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Diabetic retinal disease (diabetic retinopathy) is the most common cause of visual impairment and blindness among Americans between the ages of 25 and 74. Up to 90% of diabetic blindness can be prevented with regular dilated eye exams, which facilitate early detection and timely treatment. Our mission is to reach out to people with diabetes who are unaware of the importance of a simple eye examination, which could make the difference between seeing and not seeing. Vision loss is preventable but remains a major unresolved challenge because of delays in diagnosis. The retina is the delicate membrane which lines the interior of the back of the eyea€”much like film in a camera. The macula is the small spot located in the center of the retina which is responsible for high definition vision. Diabetic retinopathy is the term used to describe the damage that elevated blood sugar levels produce in the small blood vessels located within the retina.
Non-proliferative diabetic retinopathy is characterized by dilated capillaries (microaneurisms) which leak red blood cells and plasma into the substance of the retina. Macular swelling (edema), which is caused by leaking microaneurisms, is the most common cause of visual loss among adult onset diabetics.
Proliferative diabetic retinopathy is a more advanced stage, characterized by new blood vessel formation on the surface of the retina or the optic nerve. Note the fine network of new blood vessels on the surface of the optic nerve (yellow circle) with a small hemorrhage (red blood). Fluorescein angiography is a diagnostic test in which a very small amount of orange dye is injected into an arm vein and photographed as the dye passes through the retinal circulation. Note the fuzzy white areas, which represent dye leaking into the retina from the microaneurisms observed in the previous angiogram.
In addition to optimizing control of blood sugar, blood pressure, and cholesterol, treatment of both macular edema and neovascularization utilizes a laser to seal leaking microaneurisms located within the macula, and more extensive scatter treatment throughout the retina to eliminate neovascularization.
More advanced stages of retinopathy, including vitreous hemorrhage and retinal detachment, which have caused a loss of vision, are treated by microsurgery (Vitrectomy). Answer: Diabetic retinopathy is classically described by the presence or absence of neovascularization. Answer: With documenting retinal findings, the four main structures checked are the Macula, Vessels, Periphery, and Disk (optic nerve).
This video illustrates the important infections involving the eye: including conjunctivitis, blepharitis, HSV infection, pre-septal cellulitis, and endophthalmitis.
We begin with a review of the three types of conjunctivitis and the common symptoms with each.
When approaching a lid infection, you must determine if the infection is pre- or post-septal.
This introduction to the retina covers all the basics: anatomy, diabetic retinopathy, retinal detachments, and macular degeneration. If you can’t view the retina (for example, the patient has a dense cataract) then you can visualize key structures with ultrasound. PRP, or panretinal photocoagulation is performed to kill off ischemic retina and decrease VEGF production. Despite other problems, it’s macular edema that actually causes of majority of diabetic vision loss. PVDs (posterior vitreous detachments) are common and can be seen at the slit-lamp in this video. Macular degeneration is a leading cause of blindness in our country, and this video segment describes how it occurs.
To understand glaucoma, you must understand how aqueous fluid is produced and drained from the eye. One method of pressure measurement is with the applanation tonometer built into the slit-lamp microscope. The cup-to-disk area increases as less ganglion nerves are traveling through the optic-nerve. This gonio-video demonstrates the main structures and the trabecular meshwork can be seen as a faint line. With pseudoexfoliation syndrome, a basement-membrane material forms on the anterior lens capsule. With bad diabetic retinopathy or a central retinal vein occlusion, VEGF can float forward into the anterior chamber and lead to neovascularization of the iris and angle, creating a dangerous glaucoma.
The external eye is covered by the thin conjunctival tissue, which inserts at the limbus of the eye. The nasolacrimal duct drains tears from the eye surface into the nose – explaining why your nose runs when you cry.

