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RETINAL VASCULAR DISEASES Prof. Dr. Şengül Özdek www.sengulozdek.com

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Page 1: RETINAL VASCULAR DISEASESankararetina.com › wp-content › uploads › 2016 › 10 › Retinal-Vascula… · CRVO . Exudates Hard exudate Soft exudate Leakage of capillary →absorb

RETINAL VASCULAR DISEASES

Prof. Dr. Şengül Özdek www.sengulozdek.com

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Retinal Vein Occlusions

Retinal Artery Occlusions

Diabetic Retinopathy

Retinal Vasculitis (Behçet, Eales etc)

Retinal telangiectasis (Coats diesase)

ROP

Age Related Macular Degeneration

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Histology of retina

Internal limiting membrane

Nerve fiber layer

Ganglion cell layer

Inner plexiform layer

Inner nuclear layer

Outer plexiform layer

Outer nulear layer

External limiting membrane

photoreceptor

RPE

Bruch’s membrane

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Retinal Vasculature

inner layer→ central retinal vascular

system

outer layer→ choroid (ciliary vascular

system)

macula lutea→ choriocapillaries!

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Retinal Barriers

Inner barrier (blood–retina barrier): retinal

capillary endothelium

Outer barrier (choroid-retina barrier): zonula

occludens between the RPE, RPE- Bruch’s

membrane- choriocapillaries complex

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Symptoms

Visual impairment

Metamorphopsia

Macropsia / Micropsia

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Signs

Edema

Hemorrhage

Exudation

Neovascularization

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Signs

Intracellular edema

Extracellular edema

Cystoid macular edema

Retinal artery occlusion:

ischemia leads to edema

of bipolar cell, ganglion and RNFL

Capillary endothelium injury and

exudation

Henle’s fibers are radically located;

This pooling forms a flower-petal pattern.

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Retinal Edema

Intracellular edema

CRAO

Extracellular edema

CRVO

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Exudates Hard exudate

Soft exudate

Leakage of capillary →absorb →

deposition of lipid in outer plexiform layer

“Cotton-wool spot”

Precapillary arteriole occlusion→

axoplasmic transport blocked→organelles stack

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Cotton-wool spot

Hard exudate (Diabetic retinopathy)

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Hemorrhage

Subretinal hemorrhage

Retinal hemorrhage

Preretinal hemorrhage

Vitreous hemorrhage

Located in under retina,

mostly the source is choroid

Located in nerve fiber layer

Line, strip, flame-like, bright

red

Crescent-shaped hematocele

with transverse section

Profuse preretinal

hemorrhage into the vitreous

or hemorrhage of retinal

neospastic vasculature

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Neovascularization

Retinal ischemia

VEGF

neovascularization

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Blood vessel change

Atherosclerosis, stenosis, occlusion

Tortuous vein, dilated vein, bead-like

change

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Microaneurysm

A-v cross sign

Vessel white sheath

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CENTRAL RETINAL ARTERY

OCCLUSION

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Causes

Atherosclerosis-related thrombus

Emboli:

Carotid: arheroma plaques

Cardiac: (calcific valvular or mural thrombosis in atrial fibrillation)

Aortic

Inflammatory: Giant cell arteritis, SLE

Trauma,

Thrombophilic disorders:

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Signs-Symptoms

Sudden painless visual loss

Mostly Counting Fingers level

Examination: RAPD!

(Direct pupil reflex

Fundus!

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FFA

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Treatment

Vasodilator: antispasm or pushing thrombus to the smaller branch

Reducing IOP: Massage

anterior chamber paracentesis

CAI, Mannitol 20%

O2 inhalation: mixture of 95% oxygen &5% carbon dioxide

Fibrolytics: for patients suspect of thrombosiis: urokinase, tPA

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Prognosis

Poor

Treatment?

