Retinopathy
When a permanent or temporary damage occurs to the retina of the eye, this is called as retinopathy. Mostly, retinopathy is observed as an ocular manifestation of systemic diseases like diabetes and hypertension [1].
Presentation
Symptoms are not visible properly in the case of hypertensive retinopathy. Some patients might report reduced vision or headaches. Arteriolar changes like narrowing of arteries, advanced retinopathy lesions, like micro aneurysms, flame hemorrhages, ischemic changes and hard exudates around the retina called visual acuity loss. The affected patients might be asymptomatic or have reduced visual acuity in radiation retinopathy. Ophthalmic examination will show signs of retinal vascular disease that includes retinal hemorrhages, perivascular sheathing, disc edema and macular edema. Solar retinopathy has symptoms of long term reduced visual acuity and paracentral scotoma.
Respiratoric
Aspiration
- Ultrasound-guided cyst aspiration and sclerotherapy was performed, with subsequent improvement of the proptosis and resolution of the vessel tortuosity and intraretinal hemorrhages.[ncbi.nlm.nih.gov]
Skin
Skin Lesion
- Two years prior, the patient developed necrotic skin lesions which were biopsied and confirmed the diagnosis of calciphylaxis.[ncbi.nlm.nih.gov]
Eyes
Background Retinopathy
- Background: Retinopathy of prematurity (ROP) is a retinal vascular disease occurring in infants with short gestational age and low birth weight and can lead to retinal detachment (ROP stages 4 and 5).[doi.org]
- Read more on treating retinopathy Background retinopathy Background retinopathy, also known as simple retinopathy, involves tiny swellings in the walls of the blood vessels.[diabetes.co.uk]
- But most people who have background retinopathy have not been diabetic that long, and need better control as per these targets. Types & progression of background retinopathy Retinopathy progression appears to follow different patterns.[diabeticretinopathy.org.uk]
- The categories of retinopathy are: Background retinopathy Background retinopathy occurs in the early stages and damage is limited to tiny bulges (microaneurysms) in the blood vessel walls.[diabeticretinascreen.ie]
Night Blindness
- The short duration and rapid progression of symptoms along with the lack of family history of night blindness prompted a diagnosis of autoimmune retinopathy (AIR).[ncbi.nlm.nih.gov]
- blindness, autosomal dominant 3; Night blindness, congenital stationary, type 1g GNAT2 Achromatopsia 4 GNPTG Mucolipidosis III gamma GPR143 Ocular albinism, type I; Nystagmus 6, congenital, X-linked GPR179 Congenital stationary night blindness, type[asperbio.com]
- Retinitis pigmentosa (RP) is the name given to a group of retinal diseases that are characterized by loss of peripheral (side) vision, and frequently by difficulty seeing in dimly lighted areas (night blindness).[uclahealth.org]
- The first sign is often night blindness, followed by a slow loss of side vision. As the disease develops over the years, people with RP often bump into chairs and other objects because their side vision is worsening.[aoa.org]
Retinal Hemorrhage
- Case 1 highlights extensive choroidal detachment with subhyaloid haemorrhage and multiple intra-retinal hemorrhages in the posterior pole seen on first post-operative day in a 6 year old child with congenital glaucoma who underwent Trab & Trab.[ncbi.nlm.nih.gov]
- The retinal hemorrhages began to improve 2 weeks and had cleared by 6 weeks after surgery.[ncbi.nlm.nih.gov]
- Moderate-to-severe retinal hemorrhages and/or MA’s Patients were excluded if they had undergone previous PRP or had a macula-threatening TRD.[bu.edu]
- Research Highlights • A clinical study on 48 eyes was done to measure the ability of the Ayurvedic preparation called saptamrita lauha in absorption of retinal hemorrhages.[chrysalisnaturalmedicine.com]
- The first signs of nonproliferative retinopathy are Capillary microaneurysms Dot and blot retinal hemorrhages Hard exudates Cotton-wool spots (soft exudates) Hard exudates are discrete, yellow particles within the retina.[merckmanuals.com]
Retinal Pigmentation
- This may be due to abnormal melanin production or loss of melanin within retinal pigment epithelium cells harboring persistent rubella virus infection.[ncbi.nlm.nih.gov]
- All the retinal cells (rods and cones) are provided with oxygen and other nutrients from the retinal pigment cells (epithelium), which are kept supplied by the rich network of blood vessels in the choroid.[retinaaustralia.com.au]
- But in some people, there is a problem with these nerve cells or with the retinal pigment epithelium, which nourishes the retinal visual cells.[envisionus.com]
- Pigmentary changes may be subtle but more often become large areas of decreased or even increased pigmentation located along blood vessels and in underlying retinal pigment epithelium, as seen through an avascular retina.[doi.org]
- Retinitis pigmentosa is characterized by retinal pigment deposits visible on fundus examination and primary loss of rod photoreceptor cells followed by secondary loss of cone photoreceptors.[uniprot.org]
Cotton Wool Spots
- An ocular examination revealed multiple retinal cotton-wool spots and hard exudates. Interferon treatment was suspended.[ncbi.nlm.nih.gov]
- Cotton-wool spots are areas of microinfarction of the retinal nerve fiber layer that lead to retinal opacification; they are fuzzy-edged and white and obscure underlying vessels.[merckmanuals.com]
