T I O N R E T I N A A N A T O M Y 20. C R O S S - S E C T I O N R E T I N A A N A T O M Y 21. P H O T O R E C E P T O R M O S A I C A N A T O M Y 22. C I R C U L A T I O N 23. C I L I O R E T I N A L A R T E R Y A N A T O M Y 24. 4 L A Y E R S O F C A P I L L A R I E S 1. Radial Peripapillary network: NFL 2. Superficial capillary plexus 3. Deep capillary plexus: either side of the INL. 4. Choriocapillaris: supplied by the short posterior ciliary arteries: outer retina 25. R P E C E L L S Monolayer pigmented hexagonal, cuboidal cells approx 16 m in diameter: taller and denser in macula Continuous with the pigment epithelium of the ciliary body and iris. Apical portion envelop the outer segments of the photoreceptor cells with villous processes 26. R P E C E L L S F U N C T I O N Absorbs light (Melanosomes) Phagocytoses rod and cone outer segments/ Discs Participates in retinal and polyunsaturated fatty acid metabolism Forms the outer bloodocular barrier Maintains the subretinal space Heals and forms scar tissue 27. B R U C H M E M B R A N E http://www.eophtha.com/eophtha/Anatomy/Uvea/Bruch's.PNG 28. C H O R O I D Max thickness 0.22mm posterior to 0.1mm anterior http://www.intechopen.com/source/html/37889/media/image1.jpeg http://www.iovs.org/content/49/7/2812/F4.large.jpg posterior ciliary artery low pressure by Endarterioles Looks like lobules in center Irregular and more radial periphery 29. Date of download: 7/23/2014 Copyright 2014 McGraw-Hill Education. All rights reserved. From: Chapter 1. Anatomy & Embryology of the Eye Vaughan & Asbury's General Ophthalmology, 18e, 2011 E M B R Y O L O G Y RPE: outer layer of the optic cup: remains single layer. Pigmentation begins at 5 weeks. Secretion of the inner layer of Bruch's membrane occurs by 6 weeks. Other 9 layers: inner layer of the optic cup slowly throughout gestation. 7th month, outer nuclear layer of the rods and cones is present with bipolar, amacrine, and ganglion cells and nerve fibers. Macular region thicker than the rest of the retina until the 8 month, when the macular depression develop. Macular development is not complete in anatomic terms until 6 months after birth. 30. S T A G E S O F V I T R E O U S First Stage/Primary vitreous: 36 weeks: Fibrils from Cells and fibroblasts derived from mesenchyme at the rim of the optic cup or associated with the hyaloid vascular system, together with minor contributions from the embryonic lens and the inner layer of the optic vesicle: Ultimately, the primary vitreous comes to lie just behind the posterior pole of the lens in association with remnants of the hyaloid vessels (Cloquet's canal). http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v7/0020/036f.gif 31. S T A G E S O F V I T R E O U S Second Stage/ Secondary vitreous: 610 weeks: Fibrils and cells (hyalocytes) originate from the vascular primary vitreous. Anterior: firm attachment to the internal limiting membrane of the retina constitutes the early stages of formation of the vitreous base. The hyaloid system develops a set of vitreous vessels as well as vessels on the lens capsule surface (tunica vasculosa lentis). The hyaloid system is at its height at 2 months and then atrophies from posterior to anterior. http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v7/0020/036f.gif 32. S T A G E S O F V I T R E O U S Third Stage/Tertiary vitreous: 10 weeks on: During the third month, the marginal bundle of Drualt is forming. This consists of vitreous fibrillar condensations extending from the future ciliary epithelium of the optic cup to the equator of the lens. Condensations then form the suspensory ligament of the lens, which is well developed by 4 months. The hyaloid system atrophies complete during this stage. http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v7/0020/036f.gif 33. D I A G N O S T I C S 34. C O L O R P H O T O S 35. C O L O R P H O T O S 36. C O L O R P H O T O S 37. F I L T E R S 38. F I L T E R S 39. F I L T E R S Blue-green 490 nm NFL, ILM, EMR retinal folds & cysts Media Opacities limit 40. F I L T E R S Green 540 nm Retinal vasculature, & common findings such as hemorrhages, drusen and exudates Green filter = "red-free" baseline before FA 41. F I L T E R S Red 630 nm Pigmentary disturbances, Choroidal