1. Medical Retina and Macular Diseases
Dr. Timothy Y. Y. Lai
MBBS, MMedSc, MRCSEd, FCOphthHK, FHKAM(Ophth)
Department of Ophthalmology and Visual Sciences
The Chinese University of Hong Kong

2. Medical Retina
A specialty that deals with the investigation and non-surgical treatment of retinal disorders
Retinal diseases associated with systemic diseases
Diabetic Retinopathy
Hypertensive Retinopathy
Vascular retinopathies
Medical macular diseases
Age-related Macular Degeneration

3. Retinal Diseases Associated with Systemic Diseases

4. Diabetic Retinopathy One of the leading causes of blindness
Risk factors
Duration of diabetes
80% of type I and 70% of type II diabetics have retinopathy after 15 yrs
Type of diabetes mellitus
Control of hyperglycemia
Hypertension
Associated renal disease
Pregnancy

5. Diabetic Retinopathy Classification Non-proliferative (NPDR)
Mild
Moderate
Severe
Proliferative (PDR)

6. Non-proliferative Diabetic Retinopathy (NPDR)
Pathogenesis
Microvascular disease causing capillary damage
Leakage of blood constituents into the retina
Retinal hemorrhages
Retinal edema
Lipid exudation

7. Non-proliferative Diabetic Retinopathy (NPDR)
Dot and blot hemorrhage
Hard exudate
Cotton-wool spots
Venous beading
Venous loops

8. Non-proliferative Diabetic Retinopathy (NPDR)  

9. Progression from NPDR to PDR
Stage
Progression to PDR
in 1 year
Mild NPDR
<5%
Moderate NPDR
20%
Severe NPDR
50%

10. Proliferative Diabetic Retinopathy (PDR)
Pathogenesis
Retinal ischemia causing neovascularization
May be asymptomatic if only neovascularization without hemorrhage

11. Neovascularization at Disc Neovascularization elsewhere
(NVD)
Neovascularization elsewhere
(NVE)

12. Causes of Visual Loss in DR
Macular Edema
Complications of PDR
Vitreous hemorrhage
Fibrous tissue proliferation
Retinal detachment

13. Microaneurysms
Circinate exudate
Retinal edema

14. Vitreous Hemorrhage
Tractional Retinal Detachment
Combined
Retinal Detachment

15. Diabetic Retinopathy Treatment Laser photocoagulation
Focal or grid: for macular edema
Pan-retinal photocoagulation: for PDR
Control of systemic disease
Hyperglycemia
Hypertension
Renal disease
Vitreous surgery

16. Laser Photocoagulation
Outpatient procedure
Topical Anesthesia
Multiple Sessions
In PDR, laser should be performed before
vitreous hemorrhage and retinal detachment develops

17. Diabetic Retinopathy
Early identification of the disease and prompt referral to the ophthalmologist
Dilate your patients for examination with ophthalmoscope regularly
Prompt treatment reduces risk of visual loss by 50%
Patients may be asymptomatic but still have advanced PDR

18. Hypertensive Retinopathy
Focal or generalized narrowing of retinal arteries associated with hypertension
Clinical features
Cotton-wool spots
Hard exudates
Macular star
Macular edema
Retinal hemorrhage
Optic disc swelling

19. Hypertensive Retinopathy
Grade
Ophthalmoscopy Features 1
Mild arteriolar narrowing (copper-wiring) 2
Marked arteriolar narrowing with deflection of veins at AV crossing (silver wiring and AV nipping) 3
2 + Flame-shaped hemorrhage, cotton-wool spots 4
3 + Disc swelling

21. Severe Hypertensive Retinopathy
Macular star
Disc swelling

22. Hypertensive Retinopathy
Management
Rule out secondary hypertension
Control of hypertension

23. Vascular Retinopathies

24. Retinal Vascular Occlusions
Venous occlusion more common than arterial occlusion
Pathogenesis
Arterial occlusion – embolus
Central retinal artery occlusion (CRAO)
Branch retinal artery occlusion (BRAO)
Venous occlusion – abnormal blood flow
Central Retinal Vein Occlusion (CRVO)
Branch Retinal Vein Occlusion (BRVO)

25. Retinal Arterial Occlusions
Symptoms
Sudden, painless, marked loss of vision
Immediate treatment within hours may be beneficial in some patients
Systemic Associations
Cardiovascular disease
Carotid artery disease
Temporal arteritis / inflammatory arteritis
Coagulopathies

26. Central Retinal Artery Occlusion
Afferent Pupillary Defect
Cherry Red Spot
Retinal Edema
Branch Retinal Artery Occlusion

