This document provides an overview of vitreoretinal pathology, including techniques for indirect ophthalmoscopy, treatment of retinal breaks and detachments, and features of pathological myopia. Key topics covered include examining the fundus using indirect ophthalmoscopy, assessing and managing retinal breaks and detachments, and ocular and systemic associations of high myopia such as Stickler syndrome, Marfan syndrome, and Ehlers-Danlos syndrome.

1. VITREORETINAL
PATHOLOGY
Mr A Manna –
http://about.me/ashmanna
Vitreoretinal ASTO – Wolverhampton
Eye Infirmary
28 August 2012

2. CONTENTS
► Indirect Ophthalmoscopy
► Technique
► Retinal Breaks
► Treatment
► Retinal Detachment
► Assessment
► Pathological Myopia
► Ocular and systemic features

3. INDIRECT
OPHTHALMOSCOPY

4. ► Introduce yourself.
INDIRECT
OPHTHALMOSCOPY

5. ► Observe external cues:
► High myopic glasses: myopic
degeneration, staphyloma, laser for retinal
tear
► Hearing aid: RP
► Etc.
INDIRECT
OPHTHALMOSCOPY

6. ► Lie patient on couch
► Make sure enough room to move around
patient
INDIRECT
OPHTHALMOSCOPY

7. ► Adjust everything:
► Headband
► IPD: adjust by shining light on back of
hand
► Dim room lights
► Make sure you use the 28D or 20D lens
the right way up
INDIRECT
OPHTHALMOSCOPY

8. ► Look at the fundus:
► Move lens away from eye until stereoscopic
image obtained (5cm for 20D lens)
► Tilt lens to reduce reflections
INDIRECT
OPHTHALMOSCOPY

9. ► Examine:
► Optic Disc
► Retinal Vessels
► Macula
► Peripheral retina in all cardinal positions
INDIRECT
OPHTHALMOSCOPY

10. ► Indent:
► To view between equator (14mm
from limbus) and pars plana (Spiral of
Tillaux)
INDIRECT
OPHTHALMOSCOPY

14. ► Draw: (useful to have notes upside down)
► Red: retinal arterioles, retinal haemorrhage,
microaneurysms, neovascularisation, retinal
break
► Blue: retinal venules, detached retina, outline of
retinal break or hole
► Yellow: exudate, oedema
► Green: vitreous opacity (e.g. haemorrhage)
► Brown: pigmentation, detached choroid
► Black: ora serrata, drusen, hyperpigmentation
INDIRECT
OPHTHALMOSCOPY

16. http://www.volk.com/main/compare/indirectbio.html
Lens Magnifica Field of Image Principal
tion view use
+14 BIO 4x 40o Inverted, Fundus
Reversed, lesion
Real
+20 BIO 3x 45o Routine
examinati
on
+30 BIO 2x 50o Child,
small
pupil,
media
opacity
INDIRECT
OPHTHALMOSCOPY

17. Done!
INDIRECT
OPHTHALMOSCOPY

18. ► What to treat?
RETINAL TEARS

20. ► Treat all symptomatic tears/holes
► Notes to VR Consultant
► If low risk, discharge with Retinal Detachment
Warning
► If treatment not complete, ring me and I will
complete treatment within a week
► My job is twofold:
► Laser up to ora
► Look for other breaks
RETINAL TEARS

21. ► Anything that doesn’t need lasering?
RETINAL TEARS

22. ► Tear more dangerous than Hole
► Pigmentation is reassuring
► Symptomatic breaks more dangerous than incidental finding
► Worrying factors:
► Cataract surgery esp. with vitreous loss
► Myope
► FHx RD
► Marfan, Stickler, Ehlers-Danlos
RETINAL TEARS

26. RETINAL DETACHMENT

27. ► What the Vitreoretinal Surgeon wants to know:
► History (symptoms, duration, VF defect, trauma), vision, POH,
Myopia, Systemic Conditions (connective tissue disease,
suitability for GA), FHx RD, Tobacco dust, extent of RD (clock
hours, how close to macula, shallow, bullous, dome), Is the
retina translucent? Are there lines of pigment around the
detachment? Does the fellow eye have Retinoschisis? If mac-
on, keep NBM for now (just in case). DO NOT promise
immediate surgery!!!
RETINAL DETACHMENT

34. HIGH MYOPIA

39. ► 1. NBM
► 2. DO NOT promise immediate surgery. Consent "Right/Left Retinal
Detachment Repair".
► 3. Admit to D4
► 4. Is patient happy for LA instead of GA?
► 5. Nurses to phone Nucleus Theatres to see what's on the emergency list.
► 6. Inform on-call theatre staff and ask if surgery next morning (07:30) is an
option.
► 7. Take 2 patient stickers to Nucleus Theatres and book the case for tonight
AND tomorrow morning.
WHAT TO DO WHILE
WAITING

41. ► Dialysis, trauma related, young patient, avulsion of vitreous base may give
bucket-handle. If no RD, laser. If RD, usualy progress slowly due to healthy
vitreous gel in young individuals.