ruptures, Choroidal nevi Choroidal melanomas 42. F L U O R E S C E I N A N G I O G R A P H Y D I A G N O S T I C S 43. F L U O R E S C E I N A N G I O G R A P H Y D I A G N O S T I C S 44. F L U O R E S C E I N A N G I O G R A P H Y D I A G N O S T I C S Light from camera flash Pass through blue filter excites Fluorescein in blood vessels Emits yellow green light Excitatory Pass through yellow green filter 520530 nm465-490 nm 45. F L U O R E S C E I N A N G I O G R A P H Y D I A G N O S T I C S 46. E A R L Y P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation 1. Choroidal flush. Transit phase:10s range 10-15s 47. E A R L Y P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation 2. Arterial phase 12s 48. E A R L Y P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation 3. Arteriovenous phase 49. E A R L Y P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation 4. Venous Phase 30s 50. M I D P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation Recirculation Phase 2-4 min 51. L A T E P H A S E F L U O R E S C E I N A N G I O G R A P H Y http://www.opsweb.org/?page=FAinterpretation 7 to 15 min 52. F L U O R E S C E I N A N G I O G R A P H Y I N T E R P R E T A T I O N Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.892p 53. Hypofluorescence TWO MAIN CAUSES 1. Vascular filling defect 2. Blocked fluorescencee 54. B L O C K F R O M P R E R E T I N A L H E M E H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.894p 55. B L O C K F R O M I N T R A R E T I N A L H E M E H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896 56. B L O C K F R O M S U B R E T I N A L H E M E H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 57. B L O C K F R O M R P E H Y P E R T R O P H Y H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 58. B L O C K F R O M N E V U S H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 59. F I L L I N G D E F E C T H Y P O F L U O R E S C E N C E Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.898p 60. Filling defect: Choroideremia H Y P O F L U O R E S C E N C E http://imagebank.asrs.org/file/5375/choroideremia 61. Filling defect: Choroideremia H Y P O F L U O R E S C E N C E http://imagebank.asrs.org/file/5373/choroideremia 62. F I L L I N G D E F E C T : O P T I C N E R V E P I T H Y P O F L U O R E S C E N C E http://imagebank.asrs.org/file/544/optic-nerve-pit 63. F I L L I N G D E F E C T : O P T I C N E R V E P I T H Y P O F L U O R E S C E N C E http://imagebank.asrs.org/file/545/optic-nerve-pit 64. F L U O R E S C E I N A N G I O G R A P H Y I N T E R P R E T A T I O N Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.892p 65. Auto-fluorescence: Optic Nerve Drusen H Y P E R - F L U O R E S C E N C E : P R E I N J E C T I O N 66. Auto-fluorescence: Optic Nerve Drusen H Y P E R - F L U O R E S C E N C E : P R E I N J E C T I O N 67. Auto-fluorescence: Optic Nerve Hemartoma http://www.aao.org/publications/eyenet/200410/blink.cfm?RenderForPrint=1 (C) AAO 2014 H Y P E R - F L U O R E S C E N C E : P R E I N J E C T I O N 68. H Y P E R - F L U O R E S C E N C E : P R E - I N J E C T I O N Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 69. True Hyper-fluorescence Leakage Staining Pooling Transmission Window defect 70. TRUE HYPER-FLUORESCENCE Leakage: seepage of Fluorescein, increase in intensity and margins blur in late phase Staining: Fluorescein enters tissue that retains it: inten sity increase during transit but then stay same later, ma rgins are distinct. Pooling: accumulation of fluorescein in a fluid-filled sp ace, so fluid space from invisible become visible. Transmission or Window defect: increased normal cho roidal fluorescence through RPE defects. 71. Vascular:Neovascularization H Y P E R - F L U O R E S C E N C E : E A R L Y : V A S C U L A R This image was originally published in the ASRS Retina Image Bank. Author: Roy Schwartz, MD, Title:Proliferative Diabetic Retinopathy With Neovascularization - FA Retina Image Bank. Year 2014 Image Number: 133326. the American Society of Retina Specialists. 72. Vascular: Microaneurysms H Y P E R - F L U O R E S C E N C E : E A R L Y : V A S C U L A R This image was originally published in the ASRS Retina Image Bank. Author: James B. Soque, CRA, COA , Title: Diabetic Macular Edema, Proliferative Diabetic Retinopathy, Neovascularization Elsewhere, DME, PDR, NVE Retina Image Bank. Year 2013 Image Number: 5480. the American Society of Retina Specialists. 