Retina Conference R3 임성아/Ap.박영훈
Chief Complaint 20/M Central scotoma (OD) onset :2d ago ‘ 자동차계기판에 우안 수상 후 발생한 중심암점’ VA OD 0.02 (0.1 x -1.50Ds=-2.00Dc Ax 165)) OS 0.25 ( 1.0 x -1.50Ds=-1.00Dc Ax 180))
Past histoty DM/ HBP(-/-) Ocular op/ Trauma (-/-) Gls (+) Eyedrop (-)
Physical examination MR OD -1.50Ds=-2.00Dc Ax 166 OS -1.50Ds=-1.00Dc Ax 166 IOP 19/17 mmHg Lid mild swelling Conj. not injected Cornea clear AC deep & cell(-) Pupil round & nl sized. Lens clear / (OU) Fd OD nl .optic disc c crescent retinal whitish change c pigmentation OS nl. optic disc c good foveal reflex.
Diagnosis Choroiddal rupture(OD) Tx. ) conservative care
Chief Complaint 16/F Dec.VA (OU) onset : 2007.10.25 ‘학교 5층에서 fall down 하여 안면부 수상’ VA OD LP (+)( n-c c PH) OS 0.02 ( 0.06 c PH)
Past histoty DM/ HBP(-/-) Ocular op/ Trauma (-/+) 2007.10.25 fall down GLs (+) Eyedrop (-) 2011.11. 월 내원
Physical examination B-scan (OU) flat MR OU error IOP 8/9 mmHg Exo. 7/7 mm( base 120mm) Lid mild swelling Conj. not injected Cornea clear AC deep & cell(-) Pupil irregular & dilatated state ( 5.0mm/ 8.0mm) / (OU) Lens OD mild cortical opacity OS clear FD OD pale optic disc c macular Hm. c pre- retinal Hm c Tractional memb. (+) OS pale optic disc c macular Hm. c pre- retinal Hm c Tractional memb. (+) OU R/O choroidal rupture B-scan (OU) flat CT (head & face ) -multiple facial bone fracture eyeball structure intact
Diagnosis Traumatic optic neuropathy(OU) Macular Hm. (OU) R/O choroiddal rupture Tx. ) conservative care
2008.7.16 ( post trauma 9m) VA HM/ 0.4 IOP 15/15mmHg linear disruption that may be crescent-shaped. significant reactive RPE hyperplasia, giving the rupture a pigmented appearance.
FAG(OD) 신생혈관은 반흔형성과정에서 발생 대부분 휴유증없이 퇴화
2008.11.24 ( post trauma 13m) VA (HM)/ (0.4) IOP 15/15mmHg FAG no inter val change
2009.6.2 ( post trauma 21m) VA (HM)/ (0.63) IOP 18/15mmHg Fd OD subretinal Hm OS sl. Progression lesion Plan ) FAG (ODOS) OD subretinal hm OS sl progression lesion
FAG(OU) FAG OD leak + OS leak – CNV + 2009.6.2 Intravit. avastin inj.(OD) by St. 김규섭 2009.7.7 Intravit. avastin inj.(OD) by St. 김규섭
Dx )Choroidal rupture (OU) CNV (OD) 2009.6.2 Intravit. avastin inj.(OD) 2009.7.7 Intravit. avastin inj.(OD)
Choroidal rupture R3 임성아/Ap.박영훈
Uvea pigmented, vascular structure Consisting of the iris, ciliary body, Choroid *Eye blood supply : from anterior and posterior ciliary branches of the ophthalmic artery
Choroid Middle coat of the posterior part of eye Extends from the ora serrata to the optic nerve Attached to the sclera by connective tissue (especially posteriorly) Ant. –horizontal , Post –vertical attachement 4 layers : suprachoroid ( no vessel except passing) stroma( large artery & vein) choriocapillaris Bruch’s membrane 맥락막 박리/ 출혈은 적도부 앞쪽에서 시작
Choroid circulation Role -nourishment of photo R & the RPE complex. - heat sink - mechanical cushion Choriocapillaris - lobular structure - segmental filling - little or no functional communication between adjacent capillary lobules
MAJOR DIFFERENCES BETWEEN THE RETINAL AND CHOROIDAL CIRCULATORY SYSTEMS 맥락막은 자가 조절의 능력이 없어 안압변화가 있을때 즉각적으로 보상이 된지 않아 맥락막 박리나 포도막 유출이 발생 당뇨와 같이 교감신경 손상시 맥락막 순환 압력상승으로 edema 발생가능
Sclera – strong Retina – stretching Bruch’s memb, RPE, Choroid - easily compressed and distorted, like a sponge
Choroidal rupture Direct rupture -stab wound -anterior at the impact site -parallel with ora serrata -less common Indirect rupture -compression injury -opposite site of impact -more common Illustration of the pathophysiology of a choroidal rupture. A. In blunt trauma to the eye, the globe becomes rapidly compressed anteroposteriorly. B. The choroid is relatively anchored to the sclera at the equator by the vortex veins. As the equatorial scleral diameter is rapidly increased by the ocular distortion, the choroid, Bruch's membrane, and retinal pigment epithelium become stretched so rapidly that a break forms in these layers, usually concentric to the optic nerve.
Pathophysiology A. Initially, Hemorrhage and edema -obscured choroidal rupture -will resolve B. Reactive fibrovascular hyperplasia -heavily pigmented appearance ( If RPE rupture, RPE hyperplasia sensory retina invasion) C. Later , white, crescent-shaped, vertical streak of underlying sclera Direct or contrecoup injury can precipitate a choroidal rupture. Hemorrhage and edema may be present initially, but will resolve. Typically, reactive hyperplasia gives the rupture a heavily pigmented appearance. Often, the overlying retina is undisturbed in choroidal rupture. However, if the RPE is disturbed and becomes hyperplastic and invades the sensory retina, visual dysfunction ensues. Due to the subsequent disruption of Bruch’s membrane that occurs in choroidal rupture, choroidal neovascular membranes may develop within the rupture. This may be a late development that can occur up to five years after the precipitating trauma.
Visual prognosis As the retina overlying a choroidal rupture may be unaffected, excellent visual function Location of rupture – fovea or not Late CNVM -Sub-retinal hemorrhage As the retina overlying a choroidal rupture may be unaffected, patients may retain excellent visual function and present asymptomatically years after the trauma. A patient may have a rupture between the disc and macula, yet retain normal acuity.
Management no direct intervention in the acute phase of choroidal rupture Fundus exam. for at least five years for CNVM within the rupture scar (serial monitoring for glaucoma, cataract, and retinal breaks) There is no direct intervention in the acute phase of choroidal rupture. Educate patients about their condition and prescribe protective eye wear. Monitor the patient funduscopically for at least five years for the development of choroidal neovascularization within the rupture scar. Any late bleeding should receive a fluorescein angiogram to determine if a choroidal neovascular membrane has developed. Choroidal neovascular membranes resulting from choroidal rupture have a tendency to spontaneously involute. For this reason, laser photocoagulation is indicated only if there is imminent threat to vision.
Thank you for your attention !