- Cotton wool spots 2. Venous beading 3. Intraretinal microvascular abnormalities (IRMA) in at least 2 contiguous overlapping photographic fields 4.[bu.edu]
- When this happens, white patches of oxygen-starved retina (cotton wool spots) may remain. This can lead to the growth of new blood vessels (neovascularization) which bleed and leak fluid easily.[arleoeye.com]
- Background or nonproliferative retinopathy: cotton-wool spots, intra retinal hemorrhages, exudates, and micro vascular abnormalities (including micro aneurysms, occluded vessels, and dilated or tortuous vessels) primarily in the macula and posterior retina[bmcresnotes.biomedcentral.com]
Neurologic
Headache
- Some patients might report reduced vision or headaches.[symptoma.com]
- Late-stage diabetic retinopathy symptoms include: Blurred vision Eye strain Headaches. Causes Diabetic retinopathy is an eye disease caused by complications of diabetes.[betterhealth.vic.gov.au]
- However, as the condition progresses, symptoms include: headaches vision changes sudden loss of vision in one or both eyes double vision Making the Diagnosis Diabetic retinopathy is a long-term complication of diabetes.[medbroadcast.com]
- Rare complications of treatment may include blurred vision, headache, glaucoma, difficulty seeing in the dark, decreased peripheral and color vision, and bleeding. In most cases when treatment is recommended, the benefits outweigh the risks.[webmd.com]
- […] detachment in childhood -- Congenital anomalies of the optic discs -- Hereditary optic neuropathies -- Other acquired optic disc abnormalities in children -- Demyelinating, inflammatory, infectious, and infiltrative optic neuropathies -- The optic chiasm -- Headache[worldcat.org]
Workup
Some of the methods used for diagnosing diabetic retinopathy include visual acuity test, optical coherence tomography and ophthalmoscopy. The healthcare professional has to look for leakage in blood vessels, for damaged nerve tissue and retinal swelling. The findings of active retinopathy of prematurity are explained by the international classification of retinopathy of prematurity, which has several parameters for describing the disease. Examination of the back of the eye with funduscope will help in diagnosing purtscher’s retinopathy. The reduction in the blood flow to the white areas of the eye is measured by fluorescein angiography [8].
Other ECG Findings
Ischemic Changes
- Arteriolar changes like narrowing of arteries, advanced retinopathy lesions, like micro aneurysms, flame hemorrhages, ischemic changes and hard exudates around the retina called visual acuity loss.[symptoma.com]
Treatment
Three major treatment methods used for diabetic retinopathy are laser surgery, vitrectomy, and injection of corticosteroids. Laser photocoagulation, modified grid laser and panretinal photocoagulation, intravitreal triamcinolone acetonide are some treatment methods used for diabetic retinopathy [9]. Treatment for hypertension can reduce hypertensive retinopathy. Main treatment for retinopathy of prematurity is peripheral retinal ablation. Anti-vascular endothelial growth factors were used for treating radiation retinopathy. Purtscher’s retinopathy is treated using triamcinolone and if this is caused by any systemic disease, then they have to be treated [10].
Prognosis
Prognosis of retinopathy in newborns will be better by itself and the abnormal vessels will disappear after sometime. Advanced stage of retinopathy of prematurity can lead to blindness, retinal detachment, crossed eyes, nearsightedness, glaucoma, lazy eye and cataract. Diabetic retinopathy leads to blindness [7].
Alterations in the retina due to hypertensive retinopathy will slowly disappear when the blood pressure is reduced. The symptoms of damage will still remain in some cases. Retinopathy of prematurity is described as the threshold disease, which has 50 percent chance of progressing to retinal detachment, at stage 3 of zone I or zone II. Progression to stage 4 and 5 will lead to loss of vision. Purtscher’s retinopathy can also lead to vision loss.
Etiology
Retinopathy can develop slowly or suddenly, which can result in permanent damage. Premature birth can lead to retinopathy, which can also end up in retinal detachment causing blindness. Type1 or type2 diabetic patients develop retinopathy when the blood vessels in their retina deteriorate. Thickening or blockage of small arteries or swelling of optic nerve causes hypertensive retinopathy. Non-traumatic systemic diseases and bone fractures leads to purtscher’s retinopathy. Disorganized growth of retinal blood vessels ending up in retinal detachment is thought to be a cause of Terry syndrome or premature retinopathy [3].
Epidemiology
By 2012, of nearly 93 million people with diabetic retinopathy, 17 million were with proliferative retinopathy, 21 million people were suffering from diabetic macular edema and 28 million people were suffering from vision threatening diabetic retinopathy worldwide [4]. Research studies showed that degree and duration of hypertension enhances the retinopathy incidence. Another study reveals that large number of survived immature newborns correlate with increased risk of advanced retinopathy of premature stages. The frequency of this disease is inversely proportional to the gestational weight and age of the newborn. Prevalence of prematurity retinopathy varies from five to eight percent in developed countries to thirty percent in developing countries.