27. Retinal Venous Occlusions
Symptoms
Sudden painless loss of vision
Various extent of visual loss
Systemic Associations
Diabetes Mellitus
Hypertension
Hematological diseases
Vasculitis

28. Central Retinal Vein Occlusion
Branch Retinal Vein Occlusion

29. Laser photocoagulation
Macular edema
Neovascular glaucoma
Laser photocoagulation

30. Macular Diseases

31. Where is the macula? Choroid 鞏膜 Sclera 視網膜 Retina 角膜 Cornea 黃斑區 Macula
脈絡膜
Choroid 鞏膜
Sclera
視網膜
Retina 角膜
Cornea
黃斑區
Macula 晶體
Lens
Iris 虹膜
視神經
Optic nerve
Cilliary body
睫狀體

32. Fovea
Macula

33. Macular Diseases Common surgical macular diseases
Macular hole
Epiretinal membrane
Common medical macular diseases
Age-related macular degeneration (AMD)
Myopic maculopathy
Central serous chorioretinopathy (CSC)

34. Age-related Macular Degeneration (AMD)
Leading cause of severe vision loss in people > 50 years in the western world
Visual loss due to drusens / RPE degeneration or development choroidal neovascularization (CNV)

35. Age-related Macular Degeneration (AMD)
Two forms
Dry (non-neovascular) AMD (80% to 90%)
Wet (neovascular) AMD (10% to 20%)
90% of vision loss is caused by wet form of AMD

36. Decrease in color and contrast sensitivity
Symptoms of AMD – Early
Decrease in color and contrast sensitivity

37. Symptoms of AMD – Intermediate
Impairment of central visual function

38. Symptoms of AMD – Intermediate
Metamorphopsia,
distortion of central image

39. Symptoms of AMD – Late
Central Scotoma

40. Hallmark of AMD Development of Drusen
Bruch’s Membrane
Drusen

41. Early Dry AMD Asymptomatic
Examination reveals several small drusen or a few medium-sized drusen (63-124m)

42. Intermediate Dry AMD
Many medium-sized drusen or 1 large drusen (>125m)
Vision may be impaired

43. Advanced Dry AMD More severe visual impairment
Presence of drusen with degeneration of RPE
Geographic atrophy

44. Dry AMD  Wet AMD Formation of New Vessels
Choroidal Neovascularization

45. Diagnosis Vision function testing Ophthalmolscopy
Visual acuity
Amsler grid
Ophthalmolscopy
Fluorescein angiography

46. Early Diagnosis Amsler Grid Ask the following questions:
Adequate lighting
Wear reading glasses
Hold the Amsler grid at normal reading distance (about 30cm)
Cover one eye at a time
Stare at the center dot
Ask the following questions:
Are any of the lines wavy, missing, blurry, or discolored?
Are any of the boxes different in size or shape from the others?
5mm squares
10 cm x 10 cm

47. Self monitoring with Amsler Grid
Visual aids
Self monitoring with Amsler Grid
Normal Abnormal

48. Fluorescein angiography
Intravenous injection
Uptake of fluorescein dye at the site of abnormal vessels
- Size, Location, Activity

49. Management of AMD Treatment for neovascular AMD
Laser photocoagulation
Submacular surgery
Photodynamic therapy (PDT) with Verteporfin
Anti-angiogenesis therapy (Anti-VEGF)
Prevent progression to advanced AMD
Antioxidants
Quit smoking
Low-vision aids

50. Laser Photocoagulation
Non-selective thermal laser photocoagulation
Destroy CNV
Irreversible damage to the overlying retina and RPE
Side effects of immediate scotoma or drop in central vision
CNV persist or recur in 50% of patients

51. PDT with Verteporfin Step 2: Step 1: Nonthermal Laser Infusion
Application
Step 1:
Infusion

52. Mechanisms of action 1 2 Chain of reactions  vessel thrombosis
Non-thermal Laser 1
Drug infusion

53. .

54. High dose AREDS supplements
Beta-carotene
Vitamin A
Vitamin C
Vitamin E
Zinc
Copper
Decrease risk of progression from dry to wet AMD

55. Smoking and AMD Most important risk factors for AMD
Smokers have 300% to 400% more risk in developing AMD than non-smokers
Even passive smoking increase the risk of AMD by 30% to 40%

56. Prevention is better than cure
Increasing prevalence of AMD due to aging and western life-style
Recognize and correct risk factors
Quit smoking
Healthy diet
Self screening test in high-risk group
Regular dilated fundus examination to evaluate AMD findings
Early diagnosis is the key to save vision

57. Thank You