73. Vascular: Telangiectasia H Y P E R - F L U O R E S C E N C E : E A R L Y : V A S C U L A R This image was originally published in the ASRS Retina Image Bank. Author: Avris Romario Diparaja Siahaan, Title: Macular Telangiectasia (FA Early Phase) Retina Image Bank. Year 2014 Image Number: 17957. the American Society of Retina Specialists. 74. Vascular:Macular Pucker H Y P E R - F L U O R E S C E N C E : E A R L Y : V A S C U L A R This image was originally published in the ASRS Retina Image Bank. Author: David R. Chow, MD, FRCS(C) , Title: Pucker FA Late Retina Image Bank. Year 2012 Image Number: 1153. the American Society of Retina Specialists. 75. CHOROIDAL:CNVM H Y P E R - F L U O R E S C E N C E : E A R L Y : C H O R O I D A L This image was originally published in the ASRS Retina Image Bank. Author: Neha Goel, MS DNB FRCS (Glasg) , Title: Angioid Streaks With CNVM FFA LE Retina Image Bank. Year 2014 Image Number: 18451. the American Society of Retina Specialists. 76. WINDOW DEFECT: MACULAR HOLE H Y P E R - F L U O R E S C E N C E : E A R L Y : C H O R O I D A L Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 77. WINDOW DEFECT: MACULAR HOLE H Y P E R - F L U O R E S C E N C E : E A R L Y : C H O R O I D A L This image was originally published in the ASRS Retina Image Bank. Author: Jerald A. Bovino, MD Title: Macular hole. Retina Image Bank. Year 2013 Image Number: 5616. the American Society of Retina Specialists. 78. WINDOW DEFECT:RPE LOSS H Y P E R - F L U O R E S C E N C E : E A R L Y C H O R O I D A L Ryan, Stephen J. Retina. 4th ed. by MD, Elsevier Mosby; c2005.896p 79. WINDOW DEFECT:RPE LOSS H Y P E R - F L U O R E S C E N C E : E A R L Y : C H O R O I D A L This image was originally published in the ASRS Retina Image Bank. Author: David Callanan, MD, Title: Cuticular Drusen. Retina Image Bank. Year 2014 Image Number: 18734. the American Society of Retina Specialists. 80. WINDOW DEFECT:RPE LOSS H Y P E R - F L U O R E S C E N C E : E A R L Y : C H O R O I D A L This image was originally published in the ASRS Retina Image Bank. Author: David Callanan, MD, Title: Cuticular Drusen. Retina Image Bank. Year 2014 Image Number: 18738. the American Society of Retina Specialists. 81. Choroidal: Staining H Y P E R - F L U O R E S C E N C E : L A T E : C H O R O I D A L This image was originally published in the ASRS Retina Image Bank. Author: Jason S. Calhoun,MD Title: CNVM Staining Retina Image Bank. Year 2014 Image Number: 7706. the American Society of Retina Specialists. 82. Retinal: Cystoid edema (CME) H Y P E R - F L U O R E S C E N C E : L A T E : R E T I N A L This image was originally published in the ASRS Retina Image Bank. Author: David Callanan, MD Title: CME Retina Image Bank. Year 2014 Image Number: 15227 the American Society of Retina Specialists. 83. Retinal: Non-Cystoid edema (CSR) H Y P E R - F L U O R E S C E N C E : L A T E : R E T I N A L This image was originally published in the ASRS Retina Image Bank. Author: Carl C. Awh, MD Title: CSR Retina Image Bank. Year 2014 Image Number: 5642 the American Society of Retina Specialists. 84. A D V E R S E E F F E C T S Temp. Yellowing skin and conjunctiva 612h Orange- yellow Urine: 2436 hours Nausea, vomiting, or vasovagal reactions: 10% More severe vasovagal reactions, including bradycardia, hypotension, shock, and syncope, are rare Extravasation with subcutaneous granuloma, toxic neuritis, or local tissue necrosisthese are extremely rare Urticarial/Anaphylactoid reactions about 1% of cases Anaphylactic reactions (cardiovascular shock) less than 1 in 100,000 injections 85. A D V E R S E E F F E C T S Prior urticarial reactions increase a patients risk of having a similar reaction: Premedicating with antihistamines, corticosteroids, or both. Dye extravasate: Local pain: Ice-cold compresses 5 10 minutes. Reassessed over hours or days until the edema, pain, and redness resolve. Teratogenic effects not identified avoid in pregnant in the first trimester. Fluorescein is transmitted to breast milk Lower doses of fluorescein should be used in patients with renal insufficiency.