Only within first few hours

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CENTRAL/BRANCH RETINAL VEIN OCCLUSIONS

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Risk Factors

CRVO Systemic Hypertension Cardiovascular Disease Diabetes Mellitus POAG

BRVO Systemic Hypertension Cardiovascular Disease Glaucoma Increased Body Mass Index at 20 yrs old Hypercoaguable States

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Nonischemic vs Ischemic

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CRVO Nonischemic

CRVO ischemic

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Treatment

Antitrombotic agents?

Intravascular thrombolysis?

IV steroids

Triamcinolone

Dexamethasone implants

IV Anti-VEGFs

Bevacizumab

Ranibizumab

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Ischemic CRVO

Neovascularization: Iris&angle

Neovascular Glaucoma

Panretinal Laser Photocoagulation: PRP

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BRANCH RETINAL VEIN OCCLUSION (BRVO)

Page 38: RETINAL VASCULAR DISEASESankararetina.com › wp-content › uploads › 2016 › 10 › Retinal-Vascula… · CRVO . Exudates Hard exudate Soft exudate Leakage of capillary →absorb

Treatment

Grid Laser

Laser PC to ischemic areas if NVE (+)

IV steroids

Triamcinolone

Dexamethasone implants

IV Anti-VEGFs

Bevacizumab

Ranibizumab

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Prognosis

CRVO Approximately 30% ischemic (10 DD on FA)

NVG 40% to 60% of these eyes vs 5% Nonischemic

<10% developed retinal neovascularization

CVOS – 83% of undetermined developed ischemia or NVI

BRVO 1/3 to 1/2 recover VA of 20/40 or better w/o therapy

50% Ischemic (5 DD) of which 40% develop neovascularization; 60% of these develop VH

NVI Rare; 1%

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BRVO-Collaterals

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COATS DISEASE

Page 43: RETINAL VASCULAR DISEASESankararetina.com › wp-content › uploads › 2016 › 10 › Retinal-Vascula… · CRVO . Exudates Hard exudate Soft exudate Leakage of capillary →absorb

Unilateral gradual loss of vision

Predominantly in young males (1st decade)

Peak age of onset: 6-8 years

RD, NVG, Cataract, Leukocoria,

DD: Retinoblastoma

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Retinal Findings

Aneurismal and telangiectatic vessels

Breakdown of blood retinal barrier

Leakage of blood, serum, cholesterol to retina

Exudative RD….Loss of retinal red reflex

Loss of retinal capillary

Ischemia…. NV….NVG…

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Loss of retinal red reflex

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NOTICE!

DIFFERANTIATE FROM RETINOBLASTOMA!

Other DD:

ROP, FEVR

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Treatment

Laser PC

Cryotherapy

IV-Anti-VEGF

RD: Surgery: VRS

Enucleation

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PREMATURE RETINOPATHY

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Patogenez

Normal retinal vaskülerizasyon:

Nazal : 36 hf

Temporal: 40.hf.

İntrauterin retinal vaskülerizasyon:

rölatif hipoksik ortam

Prematürite: avasküler retina...

O2 ted.....VEGF down regülasyonu

Vaskülerizasyon duraklar.... Avasküler alandan

VEGF.... VEGF up regülasyonu… ROP

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Uluslararası ROP sınıflandırması (ICROP)

Parametreler

1. Zon (1,2,3)

2. Evre (1-5)

3. Yaygınlık (saat kadranı)

4. “Artı hastalık” varlığı

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ICROP

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Hastalığın yaygınlığı

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Evre 1: Demarkasyon hattı

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Evre 2

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Evre 2-3

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Evre III ROP Hafif-Orta-Şiddetli

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Evre 4

4a 4b 4b

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Evre 5

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Artı (plus) hastalık

Arka kutupta retinal vasküler dilatasyon ve tortuosite artışı

Aktif progresyon belirtisi

Çok hızlı ilerleme!....

