retina
DESCRIPTION
gangguan penglihatanTRANSCRIPT
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VITREORETINA
Prof. Dr. KHALILUL RAHMAN, SpM(K)Dr. HEKSAN, SpM(K)Dr. WENI HELVINDA, SpM
SUB-BAGIAN VITREORETINA ILMU KESEHATAN MATA FK UNAND/RSUP Dr M JAMIL PADANG
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RETINA• The innermost layer of the
eye, comparable to the film inside of a camera.
• It is composed of nerve tissue which senses the light entering the eye.
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PENAMPANG BOLA MATA
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STRUKTUR BOLA MATA
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RETINA•2/3 Posterior•Tipis dan transparan•Tdd 2 struktur :
Neurosensoris retina Epitel pigmen retina
•Ruang subretina→ ruang potensial•Ketebalan berbeda•Makula
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RETINA•NEUROSENSORIS RETINA
Dibedakan 3 lapis :▫Eksternal : Fotoreseptor▫Intermediate : Lapisan nuklear dalam▫Inner : Lapisan sel gangglion
2 Sinaptic atau plexiform▫Lapisan plexiform luar▫Lapisan plexiform dalam
Perdarahan :▫1/3 luar → khoriokapilaris▫2/3 dalam → a. centralis retina
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RETINA•Fotoreseptor
Rod▫Penglihatan remang-remang▫Penglihatan perifer▫Sensitifitas yang besar untuk blue-green
Cone▫Penglihatan sentral▫Penglihatan warna▫Tajam penglihatan▫Penglihatan pada cahaya terang
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Cones▫ Concentrated in the fovea▫ Most active in daylight▫ Central vision
• Rods▫ Mostly in the peripheral
retina▫ Most active in night
vision▫ Peripheral vision
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RETINA• Epitel pigmen retina
1 lapis sel kuboid Kaya dengan melanin Mengandung 3.5 juta sel Kepadatan berkurang dari fovea sentral ke perifer
▫Fungsi : Fagositosis Metabolisme retinol Outer retinal barrier Absorbsi cahaya Sintesis matrix ekstraseluler Regulasi transport ion dan bahan-bahan metabolite
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RETINA•Ruang subretina
Mikrovili EPR Matrix ekstraseluler (matrix fotoreseptor) Tekanan hidrostatik pada EPR dari vitreous Transport aktif cairan subretina oleh EPR Tekanan osmotik plasma
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RETINA
VaskularisasiA. centralis retina → 2/3 dalam
Cabang a. opthalmica dari A Carotis internaMasuk ke retina via Papil nervus optikusCabang Superior dan InferiorMendarahi sampai Lapisan nuklear dalamInner blood retinal barrier
Khoriokapilaris → 1/3 luarBerasal dari KoroidCabang dari a ciliaris posterior brevis
A cilioretina (20 %)
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RETINA
•MAKULA Sentral retina Fotoreseptor Cone Mengandung Lutein dan
Zeaxanthin Diameter 6 mm Sentral → foveola (1.5 mm) Fovea
▫daerah melingkari foveola▫3.5 mm lateral diskus optikus▫Avaskular zone▫Warna agak gelap
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JALUR VISUAL
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RETINA & GGN PENGLIHATAN•ABLATIO RETINA•RETINOPATI DIABETIKA•RETINOPATI HIPERTENSI•OKLUSI VENA RETINA
CABANG/SENTRAL•ARMD•CSCR
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ABLATIO RETINA•Terpisahnya neurosensoris retina dari
RPE akibat adanya cairan subretina
•Ada 4 tipe Rhegmatogen Traksional Rhegmatogen traksional Eksudatif (serous)
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GAMBAR ABLATIO RETINA
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ABLATIO RETINA•Rhegmatogen
Full-thickness Hole atau robekan
•Faktor etiologi Pencairan vitreous Hole atau robekan Traksi
