Macula

ARMD

• #1 cause of legal blindness in the US in people over the age of 65

• majority don’t develop legal blindness

20/200 or worse or less than 20deg of VF in the better eye

what is the definition of legal blindness?

1. >50yo

2. caucasian

3. +FHx

4. systemic disease

5. early menopause women

6. SMOKING

7. hyperopia

8. lightly pigmented fundus

9. drusen

10. significant UV exposure

11. nutritional factors

12. possible AD inheritance pattern

what are the risk factors of ARMD?

disease of RPE, choriocapillaris, & Bruch’s membrane; RPE cannot remove metabolic byproducts efficiently

describe the pathogenesis of AMD

dry, wet

____ AMD does not have bleeding, _____ AMD does

drusen

• yellow/white sub-RPE deposits

• junk accumulation due to RPE dysfunction

• extracellular material

• located in macula & posterior pole in b/t the RPE & Bruch’s membrane

• vary in size

• round

• slightly elevated

• symmetric b/t 2 eyes

hard drusen

• type of drusen

• calcific

• less risk of CNVM

• often clustered & can extend out to vascular arcades & into the equatorial retina

soft drusen

• type of drusen

• larger, less well-defined

• may coalesce to appear similar to a serous detachment

• increased risk of CNVM

dry AMD

• 90% of eyes w/ AMD

• clinically seen as alterations of the RPE

  • depigmentation

  • RPE clumping

  • RPE hyperplasia

• bilateral & symmetrical

• tx: AREDS 2

wet AMD

• characterized by CNVM

• 90% of legal blindness caused by AMD

• bilateral in 33% of patients

choroidal neovascular membrane

abnormal formation of new blood vessels in the choroid

1. subretinal/subretinal pigment hemorrhages

2. subretinal exudates

3. subretinal fibrosis

what is the wet AMD triad?

10

____% of bilateral drusen patients move to wet w/in 4y

30

the macular photocoagulation study found that eyes with soft drusen had a _____% risk of CNVM development

58-74

the macular photocoagulation study found that patients w/ CNVM in 1 eye have ______% chance of developing CNVM in the other eye over 5y, if there are more than 2 large drusen & focal hyperpigmentation of the macula

1. age related sclerosis of choriocapillaris & Bruch’s membrane

2. impaired transport of oxygen in & waste material/fluid out

3. reduced RPE phagocytosis & accumulation of drusen

4. drusenoid PED further impairs transport function

5. elevation of fovea causes loss & distortion of vision

describe the pathophysiology of dry AMD

1. age related sclerosis of choriocapillaris & Bruch’s membrane

2. impaired transport of oxygen in & waste material/fluid out

3. reduced RPE phagocytosis & accumulation of drusen

4. drusenoid PED further impairs transport function

5. growth of abnormal blood vessels

6. new vessels break through Bruch’s membrane & continue to grow under RPE
   drusen reabsorbed

7. exudation due to vessels leaking fluid into sub-RPE space

8. fluid breaks into sub-retinal space through RPE

describe the pathophysiology of wet AMD

1. serous detachment of the RPE & retina w/o CNVM

2. serous &/or hemorrhagic detachment of the retina & RPE secondary to CNVM

3. progressive geographic atrophy of RPE w/o exudate or hemorrhage

what are the 3 ways vision loss may occur with AMD?

1. VAs

2. Amsler grid

3. DFE

4. FA

5. ICG

6. SD-OCT

what is some testing to do for AMD?

1. anti-VEGF

2. AREDS

3. laser photocoagulation

what are some more common tx for AMD?

CME

• retinal swelling & cyst formation in the macular area due to breakdown of the inner BRB

• inflammatory in origin

• temporary decrease in vision

• can become permanent

• fundus view: cystic spaces &/or diffuse thickening of macular area

1. decreased vision

2. blurring/abnormal FLR

3. amsler grid defects

4. thickening of macular area (yellow/cystic appearance)

5. lamellar macular hole

what are some signs/sx of CME?

1. cataract surgery

2. scleral buckling procedure for RD

3. PK for corneal transplants

4. in conjunction w/ retinal vascular disease

what is CME most commonly associated with?

1. most cases resolve spontaneously w/in 6mo

2. grid/focal laser tx

3. topical NSAID & steroid tx after cataract surgery

what is the tx protocol for CME?

epiretinal membrane (macular pucker)

• arise from glial proliferation on the inner surface of the retina & astrocyte migration

• exact mechanism of formation is unknown

• usually in pts >50yo

• females>males

• frequently unilateral

• typically occurs after a partial or complete PVD

• appearance: shimmering, irregular light reflex, wrinkling of ILM, tortuous & stretched vessel w/ eventual punctate hemes

• contraction can lead to mechanical dragging of fovea

1. observation

2. if VA is 20/70 or worse, a surgical peeling of the membrane can be considered

what is the tx for ERM?

idiopathic macular holes

• 6th-7th decade

• 70% of females

• VA is usually 20/100-400 depending on thickness involved

• controversial etiology (vitreous/ERM traction, trauma, CME)

• 10-15% chance of bilaterality if PVD not present in fellow eye

• chance of MH in 2nd eye w/ already present PVD is next to none

• appearance: circular/oval depression in central macula, varying size

  • red, well defined red area w/ a surrounding gray halo of detached retinal elevation

  • can have a “bread crumb” appearance

  • can have a small translucent operculum floating in front

-6.00

myopic degeneration is observed most frequently in myopes greater than ______

1. myopic scleral crescent

2. obliquely inserted optic disc

3. macular pigment mottling

4. Fuch’s spot

5. posterior staphyloma

6. well circumscribed area of atrophy

7. lacquer cracks

8. risk of CNVM

what are the clinical cues of degenerative myopia?

presumed ocular histoplasmosis syndrome (POHS)

• caused by fungus with a propensity for the choroid

• affects adults 20-50yo

• endemic in Ohio-Mississippi river valley

• asymptomatic until macular involvement

1. peripheral punched out lesion

2. macula lesion

3. optic nerve peripapillary atrophy

what is the triad of POHS?

30

if 1 eye has a disciform scar due to POHS, fellow eye has _____% chance of development w/in 6-7y after the first

idiopathic central serous chorioretinopathy (ICSC)

• localized serous detachment of neurosensory retina

• no subretinal blood or exudates

• margins of detachment sloping & merging into attached retina

1. blurred or dim vision

2. distortion or central scotoma

3. colors washed out

4. usually unilateral

what are the sx of ICSC?

1. males > females

2. type A personalities, anxiety, stress, lupus

3. HRT

4. corticosteroid use

what are the predisposing factors of ICSC?

1. prognosis for spontaneous recovery better than 20/30 is excellent

2. worse prognosis if recurrent, multiple affected areas, or prolonged course

3. laser hastens recovery & is less likely for recurrence, but may reduce contrast sensitivity

what is the prognosis for ICSC?