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Zon 1, Artı hastalık (APROP)

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Tedavi endikasyonu (ICROP-revisited-2005)

zon I ROP: artı hastalık

(evre, yaygınlık önemsiz)

zon I ROP: evre 3 / artı hastalık (-)

zon II: evre 2 veya 3 / artı hastalık

International Committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol. 2005;123:991–999

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AP-ROP: Aggressive Posterior ROP (AP-ROP): ÇDDAP daha sık

Posterior yerleşim (Zone 1)

(+) hastalık

Evre önemsiz ve sınır genellikle belirsiz

72 saatte tedavi!...

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Tedavi öncesi ve sonrası

lazer

Anti- VEGF

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TARAMA

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Tarama AAP-AAO (2006 ROP Politikası)

<32hf ve <1500gr: Rutin tarama

1500-2000gr

>32 hf

Klinik gidiş stabil değilse

Kardiopulmoner destek ihtiyacı (+)

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Retina muayenesi

İlk muayene: Optimal zaman

**PP 4. hf veya PM 31. hf (hangisi daha geç ise)

Eşik veya eşik öncesi yüksek risk: 35-37hf

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TEDAVİ

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Krio - Lazer

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Zon 1 prematürite retinopatisinde tedavi sonuçları ve prognoz

Lazer tedavisi: Anatomik başarı >%90

Cerrahi tedavi: Anatomik başarı <%50

Tök L, Urgancıoğlu B, Özdek Ş, ve ark. Zon 1 prematürite retinopatisinde tedavi sonuçları ve prognoz. MN Oftalmoloji, 2008; 15(2): 101-105.

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Evre 4: Subtotal Retina dekolmanı a) extrafoveal b) foveayı da içine alan RD

TEDAVİ: CERRAHİ

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Çevresel Skleral Çökertme

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Vitrektomi

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Lens koruyucu vitrektomi

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Evre 5: Total retina dekolmanı: Lökokori

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Yeni tedaviler

Anti VEGF ajanlar (intravitreal)

Bevacizumab (Avastin/Altuzan)

Ranibizumab? (Lucentis)

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AGE RELATED MACULAR DEGENERATION

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ARMD

DRY WET

NEOVASCULAR or EXUDATIVE ARMD

EARLY VS ADVANCED DISEASE

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Risk Factors

Age >55y

Genetic predisposition: Family history

Cigarettes smoking

HT

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Signs&Symptoms

Metamorphopsia

Central scotoma

Visual loss

FUNDUS: Drusen, RPE atrophy

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Drusen Histopathology

• Small well-defined spots

• Usually innocuous

• Larger, ill-defined spots

• May enlarge and coalesce

Soft Hard

• Increased risk of AMD

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Diagnostic tests

Fundus Fluorescein Angiography (FFA)

Optic Coherence Tomography (OCT)

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FFA

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OCT

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OCT in wet ARMD

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OCT in Dry ARMD

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Advanced atrophic ARMD

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Management of Dry ARMD

Regular follow-up

Early visit if metamorphopsia develops

Anti-oxidant Vitamin-Fish oil intake to decrease the risk for neovascular ARMD

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Progression to wet type

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Neovascular ARMD

Rapidly progressive visual loss

Progressing central scotoma if untreated

Treatment:

IV-Anti-VEGF injections

PDT: rarely

Laser Photocoagulation?

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Treatment

IV Pharmacotherapy

IV Anti-VEGF:

Ranibizumab

Bevacizumab

Aflibercept (VEGF trap eye)

PDT: Rarely

Laser Photocoagulation??

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IV Injection

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Response to Anti-VEGF

%25-30: VEGF Responder: ilk 3 doz

yeterli

%65: VEGF Bağımlı

%5-10: VEGF Cevapsız

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VA:0.3…………………VA:1.0

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Treatment

VA: CF 1m

VA: 0.3

PDT+4xIVL

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Nonresponders-Hemorrhagic response

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DIABETIC RETINOPATHY

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DR-DMÖ

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PDR-NV

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Panretinal Laser Photocoagulation treatment