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ABLATIO RETINA•Patogenesis
Degenerasi kronis Robekan retina Gangguan adhesi korioretinal normal Inertial force
•Faktor presipitasi Miopia Membran epiretina Perdarahan vitreous Peradangan khorioretina Operasi intraokuler
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ABLATIO RETINA•Klinis
Gejala ▫Floaters▫Photopsia▫Defek lapangan pandang▫Visus ↓ mendadak (tertutup tirai)▫Nyeri (-)
Tanda▫RAPD (+)▫TIO ↓ (5 mmHg lebih rendah dari mata normal)▫ Iritasi ringan▫Tobacco dust (shafer’s sign)
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ABLATIO RETINA•PENATALAKSANAAN
Prinsip Temukan robekan atau hole Tutup robekan atau hole
▫Scleral buckle▫Pneumatic retinopexy▫Vitrektomi
Punctie SRF Buat iritasi korioretinal disekitar hole atau
robekan
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ABLATIO RETINA•Perawatan pasca operasi
Posisi tidur Gas intraokuler Silicon oil
Perawatan kornea dan luka
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RETINOPATI DIABETIKA•Diabetes melitus → gangguan metabolisme•2% - 4% populasi•Defisiensi relatif atau absolut atau
resistensi jaringan sasaran → insulin•Microangiopathy → diabetes•Kebutaan•IDDM (>20 tahun → 99 % RD)•NIDDM ( > 20 tahun → 60 % RD)
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RETINOPATI DIABETIKAUmur 5 tahun 15 tahun< 30 tahun 17 % 98%> 30 tahun 29 % 80%
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RETINOPATI DIABETIKA•Patogenesis
Belum diketahui Hiperglikemia jangka lama Kerusakan endotel kapiler
▫Hilangnya perisit▫Penebalan membran basal▫Perubahan lumen vaskuler▫Dekompensasi endotel
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RETINOPATI DIABETIKA•Klasifikasi
Berdasarkan stadium atau perjalanan penyakit1. Non Proliferative Diabetic Retinopathy 2. Pre Proliferative Diabetic Retinopathy3. Proliferative Diabetic Retinopathy4. Diabetic Maculopathy
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RETINOPATI DIABETIKA• NPDR
▫ Ringan▫ Mikroaneurisma minimal 1▫ Perdarahan intra retina berupa dot dan blot▫ Eksudat keras
▫ Sedang ▫ + Cotton wool spot▫ Dan/ atau IRMA
▫ Berat : (4:2:1) rule▫ Adanya 1 dari 3 karakter dibawah
▫ Perdarahan blot 4 kuadran▫ Venous beading >2kuadran▫ IRMA > 1 kuadran
▫ Sangat berat▫ Adanya 2 atau lebih dari 3 karakter diatas
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RETINOPATI DIABETIKA•Pre PDR
▫Pelebaran vena retina, venous turtuosity- venous beading
▫IRMA▫Arteriolar abnormality▫Nerve fibre layer infarcts- cotton woo; spots▫Mikroaneurisma dan perdarahan retina berat▫Daerah-daerah non perfusi
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RETINOPATI DIABETIKA• PDR
Awal▫ NVD /NVE▫ Perdarahan preretina dan atau vitreous
Risiko tinggi▫ NVD ¼ - 1/3 DD + perdarahan vitreous▫ NVD sedang-berat dengan/tanpa perdarahan▫ NVE ½ DD _ perdarahan vireous
Lanjut▫ Perdarahan vitreous ekstensif▫ Ablatio retina yang mengenai makula
• Diabetic Maculopathy (CSME) Edema makula ≤ 500 µm dari makula Eksudat keras ≤ 500 µm dari makula dengan penebalan retina
didekatnya Penebalan retina >1 DD jika lokasinya ≤ 1 DD dari makula
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RETINOPATI DIABETIKA•Penatalaksanaan
Kontrol gula darah Fotokoagulasi laser
▫Fokal▫PRP
Vitrektomi Pars plana
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RETINOPATI DIABETIKA•Follow-up
Onset Waktu dianjurkan utk pemeriksaan pertama
Follow-up
<30 tahun>30 tahunSebelum kehamilan
5 tahun setelah onsetSaat diagnosisSebelum atau sesudah konsepsi
1 tahun1 tahun3 bulan
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RETINOPATI DIABETIKA•Follow-up
Status Retinopati Follow-up(bln)