Pathophysiology
The formation of blood-retinal barrier is altered by the damages from thickening of the basement membrane and hyperglycemia induced intramural pericyte death leading to vascular wall incompetence. Tiny blood vessels filled with glucose cannot be exposed to glucose control methods. Therefore, initial stage of diabetic retinopathy is called non-proliferative and the advanced form is called proliferative [5].
If the growth of blood vessels is abnormal from the plane of retina, and if it bleeds inside the eye, then the baby develops retinopathy of prematurity. Radiation retinopathy involves damage of the endothelial cells of the retinal capillaries by radiation. Retinal damage occurring from photochemical injury is observed in solar retinopathy. Appearance of cotton wool like spots in the retina and atrophy of the optic nerve is observed in purtscher’s retinopathy [6].
Prevention
Prevention of retinopathy of prematurity can be done by addressing certain questions like how to identify the population at risk for this disease, ideal treatment needed for the affected people, what to do when treatment fails. Regular screening of blood sugar levels and high blood pressure can keep diabetic and hypertensive retinopathy under control.
Summary
There are several types of retinopathy, like diabetic retinopathy, hypertensive retinopathy, retinopathy of prematurity, radiation retinopathy, solar retinopathy, sickle-cell disease, retinal vascular disease and purtscher’s retinopathy. Diabetic retinopathy is due to microvascular retinal changes, which also result from radiation. Hypertensive retinopathy occurs due to the damage in the arterial and arteriolar circulation from high blood pressure. The eye disease that affects prematurely-born babies has received intensive neonatal care due to retinopathy of prematurity [2]. Solar retinopathy results due to eye damage from the sun. Head injuries can lead to purtscher’s retinopathy and sickle-cell anemia also leads to retinopathy.
Patient Information
- Definition: A permanent or temporary damage occurred to the retina of the eye is termed as retinopathy. Ocular manifestation of systemic diseases like diabetes and hypertension, prematurely born babies, radiation, and other reasons can lead to retinopathy.
- Cause: Enhanced blood sugar levels and blood pressure, bone fractures, disorganized growth of retinal blood vessels in the newly born, radiation and sun effect are some of the causes for retinopathy.
- Symptoms: Changes in the arterial wall, advanced retinopathy lesions, micro-aneurysms, ischemic changes, flame hemorrhages, visual acuity loss, retinal detachment, perivascular sheathing, disc edema, macular edema and paracentral scotoma are some of the symptoms of retinopathy.
- Diagnosis: Some of the tests used for diagnosing diabetic retinopathy include visual acuity test, optical coherence tomography and ophthalmoscopy. Purtscher’s retinopathy is screened using funduscope. Fluorescein angiography is used for measuring the flow of blood to the eye.
- Treatment: Laser surgery, vitrectomy, and injection of corticosteroids are the major methods used for treating diabetic retinopathy. Peripheral retinal ablation is done for treating retinopathy of prematurity. Anti-vascular endothelial growth factors and triamcinolone are used in the treatment of radiation retinopathy and purtscher’s retinopathy respectively.
References
Article
- Federman JL, Gouras P, Schubert H, et al. Systemic diseases. In: Podos SM, Yanoff M, eds. Retina and Vitreous: Textbook of Ophthalmology. Vol 9. 1994:7-24.
- Ashton N. Oxygen and the retinal blood vessels. Trans Ophthalmol Soc U K. Sep 1980;100(3):359-62.
- Csak K, Szabo V, Szabo A, et al. Pathogenesis and genetic basis for retinopathy of prematurity. Front Biosci. Jan 1 2006;11:908-20.
- Williams R, Airey M, Baxter H, Forrester J, Kennedy-Martin T, Girach A. Epidemiology of diabetic retinopathy and macular oedema: a systematic review. Eye (Lond). Oct 2004;18(10):963-83.
- Benson WE, Tasman W, Duane TD. Diabetes mellitus and the eye. In: Duane's Clinical Ophthalmology. Vol 3. 1994.
- Fielder AR, Shaw DE, Robinson J, et al. Natural history of retinopathy of prematurity: a prospective study.Eye. 1992;6 (Pt 3):233-42.
- Quillen DA, Gardner TW, Blankenship GW. Clinical Trials in Ophthalmology: A Summary and Practice Guide. In: Kertes C, ed. diabetic retinopathy study. 1998:1-14.
- Lajoie A, Koreen S, Wang L, et al. Retinopathy of prematurity management using single-image vs multiple-image telemedicine examinations. Am J Ophthalmol. Aug 2008;146(2):298-3.
- Laser ROP Study Group. Laser therapy for retinopathy of prematurity. Arch Ophthalmol. Feb 1994;112(2):154-6.
- Harrison P. Monthly Ranibizumab Improves Diabetic Retinopathy. Medscape Medical News. Sep 5 2013.