2014-2015 Basic and Clinical Science Course (BCSC): Section 12: Retina and Vitreous

442 Pages·2014·171.024 MB·English

by  Hermann D. Schubert

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Visual Acuity Conversion Chart
Snellen Fraction
Decimal LogMAR
4-Meter Notation Visual Angle (Minimum Angle
Feet Meters Standard (Visus) Minute of Arc of Resolution)
20/10 6/3 4/2 2.00 0.50 -0.30
20/15 6/4.5 4/3 1.33 0.75 -0.12
20/20 6/6 4/4 1.00 1.00 0.00
20/25 6/7.5 4/5 0.80 1.25 0.10
20/30 6/9 4/6 0.67 1.50 0.18
20/40 6/12 4/8 0.50 2.00 0.30
20/50 6/15 4/10 0.40 2.50 0.40
20/60 .. 6/18 4/12 0.33 3.00 0.48
20/80 6/24 4/16 0.25 4.00 0.60
20/100 6/30 4/20 0.20 5.00 0.70
20/120 6/36 4/24 0.17 6.00 0.78
20/150 6/45 4/30 0.13 7.50 0.88
20/200 6/60 4/40 0.10 10.00 1.00
20/400 6/120 4/80 0.05 20.00 1.30
For discussion of this chart, see BCSC Section 3, Clinical Optics.
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Retina and .
.J ........� ..· ��
Vitreous
Section 12
2014-2015
(Last major revision 2012-2013)
Funded in part by the Educational
Trust Fund/Retina Research Foundation
£1�
AMERICAN ACADEMY"
\!!I
OF OPHTHALMOLOGY
The Eye M.D. Association
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The American Academy of Ophthalmology is accredited by the Accreditation Coun
cil for Continuing Medical Education to provide continuing medical education for
physicians.
The American Academy of Ophthalmology designates this enduring material for a
maximum of 15 AMA PRA Category 1 Credits™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
Originally released June 2012; CME expiration date: June 1, 2015. AMA PRA Category 1
Credits TM may be claimed only once during this period.
The BCSC is designed to increase the physician's ophthalmic knowledge through study
and review. Users of this activity are encouraged to read the text and then answer the
study questions provided at the back of the book.
To claim AMA PRA Category 1 Credits TM upon completion of this activity, learners must
demonstrate appropriate knowledge and participation in the activity by taking the post
test for Section 12 and achieving a score of 80% or higher. For further details, please see
the instructions for requesting CME credit at the back of the book.
The Academy provides this material for educational purposes only. It is not intended
to represent the only or best method or procedure in every case, nor to replace a physi
cian's own judgment or give specific advice for case management. Including all indica
tions, contraindications, side effects, and alternative agents for each drug or treatment
is beyond the scope of this material. All information and recommendations should be
verified, prior to use, with current information included in the manufacturers' package
inserts or other independent sources, and considered in light of the patient's condition
and history. Reference to certain drugs, instruments, and other products in this course
is made for illustrative purposes only and is not intended to constitute an endorsement
of such. Some material may include information on applications that are not considered
community standard, that reflect indications not included in approved FDA labeling, or
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Cover image courtesy of Michael F. Marmor, MD.
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Copyright© 2014
American Academy of Ophthalmology
All rights reserved
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.
Basic and Clinical Science Course
Louis B. Cantor, MD, Indianapolis, Indiana, Senior Secretary for Clinical
Education
Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for
Ophthalmic Knowledge
George A. Cioffi, MD, New York, New York, BCSC Course Chair
Section 12
Faculty
Hermann D. Schubert, MD, Chair, New York, New York
Neal H. Atebara, MD, Honolulu, Hawaii
Richard S. Kaiser, MD, Philadelphia, Pennsylvania
Adam A. Martidis, MD, Ventura, California
Colin A. McCannel, MD, Los Angeles, California
David N. Zacks, MD, PhD, Ann Arbor, Michigan
Hardeep S. Dhindsa, MD, Reno, Nevada
Practicing Ophthalmologists Advisory Committee for Education
The Academy wishes to acknowledge Neil M. Bressler, MD, Committee on Aging, and
Janet S. Sunness, MD, Vision Rehabilitation Committee, for their reviews of this edition.
The Academy also wishes to acknowledge the American Society of Retina Specialists, the
Macula Society, and the Retina Society for recommending faculty members to the BCSC
Section 12 committee.
Financial Disclosures
Academy staff members who contributed to the development of this product state that
within the past 12 months, they have had no financial interest in or other relationship with
any entity discussed in this course that produces, markets, resells, or distributes ophthal
mic health care goods or services consumed by or used in patients, or with any competing
commercial product or service.
