Retina

Zarieh Dawn L. Novela Medicine 2

Retina

Layers of Retina
1. Pigment epithelium Derived from outer layer of optic cup Composed of single layer of polygonal cells Source of metabolic enzymes, as well as vit.A Phagocytosis of degenerated fragments of outer segment

Layers of Retina
1. Pigment epithelium It prevents light reflection throughout the eyeball w/o it, light rays would be reflected in all directions within the eyeball and would diffuse lighting of retina

Layers of Retina
2. Rods and Cones (photoreceptors) Outer segment
Contains light sensitive photochemicals converting light energy into chemical energy nerve impulse

Inner segment
Connected to outer segment by constriction containing cilia (w/c transmits impulses) Mitochondria: amplifies weak impulses

Layers of Retina
3. External limiting membrane Fenestrated membrane composed of terminal bars Formed by junctional attachment bw membrane of Mullers cells and inner segment of photoreceptors

Layers of Retina
4. Outer nuclear layer Composed of nuclei of photoreceptors 5. Outer plexiform layer Composed of axons of photoreceptors and dendrites of bipolar cells 6. Inner nuclear layer Composed of nuclei of several cells (bipolar, Muller, horizontal and amacrine cells)

6 5 4

Layers of Retina
9 8 7
7. Inner plexiform layer Composed of axons of bipolar cells and dendrites of ganglion cells 8. Ganglion cell layer Composed of ganglion cells 9. Nerve fiber layer Composed of axons of ganglion cells wc converge toward posterior pole of eye forming optic nerve

Layers of Retina
10
10. Inner plexiform layer The cuticular derivative of Mullers cells Serves to delineate the retina from overlying vitreous

 Blood supply
Central retinal artery and vein (wc enters the eye thru optic disk)

As retinal arteries enter the eye, it loses it internal elastic lamina and the medial muscular coat becomes incomplete. The neurosensory retina has no sensory supply
Thus disorders of retina are painless

2 capillary networks in retina

In nerve fiber layer and inner nuclear layer

Physiology and Biochemistry of retina Rods

func at low level illumination or night vision (scotopic vision) peripheral vision 500x more photosensitive than cones

Cones
func at high level illumination or daytime vision (photopic vision) Central vision 3 typers: Blue, Green, and Red cones

Physiology and Biochemistry of retina Fovea centralis

Center of acute vision (point at which visual perception is sharpest) Contains only cones (each with its own neural supply) Light stimuli in this region can directly act on the sensory cells because bipolar cells and ganglion cells are displaced peripherally.

Retina is dependent on constant supply of glucose for its metabolism Muller cells
Storehouse of glucose in the form of glycogen

Symptomatology Principal symptom: visual disturbance Visual blurring

If macula is involved (central serous retinopathy, macular degeneration) central vision is affected If extramacular (pigmentary degeneration) peripheral vision
Seeing flashes of light Caused by the fact that any stimulus on eye results in only one retinal response, that is seeing light May be experienced in retinal and vitreous detachment

Photopsia

Symptomatology Sector visual field defect

Actual loss of part of field of vision or Sensation of curtain or fog covering the involved portion of field vision Condi: partial retinal defect, branch occlusion on retinal vessels, and large retinal hemorrhage Metamophopsia: distorted image Micropsia: small image Macropsia: large image Main cause disturbance in alignment and position of visual cells

Disturbance of image size or shape

Vascular Disturbance
Central retinal artery occlusion (CRAO) Definition: Retinal infarction due to occlusion of an artery in the lamina cribrosa or a branch retinal artery occlusion. Epidemiology. CRAO occur less often than vein occlusions. Common symptom
Blurring or complete loss of vision Impairment of central vision

CRAO

in ophthalmoscope constricted retinal arteries pale optic disk rest of the eye ground is white (due to coagulation necrosis) cherry red spot box car appearance - uninterrupted blood stream

CRAO

Vascular Disturbance
Central retinal artery occlusion (CRAO) Tx:
Ocular massage, medications that reduce intraocular pressure, or paracentesis are applied in an attempt to drain the embolus in a peripheral retinal vessel. Calcium antagonists or hemodilution are applied in an attempt to improve vascular supply. Work-up to identify the source of the embolus is important in order to treat the underlying disease and prevent another embolization (such as stroke).

Vascular Disturbance
Central retinal vein occlusion (CRVO) Definition: Vein occlusion occurs as a result of circulatory dysfunction in the central vein or one of its branches. Epidemiology. CRVO is the second most frequent vascular retinal disorder after diabetic retinopathy. Etiology. Frequently due to local thrombosis at sites where sclerotic arteries compress the veins. Common symptom: rapid loss of vision (but not as instant nor complete as CRAO)

CRVO

in ophthalmoscope retinal engorgement retinal hemorrhage hotdog and catsup appearance Disk is hyperemic with blurring of the margin

Vascular Disturbance
Central retinal vein occlusion (CRVO) Common complication: Glaucoma
Occurs 3 mos after onset Shows neurovascularization of iris surface (rubeosis iridis) w/ occasional vitreous hemorrhage

Treatment
In acute stage, hematocrit should be reduced to 3538% by hemodilution. The underlying disorders have to be treated. Laser treatment is performed in ischemic occlusion that progresses to neovascularization or rubeosis iridis.

Retinopathy
Hypertensive retinopathy Definition: Arterial changes in hpn are primarily caused by vasospasm Pathogenesis.
High bp can cause breakdown of the bloodretina barrier or obliteration of capillaries. This results in intraretinal bleeding, cotton- wool spots, retinal edema, or swelling of the optic disc.

