1. OVD of the retina CRAO Hypertensive retinopathy Ayesha S abdullah

2. Learning outcomes
By the end of this lecture the students would be able to
Diagnose CRAO on the basis of clinical presentation or on fundus photoraphic findings.
Identify risk factors and complication of CRAO.
Outline treatment of CRAO and describe the prognosis.
Diagnose hypertensive retinopathy on the basis of clinical data or signs in fundus photographs and correlate them with the underlying patho-physiological derangement
List the ocular complications of Hypertension and correlate them with the underlying patho-physiological processes

3. Hypertensive Retinopathy
Pathogenesis
Arteriosclerosis
Vasoconstriction- Arterial narrowing and closure
Cotton Wool Spots
Vascular leakage
Flame-shaped Hemorrhages
Retinal edema
Hard exudates
AV nipping
Choroidal changes-Infarcts

4. Symptoms Asymptomatic Reduced vision Sudden loss of vision
Visual disturbances

5. Signs- Arteriolar Narrowing- focal

6. Arteriolar Narrowing- Generalized

7. Copper wiring

9. AV crossing changes

11. Vascular Leakage Flame shaped haemorrahges Exudates Macular star
Swelling of the optic disc

12. Vascular Tortuosity

13. Cotton Wool Spots & macular star

14. Macular star

15. Disc Edema

16. Hypertensive Retinopathy

17. Hypertensive Eye Disease
Hypertensive Choroidopathy
(In young patients with acute hypertension.)
Elschnig spots
Siegrist streaks
Hypertensive Optic Neuropathy
Swelling, Ischemic Optic atrophy
Exudative Retinal Detachment
Other ocular problems?

18. Hypertensive Retinopathy -Grades

19. Choroidopathy

20. Case
a 54-year-old school teacher presented with acute visual loss in the left eye. He had history of uncontrolled hypertension and open angle glaucoma.
Ophthalmologic exam showed best corrected visual acuity (BCVA)of 6/9 OD, 6/60 OS . Pupil exam showed sluggish left pupil with relative afferent papillary defect, and a reactive pupil on the right side.
IOP: 11 mmHg in the right, and 24mmHg in the left.
Slit lamp exam showed normal anterior segments with open angles bilaterally.

22. What is the most likely diagnosis?
How many risk factors can you identify in this case?
What is the significance of relative afferent pupillary defect ?

23. Case 02- History ( )
A 65 year old man presented to the eye OPD with the complaints of sudden painless loss of vision in the left eye. He described the visual loss as seeing a black spot in his vision which spread over the entire visual field with in minutes. He didn’t have any pain or discomfort prior to his symptoms. He gave history of experiencing transient visual loss lasting for a minute or two for the past 06 months.
He was a known hypertensive and had history of Myocardial Infarction and CVA.

24. Physicals VA : (BCVA) 6/12 OD, HM OS Pupils: RAPD OS.
Fundus: normal OD, see photos OS
BP: 160/100 mm Hg
IOP 12 OD , 14 OS

28. Questions What is the most likely diagnosis?
Central Retinal Artery Occlusion
Is it a common disorder?
Fortunately, No (0.85/100,000/year)
Which part of the retina is affected?
Why the Cherry red spot?

29. Questions How severe could be the visual loss?
Loss of vision can be profound and permanent without immediate treatment. Irreversible retinal damage occurs after 90 minutes, but even 24 hours after symptoms begin, vision can still be partially restored
Why is it considered an ophthalmic emergency?

30. Who can be affected? Risk factors Age > 60 years
Male more than female
Arteriosclerois
Hypertension and other vascular disorders
CAD and angioplasty
Thromboembolic diseases
Glaucoma
Giant cell arteritis
Retinal migraine

31. Who can be affected? CATH Risk factors Systemic Ocular
CAD and angioplasty
Arteriosclerois
Thromboembolic diseases
Hypertension and other vascular disorders
Ocular
Glaucoma
Giant cell arteritis
Retinal migraine
Trauma
CATH

32. How can it be treated?
The goal of emergency treatment is to restore retinal blood flow
Ocular massage
Paracentesis
Lowering of the IOP through medications

33. How can it be treated?
There are no proven medical or surgical techniques for treating retinal artery occlusions
Oral vasodilators, intravenous fibrinolytic agents tried with varying success.
Anti VEGF, if neovascularization happens
Risk modification

34. Prognosis Over 90% have VA of CF or less at presentation
1/3rd retain some vision
NVI- upto 18%
NVD- 2%

35. Patent cilioretinal artery: A cilioretinal artery is present in 15–50% of eyes, providing the central macula with a second arterial supply derived from the posterior ciliary circulation. Its main importance is that when present it may facilitate preservation of central vision following central retinal artery occlusion

37. Cattle Trucking

38. The orange reflex from the intact choroid stands out at the thin foveola, in contrast to the surrounding pale retina, giving rise to a ‘cherry-red spot’ appearance. Over a few days to weeks the retinal cloudiness and ‘cherry-red spot’ gradually disappear although the arteries remain attenuated. Later signs include optic atrophy, vessel sheathing and patchy inner retinal atrophy and RPE changes

39. 1 2 3 4
1- CRVO
2- CRAO
3-BRAO
4-BRVO