Tidak ada retinopati (hanya mikroaneurisma)NPDR ringan/sedang tanpa edema makulaNPDR ringan/sedang dengan non CSMENPDR ringan/sedang dengan CSMENPDR berat/sangat beratPDR
126-124-63-43-42-3
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NPDR SANGAT BERAT DENGAN EDEMA MAKULA
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OKLUSI ARTERI RETINA•Kelainan vaskuler retina •Diskontinuitas sirkulasi
•Ada 2 :1. Oklusi arteri retina sentralis (CRAO)2. Oklusi arteri retina cabang (BRAO)
•Insiden : Usia pertengahan Tua
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OKLUSI ARTERI RETINA•Faktor risiko
Hipertensi (tipe esensial) Kebiasaan merokok Dislipidemia Diabetes melitus Penyakit vaskuler karotis Pemakai kontrasepsi estrogen (usia muda) Pasca menopause dgn terapi sulih estrogen
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OKLUSI ARTERI RETINA•Etiologi dan Patofisiologi
Trombosis akibat aterosklerosis lokal pd arteri di lamina kribrosa
Bisa akibat embolisasi krn perdarahan plak aterosklerotik, trombosis, spasme
Giant cell arteritis (1-2% kasus CRAO)
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OKLUSI ARTERI RETINA•Klinis
Visus turun mendadak tanpa nyeri Retina edema (opak) Cherry-red spot Kerusakan retina irreversibel setelah 90
menit
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GAMBAR CRAO
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OKLUSI ARTERI RETINA•Penatalaksanaan
▫Penyakit dasar▫Okuler
▫Massase okuler▫TIO turunkan dgn mendadak▫Pemberian streptokinase (trombolitik) atau tissue
plasminogen activator (tPa)▫Pemberian aspirin/persantin untuk jangka panjang
•Prognosis ▫Buruk karena keterlambatan
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OKLUSI VENA RETINA•Sumbatan vena retina dgn karakteristik
Dilatasi dan turtositas vena retina Edema papil Perdarahan intraretina Edema retina
•Insiden Usia > 50 than (90%)
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OKLUSI VENA RETINA•Faktor risiko
Penyakit kardiovaskuler Hipertensi arterial sistemik Diabetes melitus Glaukoma sudut terbuka Dislipidemia Tekanan intra orbita (jarang) Body mass index at 20 years old > Panjang aksial bola mata <
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OKLUSI VENA RETINA•Etiologi
Trombosis vena ▫Di posterior lamina kribrosa ▫Di persilangan arteri vena
•Patofisiologi Lokal
▫Blokade secara fisik di darah lamina kribrosa Sitemik
▫Sumbatan karena faktor hemodinamik
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OKLUSI VENA RETINA•Green dkk,
Penyempitan vena di lamina kribrosa Terjadi aliran turbulensi Kerusakan endotel vena retrolaminer Kolagen terpapar Reaksi agregasi trombosit Trombosis Trombus menempel pada endotel yang rusak Proliferasi sel endotel dan rekanalisasi
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OKLUSI VENA RETINA•Klasifikasi
Non iskemik▫Partial, perfused or venous stasis retinopathy (ringan)
Iskemik▫Nonperfused, complete or haemorrhagic
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OKLUSI VENA RETINA•Klinis
▫Penurunan visus mendadak tanpa nyeri▫Kadang2 penglihatan normal dlm beberapa
dtk/mnt▫Kadang2 mata merah dan fotofobia▫RAPD (+) menunjukan tipe iskemik▫Injeksi siliar dan pelebaran pembuluh darah iris▫Tahap lanjut bisa nyeri, neovaskularisasi iris dan
glaukoma neovaskuler- 90-day glaucoma
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OKLUSI VENA RETINA•Komplikasi
Visus buruk Glaukoma neovaskuler
•Penatalaksanaan▫Obati penyakit dasar▫Deteksi komplikasi▫Fotokoagulasi laser▫Anti inflamasi atau anti VEGF
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GAMBAR CRVO