Symptoms.
headache or eye pain dt high bp Impaired vision or loss of visual acuity only occurs in stage III or IV hypertensive vascular changes.

Retinopathy
Hypertensive retinopathy
High degree of narrowing Retinal edema, exudates or hemorrhage results Reduced flow to retina Serum or whole blood leaks out into tissue Anorexia

Incd capillary permeability

Severe edema may involve the optic disk papilledema/chocked disk Absorption of edema fluid may leave protein residues form yellow spots hard exudate At region of macula, residues are arranged in the form of fan macular star Hemorrhage located in nerve fiber layer striate or flameshaped appearance Marked constriction of terminal arterioles may produce zone of infarcts cotton wool patches

Retinopathy
Hypertensive retinopathy

Hypertensive retinopathy

Hypertensive retinopathy

Retinopathy
Arteriosclerotic retinopathy Definition: Arterial changes in hpn as a result of thickening of the wall of the arteriole. Commonly seen in atherosclerosis and arteriole sclerosis Atherosclerosis.
Whitish plaques of lipid deposits seen in wall of retinal a. Lipoidal infiltration as white streak at side of blood column (pipestem sheathing)

Retinopathy
Arteriosclerotic retinopathy Arteriole sclerosis. 1. Change in median arterioles light streak
Median streak is produced by light reflexed from cylindrical blood column of artery In thickening and hyalinization of medial coat, MS widens copper-wire artery when MS completely covers entire blood column silver-wire artery when sclerosis reaches the advance stage (wc reflects back all the light falling on its surface

Retinopathy
Arteriosclerotic retinopathy Arteriole sclerosis. 1. Atrio-venous crossing changes
Concealment of vein (Gunns sign) Tapering of veins dt extension of arteriosclerotic changes Depression of vein dt pressure by hardened arterial wall Humping of vein (Salus arch) Venous banking dt dilatation of vein prox to AV crossing Deflection of vein as S or Z-shaped bent Turtousity of vessels dt inc length of arterioles Attenuation of arteries dt thickening of arterial wall

Retinopathy
Arteriosclerotic retinopathy

Retinopathy
Central serous retinopathy Edema of macular region More common in male Occurs >20 y/o Either defect in retinal pigment epith allowing choroidal transudate to seep into retina, some form choroiditis or vascular spasm Principal symptoms
Blurring of central vision Metamorphopsia, micropsia and macropsia dt disruption of arrangement of visual cells by edema

Retinopathy
Pigment degeneration of Retina Charac initially by premature death of photoreceptor cells w/ subsequent changes in pigment epith Transmitted as dominant, recessive or sex-linked trait Mc initial symptom is night blindness dt early involvement of rods Field studies show ring of scotoma wc extends peripherally loss of peripheral vision End stage: central vision eventually fades away

Retinal detachment
Definition: Retinal detachment refers to the separation of the neurosensory retina from the underlying retinal pigment epithelium, to which normally it is loosely attached.
Primary retinal detachment Always asso w/ breaks (usually in periphery) in retina Vitreous fluid seeps in thru retinal break and initiate separation

Retinal detachment
Secondary retinal detachment
Dt dse process of retina, vitreous or choroid Caused by exudates (choroiditis, Haradas dse); tumor cells or traction on retina

MC symptom: photopsia Ophthalmoscopic findigs

Elevated retina Grayish retina Retinal vessels appear constricted and darker

Retinoblastoma
Definition: Retinoblastoma is a malignant tumor of early childhood that develops from immature retinal cells. MC intraocular tumor Pathogenesis.
A somatic mutation is detected in about 95% of patients. In other patients, it is inherited as an autosomaldominant trait. Changes on chromosome 13q have been observed in germ-cell mutations

Symptoms.
manifests itself before the age of 2 in 70% of affected children. Parents observe leukocoria, a whitish-yellow pupil; in 60% of these children, strabismus in 20%, and a reddened eye in 10%.

Leucocoria cats eye reflex

Retinoblastoma
Intraocular stage:
soapy white mass in retina

Glaucomatous stage
IOP increased Ocular congestion and corneal edema Vitreous filled with tumor cells

Extraocular stage
Tumor extends out of eye into orbit via occular emissaria or thru optic nerve

Metastasis
Hematogenous spread to long bones Manifests as painfull swelling of prox/distal ends

Treatment.
Tumors <4 pupil diameters can be managed with radiation therapy delivered by plaques of radioactive ruthenium or iodine (brachytherapy) and cryotherapy. Larger tumors require enucleation of the eye.

Short Quiz!

Now, Eyem gonna ask questions coz Eye saw you listening

No. 1
10 layers of retina (from outside to inside)

No. 2
In visual blurring, if macula is involved, what vision is affected? (Central/Peripheral)

No. 3
What retinal disease is this?

No. 4
What retinal disease is this?

No. 5
What stage of hypertensive retinopathy shows areas of hemorrhage, cotton wool spots and papilledema?

No. 6
It refers to the separation of the neurosensory retina from the underlying retinal pigment epithelium, to which normally it is loosely attached.

No. 7
What do you call this condition? What disease manifests it?

No. 8
True or False: Pulsation in retinal vein is normal.

No. 9
True or False: Disorders of the retina are painful.

No. 10
What is the function of Vitamin A in the retina?

Thank you!