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Diabetic retinopathy screening NSF-based training Anatomy and physiology Tunde Peto Head of Reading Centre Anatomy and physiology of the normal human eye Key issues for discussion • Review the gross anatomical structures within and related to the eyeball and discuss their basic function • Review the basic physiology of refraction and vision Learning outcome • Identify the different structures of the eye and discuss their basic function • Identify different anatomical structures on teaching slides Basic Science in relation to eye disease: the normal retina and vision Key issues for discussion • The normal anatomy of the retina • Photoreceptors and their biochemistry • Physiology of vision including colour vision Learning outcome • Identify normal retinal structure on teaching slides Vision • Reflected light translated into mental image • Pupil limits light, lens focuses light • Retinal rods and cones are photoreceptors Figure 10-36: Photoreceptors in the fovea Photoreceptors • Rods – monochromatic, provide night vision: most numerous in periphery, sees all shades of grey and white; see in dark and around us • Peripheral changes might not affect the vision at all • Laser treatment and retinal detachment might result in visual field loss • Cones – red, green, & blue; color & details, most numerous in macula; you need very few for good vision! Photoreception and Local Integration Figure 10-35: ANATOMY SUMMARY: The Retina Retina: More Detail Figure 10-38: Photoreceptors: rods and cones Vision: Integration of Signals to Perception • Bipolar • Ganglion – Movement – Color • • • • • Optic nerve Optic chiasm Optic tract Thalamus Visual cortex Figure 10-29b, c: Neural pathways for vision and the papillary reflex The aging retina: Age Related Maculopathy (ARM) and Macula Degeneration (AMD) Key issues for discussion • Normal changes in the aging retina • Abnormal changes in the aging retina • The constituents of drusen • Geographic atrophy • Neovascular AMD Learning outcome • Identify age related changes in the retina • Identify and discuss different types of drusen • Identify geographic atrophy • Identify and discuss the main features of neovascular AMD Hard drusen (<63 mikron) Normal SLO image Hard and intermediate soft drusen (63-125 mikron) Large soft Drusen on the posterior pole Watch it developing over the years 2 years later 5 years later 7 years later 10 years later: some areas atrophied Geographic Atrophy Neovascular membrane at the fovea Neovascular membrane at the fovea FFA of the neovascular membranes: R eye: occult, L eye classic membrane Right eye: occult membrane Left eye: classic membrane Fibrovascular scar and secondary atrophy Neovascular membrane on SLO imaging Pigment epithelial detachment: colour image Pigment epithelial detachment on FFA Pigment epithelial detachment: SLO image Vascular occlusion Key issues for discussion • Learn normal vasculature of the eye • Discuss most common systemic causes of vascular problems in the eye • Discuss vein occlusion • Discuss arterial occlusion • Discuss clinical implications of these diseases Learning outcome • Identify normal and abnormal vascular structures in the eye on teaching slides • Identify strategies to deal with these diseases Central retinal vein occlusion: Introduction • • • • dilated, tortuous veins & haems in all 4 quadrants ischaemic (iCRVO) vs. non ischaemic (niCRVO) ischaemic = non perfused, haemorrhagic non-ischaemic = perfused, venous stasis retinopathy Epidemiology (EDCCS) • 2 per 1000 > 40 years, 5.5 per 1000 > 64 years • 33% ischaemic, 67% non ischaemic • 13% < 45 years, 11% 45-54 years, 76% > 55 years Clinical features • reduced visual acuity • RAPD • retinal predictors of ischaemia – degree of intraretinal haemorrhage – venous dilatation – venous tortuosity • as chronicity develops – IRMA, microaneurysms, collateral vessels Complications • macular oedema, ischaemia • NVE / NVD (6-7%) • iris neovascularisation (NVI), neovascular glaucoma (NVG) (21%) • cilioretinal artery occlusion • combined with CRAO Large areas of ischaemia on FFA Iris neovascularisation Comined with CRAO: cherry red spot with white macula Classification • ischaemic vs non-ischaemic – two ends of a spectrum – elderly: if severe, retinal capillaries decompensate, iCRVO – young: if mild or moderate, retinal capillaries withstand increased venous pressure, niCRVO • young vs old – 40 yrs, 64% final VA 6/9 – > 40 yrs, 40% iCRVO Good perfusion on FFA Poor peripheral perfusion on FFA Differential diagnosis • Anterior ischaemic optic neuropathy / optic neuritis / optic nerve invasion • asymmetrical diabetic retinopathy • ocular ischaemic syndrome • severe anaemia, leukaemia • Waldenstroms macroglobulinaemia • carotico-cavernous fistula Branch retinal vein occlusion • A cause should be found for it! • Most common caused: diabetes mellitus, hypertension and lipid abnormalities • Investigations need to be done by the referring physician, not in screening setting, however, you need to notify the physician • You will find asymptomatic old BRVO-s in screening setting Embolic disease: local protocol, but requires GP notification so risk factors for stroke and sight threatening disease can be addressed The normal optic nerve and its pathological changes Key issues for discussion • Learn the normal anatomy of the optic nerve • Discuss the function of the optic nerve and its connection to the brain • Discuss major illnesses affecting the optic nerve • Discuss the main features of the glaucomatous changes of the optic nerve Learning outcome • Identify the main features of the optic nerve and discuss the function • Identify normal optic nerve on teaching slides • Identify the main features of the diseases optic nerve The Normal Optic Nerve Head • The optic nerve head can be imagined as a ‘plug-hole’ down which over 1 million nerve fibres descend through a sieve-like sheet known as the lamina cribrosa. These fibres are then bundled together behind the eye as the optic nerve which continues towards the brain. • The retinal nerve fibres are spread unevenly across the surface of the retina in a thin layer. As the nerve fibres converge on the edge of the disc they pour over the scleral ring and then down its inner surface. This dense packing of nerve fibres just inside the scleral ring is visualized as the neuroretinal rim. • The inner (with respect to the centre of the optic nerve head) edge of this neuroretinal rim marks the most central of the nerve fibres. This edge is usually sloped, yet may be range from an overhang to vertical to a gentle slope towards the centre of the disc. This inner edge marks the cup edge. Scleral Ring Outer edge Inner edge (outer edge of disc or neuroretinal rim Neuro-retinal rim Cup Edge Change in direction of blood vessel The Scleral Ring • This ring is usually pale allowing it to be distinguished from the neuroretinal rim tissue which is pink. The ring may not be visible in a given disc image, or the visibility may vary in different areas of the circumference of the disc. It is often easier to see on the temporal side of the disc than on the nasal side. Scleral ring As vessels bridge the scleral ring, they often make a slight change in direction (black arrow) which may be a clue to its inner edge, Inner The change in colour is also evident in this case (arrows mark inner and outer edges) Blurring of the image may occur due to media opacity or resolution of the image- this can make appreciation of the anatomy difficult. Outer The Cup edge • • • • • This is undoubtedly the most difficult contour to identify, and is subject to more variability than the disc edge. The inner edge of the neuroretinal rim (=cup edge) may be sloped (especially on the temporal side of the disc) or vertical. In some cases the edge may be an overhang. The most effective way of drawing this ring is to identify certain points on the cup edge where you are sure of its location, and then using a dot-to-dot procedure link up these points into a ring. First look for a blood vessel, preferably a small to medium-sized one (large vessels do not hug the surface and may not be tethered to the surface and therefore are unhelpful). Trace its path across the scleral ring and then over the rim tissue- at some point it will change direction as it bends inward towards the centre of the disc. If the slope is shallow this will be a gradual change in direction, however if vertical it will be an obvious bend, and in the case of an overhang it will suddenly disappear from view. It is the point of maximum change of direction of the vessel that marks the cup edge. When viewing the disc in stereo, the edge of the cup can often be clearly seen in areas where there are no vessels as a guide. There can be a temptation to mark the cup edge where the colour changes from the pink of the rim to the pallor of the cup. In many situations this would be correct, yet in some situations the edge of pallor is not necessarily the edge of the cup, and hence it is better to rely on vessels and stereo cues as described above. The following images illustrate these points. The cup edge The Cup Edge: 3 blood vessels here show the edge of the cup: The points of maximum inflection (bend) are marked by arrows. The cup edge Cup Edge: In this very clear image, the arrows mark the cup edge. This illustrates that occasionally large vessels may obscure the edge from view, and in this case one should mark points of certainty either side of the vessel and link these up. Optic nerve head assessment Dr. Patricio Schlottmann Research Fellow Glaucoma Research Unit Overview • Glaucoma definition • Anatomy • Risk factors • Cup/disc Definition • Glaucoma is a chronic, progressive optic neuropathy that manifests by a characteristic Visual Field loss and distinctive structural changes recognizable at the level of the Optic nerve head or the Retinal Nerve Fibre Layer (RNFL) Definition • Chronic: having a progressive course of indefinite duration • Progressive: tending to become more severe • Optic neuropathy: disease of the of the optic nerve Definition • Optic neuropathy – The ganglion cells and their axons are the damaged structures – Other cells within the retina are also affected Anatomy Anatomy Risk Factors • Major risk factors for developing glaucoma are: • 1. elevated intraocular pressure • 2. African descent • 3. family history of glaucoma • 4. increased age Risk factors • Elevated intraocular pressure Risk factors • African derived individuals – – – – Glaucoma is 4 times more prevalent Is usually more severe Starts at earlier age Progresses more rapidly Risk Factors • Family history of glaucoma – A first degree relative affected by glaucoma increases the risk of developing the disease in the future – Patients should be questioned about the severity of glaucoma in the affected relative Risk Factors • Increased age – Prevalence increases with age – It is 10% of subjects over 80 years Cup/disc • Definition – Relationship between cup area and disc area Disc Cup Cup/disc • Examples 0.1 0.7 0.3 0.5 0.8 0.95 What to look for? • Large cup/disc – >0.7-0.8 • Asymmetry – >0.2-0.3 between eyes • Haemorrhages What to look for? • Notches – Focal loss of fibres • Areas of thinning – Diffuse thinning of the rim Screening for glaucoma • Too many false positives – 2% subjects over 40 – Advanced condition is easier to diagnose What to do with a suspect? • They will need referral to eye department – Phenotyping – Decision on treatment or observation Phenotyping • Complete evaluation of the patient – Medical history – Risk factors – Medications – Scans – VF – Clinical examination w/dilation 3 hours visit Examples Examples Examples Examples