Retina 2 hypertensive changes crvo crao dr.k.n.jha -01.06.16
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Transcript of Retina 2 hypertensive changes crvo crao dr.k.n.jha -01.06.16
Retina 2
Professor K N Jha, [email protected]
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
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
• 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
Focal Intraretinal Periarteriolar Transudate
Elschnig spots
Hypertensive Optic Neuropathy
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
Retinal vascular occlusionArterial OcclusionVenous Occlusion
Arterial Occlusive Disease
• Branch Retinal Artery Occlusion(BRAO)
• Central Retinal Artery Occlusion(CRAO)
Arterial Occlusive Disease
Fundamentals:
• Retinal ischemia results from occlusion of
common carotid artery to intraretinal arteries
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
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
Other rare causes
• Migraine• Trauma• Coagulation disorders• Sickle cell disease• MVP• Oral contraceptive• Toxoplasma/syphilitic retinochoroiditis
Symptoms and signs
BRAO
• Initially may remain clinically silent
• Later: Edematous opacification of retina
• Permanent field defect
Management:BRAO
• Determine systemic etiology
• No ocular therapy
• Massage of the globe may be tried
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
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.
Investigations
-Same as BRAO
-Look for evidences of giant cell arteritis
-Blood for ESR and C-reactive protein
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
Venous Occlusive Disease
• Branch Retinal Vein Occlusion(BRVO)
• Central Retinal Vein Occlusion(CRVO)
Retinal venous occlusion
• Predisposing conditionsSystemic-Hypertension-Arteriosclerosis-Cardiovascular diseaseOcular-History of glaucoma
Retinal venous occlusion
• In young people
-Infective periphlebitis
-Facial erysipelas
-Orbital cellulitis
Pathology
• Common adventitia
• Thickening of the arterial wall
• Turbulence in blood flow, endothelial damage
• Thrombotic occlusion
Pathophysiology of venous occlusion
Venous Occlusion
Stagnation
Increased extravascularpressure
Hypoxia
Oedema andhaemorrhage
Sec art narrowing
Symptoms
BRVO
Depends on whether central vision (macula) is
involved or not
Branch Retinal Venous Occlusion
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.
Management
• FFA• BRVO study• Photocoagulation
Focal for macular edemaPRP for retinal neovascularisation
CRVO:Types
• Non-ischemic
• Ischemic (diagnosis by FFA)
• Papillophlebitis (combined inflammatory and
occlusive mechanism)
CRVO
Clinical features: Symptoms: transient blurring of vision
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
Vascular sheathing and collaterals Hard exudates
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
Management
• CRVO study
• Associated medical condition
• Glaucoma
• Panretinal photocoagulation for iris
vascularization
Hyperviscosity retinopathy
• Generally bilateral
• They are related to disproteinemias e.g.
Waldenstrom macroglobulinemia or,multiple
myeloma
Macular edema
• Laser photocoagulation :No benefitmay benefit in young in improving VaCorticosteroid and aspirin:efficacy is
unprovenSystemic anticoagulation: not
recommendedIntravitreal triamcinolone acetonide
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
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
Management
• Photocoagulation
• Pars plana vitrectomy
• Intravitreal trimcinolone
Photocoagulation
• Indications:
-Chronic macular edema with intact perifoveal
retinal capillary perfusion
-Posterior segment neovascularisation
-Iris neovascularisation
Photocoagulation
• Visual acuity 6/12 to 6/60
• Argon Laser grid pattern photocoagulation is
applied in areas of capillary leakage identified
by FFA
Panretinal photocoagulation
• For areas of retinal capillary non-perfusion
• Disc neovascularisation
Peripheral retinal cryoablation
• In those cases where hazy media due to
vitreous haemorrhage do not permit
photocoagulation
Vitrectomy and/or RD Surgery
• For non-resolving vitreous hemorrhage
• Retinal detachment
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.
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.