42. Don’t miss the elephant in the room

46. ► Convex, smooth (not corrugated)
► Mobile, with ‘shifting fluid’ phenomenon
► Systemic disease: Harada disease, toxaemia of
pregnancy
EXUDATIVE RD

47. ► Causes:
► Choroidal tumours: melanomas, haemangiomas,
metastases
► Inflammation: Harada, scleritis
► Bullous CSR: rare
► Iatrogenic: RD surgery, PRP
► CNVM
► Hypertensive choroidopathy: toxaemia of pregnancy
► Idiopathic: Uveal effusion syndrome
EXUDATIVE RD

50. ► Grade A (minimal) PVR: diffuse vitreous haze and
tobacco dust. Pigmented clumps under retina.
► Grade B (moderate) PVR: wrinkling of inner retinal
surface, tortuosity of blood vessels, retinal
stiffness, decreased mobility of vitreous gel, rolled
edges of retinal breaks
► Grade C (marked) PVR: full thickness rigid retinal
folds. Heavy vitreous condensation and strands.
Described as Anterior/Posterior + Clock hours.
PVR IN LONGSTANDING RDS

51. HIGH MYOPIA

52. ► Refractive error > -6D and axial length > 26mm
► 0.5% of population
► Maculopathy commonest cause of visual loss
HIGH MYOPIA

53. Pale tessellate (tigroid) appearance due to diffuse attenuation of the RPE with
visibility of large choroidal vessels.

54. Focal chorioretinal atrophy characterised by visibility of the larger choroidal
vessels and eventually the sclera

55. ‘Lacquer cracks’ consist of ruptures in the RPE-Bruch membrane-choriocapillaris
complex characterised by fine, irregular, yelow lines, often branching and criss-
crossing at the posterior pole

56. Fuchs spot is a raised, circular, pigmented lesion that may develop after a
macular haemorrhage has absorbed

57. Subretinal ‘coin’ haemorrhages, which may be intermittent, may develop from
lacquer cracks in the absence of CNV

58. Staphylomas are due to expansion of the globe and scleral thinning. They may
be peripapillary or involve the posterior pole and be associated with macular
hole formation.

59. ► Foveal retinoschisis: in the absence of macular hole.
► Peripapillary detachment: asymptomatic, innocuous,
yellow-orange elevation of the RPE and sensory
retina at the inferior border of the myopic conus.
HIGH MYOPIA

60. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
► Systemic:
► Stickler
► Marfan
► Ehlers-Danlos
► Pierre-Robin
HIGH MYOPIA

61. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Stickler Syndrome
► Stickler Hereditary arthro-ophthalmopathy
► Marfan Abnormal vitreous
► Ehlers-Danlos High myopia
► Pierre-Robin Orofacial abnormality
Deafness
Arthropathy
Mitral valve prolapse
AD inheritance with variable expressivity
HIGH MYOPIA Commonest inherited cause of retinal
detachment in children.

62. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Marfan Syndrome
► Stickler Connective tissue disorder – mutation of fibrillin
► Marfan gene on chromosome 15q.
► Ehlers-Danlos Tall, thin, long limbs compared with trunk
► Pierre-Robin Arachnodactyly, joint hypermobility
Gothic palate
Dilatation of ascending aorta, aortic
incompetence, heart failure, mitral valve
disease, aortic dissection
HIGH MYOPIA Ectopia lentis, myopia, RD
AD inheritance with variable expressivity.

63. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Ehlers-Danlos syndrome type 6
► Stickler 9 subtypes, but only type 4 and 6 affect the
► Marfan eye.
► Ehlers-Danlos Rare, usually AR disorder of collagen caused by
► Pierre-Robin deficiency of procollagen lysyl hydroxylase.
Thin hyperelastic skin.
Hypermobile joints.
Cardiovascular disease: bleeding diathesis,
HIGH MYOPIA dissecting aneurysms, spontaneous rupture of
large blood vessels, mitral valve prolapse
Ocular fragility with increased vulnerability to
mild trauma, high myopia, retinal detachment,
keratoconus

64. ► Associations:
► Cataract
► POAG
► Pigmentary glaucoma
► ROP can be related to subsequent high myopia
► Amblyopia uncommon, but can be there due to
anisometropia
Systemic:
►
Pierre-Robin syndrome
► Stickler
► Marfan Micrognathia, small tongue, cleft soft palate,
► Ehlers-Danlos high-arched palate.
► Pierre-Robin
Jaw that is very small with small (receding) chin
Jaw that is far back in the throat
Repeated ear infections
Small opening in the roof of the mouth, which
HIGH MYOPIA causes choking
Teeth that appear when the baby is born (natal
teeth)
Tongue that is large compared to the jaw