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GAMBAR BRVO
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CSCR•Central serous chorioretinopathy
▫Penimbunan cairan diantara epitel pigmen retina (EPR) dan lapisan neurosensoris retina di daerah makula
▫Sinonim :▫ Idiopathic central serous chorioretinopathy▫ Central serous retinopathy
•Etiologi▫Belum diketahui▫Faktor psikis
▫ Hipokondriasis, histeria▫ Personalitas tipe A▫ Stress – kortisol dan epinefrin
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CSCR•Epidemiolgi
▫90% pria sehat▫Usia 30 – 50 tahun▫Ras hispanik dan asia
•Patogenesis▫Hipermeabilitas vaskular koroid – eksudasi▫Peningkatan tekanan hidrostatik koroid▫Pelepasan EPR dan kerusakan EPR▫Penimbunan cairan subretina
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CSCR•Jenis CSCR
Tipikal (akut) Kronis (dekompensated CSR) Bulosa
▫CSCR tipikal (akut)▫Unilateral, asimptomatik▫Penurunan visus akut (6/9 – 6/18)▫Metamorfopsia, skotoma sentral▫Mikropsia▫Penurunan penglihatan warna▫Elevasi makula oval– dome-shaped▫FFA : expansile dot atau smoke-stack
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CSCR•Penatalaksanaan
▫Observasi 3-4 bulan▫Terapi medikamentosa
▫ Tranquilizer▫ Beta-blocker▫ acetazolamide
▫Fotokoagulasi laser▫Anti VEGF
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CSCR•Fotokoagulasi laser
▫Menetapnya cairan subretina setelah 3-4 bulan▫Rekurensi pada mata dengan penurunan tajm
penglihatan akibat serangan sebelumnya▫Timbulnya penurunan tajam penglihatan yang
permanen pada fellow-eye akibat serangan sebelumnya
▫Munculnya tanda kronik seperti perubahan kistik neurosensorik retina atau kelainan luas RPE
▫Penderita yang bekerja atau yang memerlukan kembalinya penglihatan dan stereopsis
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CSCR•Fotokoagulasi laser
Dilakukan pada tempat kebocoran Dapat mempersingkat masa sakit Penyerapan sempurna cairan subretina dapat
terjadi dalam 4 mingu pasca terapi Bila setelah 4 minggu pasca terapi, cairan
masih ada, visus tidak membaik dan kebocoran masih terjadi, perlu dipertimbangkan terapi laser ulang
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CSCR•Prognosis
▫Baik pada sebagian besar kasus▫Kurang baik pada kasus kronis dan rekuren▫Resolusi spontan bisa terjadi dalam 3-4 bulan▫Rekurensi
▫ Timbul pada 20 – 30 % kasus▫ Umumnya 1 tahun setelah serangan sebelumnya▫ Dapat pada tempat yang sama atau 0.5 – 1.0 mm dari
tempat sebelumnya
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ARMD•Age Related Macular Degeneration
Penurunan tajam penglihatan pada satu atau kedua mata pada usia diatas 50 tahun akibat kerusakan lapisan luar retina, RPE, membrana Bruch’s dan koriokapilaris
Perubahan yangterjadi :▫Berkurangnya ketebalan dan distribusi fotoreseptor▫RPE : hilangnya melanin, lipofuchsin dan penumpukan
residual bodies▫Deposit lamina basal
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ARMD•Insiden
Umur : ▫43 - 54 tahun : 3.9%▫>75 tahun : 22.8 %
Kelamin▫Tidak ada perbedaan▫Tipe exudative : > 75 tahun wanita >>
•Klasifikasi Dry : nonneovascular/noneexudative Wet : neovasculer/exudative
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ARMD•Tipe Dry
Klinis :penurunan visus perlahan, simptomatikfundus : drusen berbentuk bulat, kuning
Terapi :Roborantia mengandung vitamin
antioksidan
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ARMD•Tipe Wet
Kilnis▫Visus menurun mendadak, metamorphopsia, skotoma sentral▫Fundus
▫ Neovasculer dari koriokapilaris▫ Sikatrik fibrovaskuler disiformis▫ Perdarahan subretina▫ Perdarahan vitreous▫ Ablatio retina eksudatif
Terapi▫Roborantia▫Kacamata pelindung▫Anti VEGF▫PDT