The authors state the following financial relationships:
Dr Kaiser: Alimera Sciences, consultant; Neovista, consultant, equity owner; Ophthotech,
consultant, equity owner
Dr Martidis: Genentech, lecture fees; Ophthalmic Imaging Systems, consultant
Dr McCannel: Genentech, grant support; Savient Pharmaceuticals, consultant, equity owner
Dr Zacks: ONL Therapeutics, equity owner, patent/royalty
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Reviewers:
Dr Bressler: grant support from the following: Abbott Medical Optics, Alimera Sciences,
Allergan USA, Bausch & Lomb, Carl Zeiss Meditec, DIAGNOS, EMMES, ForSight Labs,
Genentech, Genzyme, Lumenis, Notal Vision, Novartis Pharmaceuticals, Pfizer, Quark
Biotech, Regeneron Pharmaceuticals, Research to Prevent Blindness, Steba Biotech
Dr Sunness: consultant for the following: Acucela, Alcon Laboratories, Cell Cure Neu
rosciences, Genentech, GlaxoSmithKline, Neurotech Pharmaceuticals, Novartis Pharma
ceuticals, Potentia Pharmaceuticals, Shire, Sucampo Pharmaceuticals
The POACE reviewer and other authors state that they have no significant financial inter
est or other relationship with the manufacturer of any commercial product discussed in
the chapters that they contributed to this course or with the manufacturer of any compet
ing commercial product.
Recent Past Faculty
Nancy M. Holekamp, MD
Mark W. Johnson, MD
Peter K. Kaiser, MD
Carl D. Regillo, MD
Ursula M. Schmidt-Erfurth, MD
Richard F. Spaide, MD
In addition, the Academy gratefully acknowledges the contributions of numerous past
faculty and advisory committee members who have played an important role in the devel
opment of previous editions of the Basic and Clinical Science Course.
American Academy of Ophthalmology Staff
Richard A. Zorah, Vice President, Ophthalmic Knowledge
Hal Straus, Director, Publications Department
Christine Arturo, Acquisitions Manager
Stephanie Tanaka, Publications Manager
D. Jean Ray, Production Manager
Ann McGuire, Medical Editor
Crissa M. Williams, Administrative Coordinator
® AMERICAN ACADEMY"
OF OPHTHALMOLOGY
The Eye M.D. Association
655 Beach Street
Box 7424
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Contents
General Introduction xiii
Objectives .. .1
Introduction . .3
PART I Fundamentals and Diagnostic
Approaches . . . . . .5
1 Basic Anatomy. .7
The Vitreous . . . . . 7
Neurosensory Retina .8
Retinal Pigment Epithelium 14
Bruch Membrane . 17
Choroid. 17
Sclera ..... . 18
2 Diagnostic Approach to Retinal Disease . 19
Techniques of Examination . . . 19
Retinal Angiographic Techniques . . 20
Fluorescein Angiography. . . . 20
Indocyanine Green Angiography 25
Optical Coherence Tomography . 26
Scanning Laser Ophthalmoscopy . 29
Fundus Autofluorescence . . . . 30
Infrared Reflectance Imaging. . . 30
Fundus Near-Infrared Autofluorescence . 31
Conditions Commonly Diagnosed Using Imaging Technology 32
3 Retinal Physiology and Psychophysics 33
Electroretinogram . . . . . . . . . . . . 33
Recording and Interpreting the Response. 33
Specialized Types of ERG. .... 37
Applications and Cautions . . . . 39
Electro-oculogram and RPE Responses 42
Electro-oculogram . . . 42
Cortical Evoked Potentials . . . . 44
Visually Evoked Potentials . . 44
Electrically Evoked Potentials . 45
V
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vi • Contents
Psychophysical Testing 45
Dark Adaptation . 46
Color Vision . . . 46
Contrast Sensitivity 50
PART II Disorders of the Retina and Vitreous 53
4 Age-Related Macular Degeneration and Other
Causes of Choroidal Neovascularization . 55
Age-Related Macular Degeneration . 55
Genetics and AMD 56
Nonneovascular Abnormalities in AMD 57
Neovascular AMD 63
Other Causes of Choroidal Neovascularization . 80
Ocular Histoplasmosis Syndrome . 80
Idiopathic CNV. 83
Angioid Streaks . 84
Pathologic Myopia 85
Miscellaneous Causes of CNV 87
Anti-VEGF Therapy for Secondary Causes of CNV 87
5 Retinal Vascular Disease: Diabetic Retinopathy. 89
Terminology and Classification . 89
Diabetes Terminology . 89
Diabetic Retinopathy Terminology 89
Epidemiology of Diabetic Retinopathy. 90
The Wisconsin Epidemiologic Study of Diabetic Retinopathy . 90
Pathogenesis of Diabetic Retinopathy . 90
Systemic Medical Management of Diabetic Retinopathy 91
Conditions Associated With Vision Loss From
Diabetic Retinopathy . 95
Nonproliferative Diabetic Retinopathy. 95
Diabetic Macular Edema . 95
Diabetic Macular Ischemia . . 103