The cornea and sclera are continuous with each other … however, the cornea is clear because it is relatively dehydrated. The cornea has five layers – the endothelial layer acts as a pump to keep the cornea dehydrated. The ciliary body sits behind the iris and tethers the lens in place by a 360 degree network of zonular fibers. The lens has the configuration of a peanut M&M with an outer capsule, middle cortex, and central nucleus.
Eye movement is controlled by rectus and oblique muscles that tether the eye and connect at the orbital apex.
You can see the orbital bones and the extraocular muscles on CT – a coronal view like this one works best. Visual fields are tested on each eye separately, with your hand held equadistant from you and the patient. Pinholing can improve vision by several diopters and improvement can indicate refractive problems or media opacities. The Tono-pen device is an easy way to check pressure in patients who can’t get up to the microscope. Afferent pupillary defect, or a Marcus Gunn pupil can be checked with the Swinging-Light test. Ophthalmology is a field that lends itself to photography, as there is a lot to be seen inside the eye.
This large database has an impressive number of photographs that are broken down into subspecialty. This atlas, put together by Suzanna Airiani and the Columbia department (my alma mater) is quite good.
If you’ve any interest in neuroophthalmology, than this is the greatest free resource available. Everyone learns differently, so it’s hard to predict the best approach for your studies. This book is written by the American Academy of Ophthalmology, and is geared toward medical students. The emphasis for a new ophtho resident is a little different … not only must you get up to speed quickly, you also need to do well on your OKAP in-service exam. Probably the greatest ophthalmology book ever written for residents: high yield, easy-to-read question format, and comprehensive. Answer: Grossly the eyes of patients with birdshot retinochoroiditis are quiet without significant conjunctival injection or ciliary flush. Answer: Early in the angiogram the fluorescein appears darker than normal due to diffuse blockage of choroidal fluorescence by retinal edema. Answer: Single antigen haplotyping for HLA-A29 can be very helpful for confirming the diagnosis. Answer: Initial treatment of birdshot should begin with prednisone, although historically less than 15% of patients will achieve a good clinical response with steroids alone. Diabetic macular edema (DME) is the leading cause of blindness in diabetic patients, the second most common one being diabetic retinopathy (DR). It contains highly specialized nerves which sense light, and small blood vessels which provide the nerves with oxygen and nutrients.
This results in the appearance of retinal hemorrhages, edema (swelling), and deposits (exudates). Severe visual loss can occur due to bleeding within the eye (vitreous hemorrhage) and retinal detachment. This technique is utilized to visualize both microaneurisms causing macular edema and neovascularization. Laser therapy can be supplemented by injections of steroids and other medications placed within the eye. I’ve included some full-motion videos and full CT scans demonstrating orbital cellulitis findings.
These small glands pump oil into the tear film – this oil keeps the tears from evaporating too quickly. This is different from a stye, which is an infection of a sweat-gland or hair follicle, similar to a pimple. The key point here is that the photoreceptors lay pretty deep in the retina, with the ganglion nerve fiber layer superficial. This full-motion video segment shows the kind of view you can expect when using a 90-diopter lens. The field of view is much greater and lets you look all the way out in the peripheral retina.

Dot-blot bleeding is discreet because they occur in the deeper, vertically-arrayed layers of the retina. You can relieve traction by cutting the band (vitrectomy) or by shortening the band (buckle).
In addition, treatment options, pressure-concepts, and exam findings are shown with full-motion video clips.
A goniolens breaks the cornea-air interface, and allows direct visualization of these structures. The eye is a complex structure with layers, lens, muscles, receptors, that is surrounded by many bones.
In this advanced cataract, the cortex has liquefied into a milky consistency, and the central brown nucleus has sunk to the bottom. Unfortunately, it’s not always easy to Google this information, as the search engines are innundated by unhelpful drug and consumer awareness sites. Online collections are great for review, and for presentation preparation (reminder: all these images are copyrighted, of course). While not as all-encompassing as redatlas, each image has outlined information about the pathology seen.
Ophthalmology is completely different than the rest of medicine, so you don’t have any scaffolding to build from. Read this one first, then consider delving into more challenging review books like PreTest and the Mass Eye and Ear series. Figures 1 and 2 SHOW the right and left eyes of a 55 year old patient who complains of gradual painless bilateral loss of vision and floaters.
Ovoid cream colored lesions deep in the retina with a radial orientation associated with vitreous cells is typical in appearance for Birdshot retinochoroiditis. Ninety-seven percent of patients with birdshot retinochoroiditis will have this HLA phenotype. Approximately 40% of patients will develop loss of useful vision in one or both eyes usually as a result of cystoid macular edema or choroidal neovascularization. Both DME and DR result from metabolic and microvascular disorders that typically DIABETIC MACULAR EDEMA affect patients with diabetes.
You should not rely on this information as a substitute for personal medical attention,  diagnosis or hands on treatment. It is essential to have regular, dilated examinations even if one isna€™t having any problems with their eyes.
I keep things simple in this video, and correlate directly with the anatomy chapter from the book.
All of this is new, so you should probably start with a short book that you can read front-to-back, then expand with more in-depth material. This might make a good second book to peruse, but I don’t really like it as a primary text as the entire series reads like an encylopedia. Like a dictionary, this text is all-inclusive, but not quite deep enough to be interesting. Patients with birdshot retinochoroiditis have an average age of 50 and will usually present with chronic painless blurring of vision and floaters. However, this immunosuppressive must be used cautiously because of its potential to cause kidney damage. It is still unclear how the use of cyclosporine modifies the natural history of this condtion. Thus, early detection of any eye disease by means of ophthalmologic evaluations and control is extremely important in order to treat them in time. I’ve also scanned in an entire head CT to help you correlate the cartoons with real clinical imaging. It is more useful for the beginning resident who can use this intro book to branch into the other 13 books of the series. The books do end with board-style questions that are quite useful to review prior to the OKAPS.
They do not usually block early choroidal hyperfluorescence and only SHOW mild hyperfluorescense and staining in late phases of the study.

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