Severe Nonproliferative Diabetic Retinopathy . . 104
Proliferative Diabetic Retinopathy. . 105
Nonsurgical Management of Proliferative Diabetic Retinopathy . . 106
Surgical Management of Proliferative Diabetic Retinopathy . . 106
Vitrectomy Surgery for Complications of Diabetic Retinopathy . 109
Cataract Surgery in Patients With Diabetes Mellitus . . 111
Recommended Diabetes-Related Ophthalmic Examinations . 111
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Other Retinal Vascular Diseases. 113
Systemic Arterial Hypertension. . 113
Hypertensive Retinopathy . 113
Hypertensive Choroidopathy . . 114
Hypertensive Optic Neuropathy. . 115
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Contents • vii
Sickle Cell Retinopathy . . . . . . . . . . 115
Nonproliferative Sickle Cell Retinopathy . . 118
Proliferative Sickle Cell Retinopathy . . . . 119
Other Ocular Abnormalities in Sickle Cell Hemoglobinopathies . . 120
Management of Sickle Cell Retinopathy . 120
Peripheral Retinal Neovascularization . . 121
Venous Occlusive Disease . . . . . . 121
Branch Retinal Vein Occlusion . . . 121
Central Retinal Vein Occlusion . . . 127
Ocular Ischemic Syndrome and Retinopathy of Carotid
Occlusive Disease . . . 133
Symptoms and Signs. . . . . . . . . . . 133
Etiology and Course . . . . . . . . . . . 133
Treatment of Ocular Ischemic Syndrome . . 134
Arterial Occlusive Disease . . . . . . . . . . 135
Capillary Retinal Arteriole Obstruction (Cotton-Wool Spots) . . 135
Branch Retinal Artery Occlusion . 136
Cilioretinal Artery Occlusion . . . 137
Central Retinal Artery Occlusion . 138
Ophthalmic Artery Occlusion. . 140
Vasculitis . . . . . . . . 140
Cystoid Macular Edema . . 142
Etiologies for CME . 142
Incidence of CME . . 143
Treatment for CME . 143
Coats Disease . . . . . 143
Parafoveal (Juxtafoveal) Retinal Telangiectasia . 145
Arterial Macroaneurysms . 147
Phakomatoses . . . . . . . . . . . . . . . 148
Retinal Angiomatosis . . . . . . . . . . 148
Congenital Retinal Arteriovenous Malformations . 151
Retinal Cavernous Hemangioma . 151
Radiation Retinopathy. . . . . . . . . . . . . . . 151
Valsalva Retinopathy . . . . . . . . . . . . . . . 153
Purtscher Retinopathy and Purtscherlike Retinopathy . . 154
Terson Syndrome. . . . . . . . . . 155
7 Retinopathy of Prematurity 157
Introduction . . . . . . . . . . 157
Epidemiology. . . . . . . . 157
Classification and Terminology . . 157
Pathogenesis . . . . . . . . . . 162
Natural Course . . . . . . . 163
Associated Conditions and Late Sequelae. . 163
Screening Recommendations . . 164
Screening Criteria . . . . . . . . . . . 164
Screening Intervals . . . . . . . . . . 164
Fundus Photographic Screening ofROP . 165
viii • Contents
Prevention and Risk Factors . 165
Treatment ..... . . . . 166
Laser and Cryoablation Surgery . . 167
Anti-VEGF Drugs ...... . . 169
Vitrectomy and Scleral Buckling Surgery . . 170
8 Choroidal Disease. . . . . . 171
Central Serous Chorioretinopathy. . . 171
Fluorescein Angiography of CSC . 172
Other Imaging Modalities for CSC. . 173
Differential Diagnosis of CSC . . . . 174
Natural Course and Management of CSC. . 175
Choroidal Perfusion Abnormalities . . 176
Increased Venous Pressure . . 176
Hypertension. . . . . . . 176
Inflammatory Conditions . 177
Thromboembolic Disease . 179
Iatrogenic Abnormalities . . 180
Choroidal Hemangioma . . . . 180
Uveal Effusion Syndrome . . . 182
Bilateral Diffuse Uveal Melanocytic Proliferation . 183
9 Focal and Diffuse Choroidal and
Retinal Inflammation. . . . . . . 185
Noninfectious Retinal and Choroidal Inflammation . . 185
White Dot Syndromes . . . . . . 185
Acute Macular Neuroretinopathy . . 193
Acute Idiopathic Maculopathy . . . 193
Acute Retinal Pigment Epitheliitis . . 193
Solitary Idiopathic Choroiditis . 194
Inflammatory Vasculitis . 194
Intermediate Uveitis . . 196
Panuveitis . . . . . . . 196
Uveitis Masquerade . . . 199
Infectious Retinal and Choroidal Inflammation . . 200
Cytomegalovirus Infection . . . . . . . 200
Necrotizing Herpetic Retinitis . . . . . 201
Endogenous Bacterial Endophthalmitis . 202
Fungal Endophthalmitis . . 203
Tuberculosis . . . . . . . 204
Syphilitic Chorioretinitis . . 205
Cat-Scratch Disease . . . . 206
Toxoplasmic Chorioretinitis . 206
Toxocariasis . . . . . . . . 209
Lyme Disease . . . . . . . . 210
Diffuse Unilateral Subacute Neuroretinitis . 210
West Nile Virus Chorioretinitis . . . . . . 211
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