These notes summarise the hospital management of
common or serious retinal conditions. To navigate to a particular
condition click on the link below:
If you have questions about a condition not listed on this page please do get in touch (contact details).
Age-related macular degeneration (AMD) There have been important advances in the treatment of AMD in recent
years, most notably the introduction of agents that inhibit vascular endothelial
growth factor (VEGF). Anti-VEGF agents target the new vessels responsible for
exudative (wet) AMD and the results of two large radomised clinical trial (MARINA and ANCHOR) establised ranibizumab
as an effective treatment. Anti-VEGF
treatment is available for many patients through the NHS, depending on their visual function and prognosis.
Because of the high drug cost of Lucentis, self-paying patients are often given Avastin
off-label, a much cheaper agent that is chemically related to Lucentis.
Although Avastin has not been subject to a large trial like Lucentis,
many clinicians feel it has a similar clinical effect. I am currently a principal investigator for a new surgical treatmentof
wet AMD that delivers a focal dose of radiation to the macula
via vitrectomy. Surgery has commenced recently at King's College
Hospital, and it is anticipated that centres in Southampton and Belfast
will soon follow. The potential advantage of
radiation is that it can eradicate the new vessels that
cause leakage in a one off procedure, unlike Lucentis which
requires regular injections for life. The study is called CABERNET and
the commercial spopsors are a US biotechnology company
called NeoVista. Preliminary results from America look
with visual outcome similar or better than Lucentis treatment, but
until the CABERNET study is completed a firm conclusion on
efficacy cannot be drawn. Patients wishing to be involved in this
study should click here.
Sadly, for atrophic (dry)
AMD there are no breakthrough medical or surgical treatments on the
horizon - low vision aids remain the mainstay of treatment. There
is some interest in implantable telescopic lenses for dry AMD and a
trial of these is underway at King's. Contact details are available by clicking here. A
guide to AMD referral is available by
clicking here. A patient information sheet is available here.
Severe, exudative, age-related macular degeneration
Diabetic retinopathy The
treatment of diabetic retinopathy has remained much the same for over a
decade. Those with mild disease (NAD or background diabetic
retinopathy) continue to require regular screening, such as annual
photographs via DECS (diabetic eye complication screening).
Moderate to severe non-proliferative retinopathy is
often reviewed regularly by an ophthalmologist.
disease (proliferative retinopathy or maculopathy) is usually treated
with laser - pan retinal photocoagulation (PRP) - to treat proliferating
new vessels, or macular grid laser to reduce macular oedema.
Severe proliferative disease not responding to treatment, or
vitreous haemorrhage from new vessels, may require vitrectomy and laser
in a small proportion of patients. Tight glucose control has been
proven to slow the progression of diabetic retinopathy. Control
of hypertension is also important. For referral guidelines click here. A patient information sheet is available here.
Retinal vein occlusion Retinal
vein occlusions can be divided into branch retinal vein occlusion
(BRVO) or central retinal vein occlusion (CRVO), depending on which
vessels are involved. CRVO produces haemorrhage throughout the
retina, whereas BRVO produces focal involvement. BRVO is
initially managed by observation alone, but if macular oedema develops
a macular grid laser is often required and there are studies
suggesting newer anti-VEGF agents such as Avastin may have a role to
play. BRVO and CRVO may
develop new vessels that are treated by panretinal
photocoagulation (PRP laser). Neovascularisation is usually a
response to extensive retinal ischaemia. In general,
ischaemic vein occlusions do worse than non-ischaemic cases,
particularly if the fovea is ischaemic. CRVO macular oedema
is difficult to treat and does not usually respond to grid laser.
Recently people have been
trying intravitreal steroid injections, and novel surgical techniques
such as radial optic neurotomy (RON) which is available to select
patients. Patients diagnosed with vein occlusion should have their
cardiovascular risk factors carefully managed to reduce the chance of
recurrence. Blood tests such as Full Blood Count, Fasting Glucose,
Lipids, ESR and others may be appropriate to exclude underlying
disease. Most patients with acute onset retinal vein occlusion should
by an ophthalmologist within approximately 1-2 weeks.
Vitreous floaters and posterior vitreous detachment Patients commoly have a few
floaters in their vision or the occasional flash of light (photopsia). These
patients can be referred routinely to an optometrist with a
request that they dilate the pupil and check the retina. More worrying symptoms include a sudden increase in the number of
floaters or change in their nature, significant photopsia, or field
defects - in this setting retinal detachment needs to be promptly
exluded with same-day ophthalmology review. Risk
retinal detachment include high myopia, complicated cataract
surgery, trauma, a postitive family history, and previous retinal detachment in either
commonest differential of photopsia is migraine but this is
usually experienced in both eyes simultaneously, unlike vitreoretinal photopsia that
usually occurs in the temporal field of one eye. The commonest
finding in patients referred to hospital with new floaters is a posterior vitreous
detachment. This occurs when the vitreous gel collapses, and
the posterior surface of the vitreous separates
from the retina. It is not in itself harmful, however, it can be
a prelude to retinal tears and detachment in a small minority of patients and
thus careful fundus examination is important. A patient information sheet is available here. For patients
who present with floaters always provide a retinal detachment warning,
advising them to present immediately if they develop flashes, increasing floaters, or a visual field defect.
Retinal tears and holes Retinal
tears usually occur when the vitreous pulls away from the
retina (see posterior vitreous detachment above) and
an abnormally strong vitreoretinal adhesion pulls a
break in the retina. These typically have a U-shaped or
horseshoe configuration and acute tears usually require treatment
(retinopexy) with laser or cryotherapy to reduce the risk
of retinal detachment. Longstanding tears sometimes lead to
a healing response that creates an adhesion between the retina and the
underlying RPE (retinal pigment epithelium), creating much the same
effect as retinopexy - in this setting retinopexy may not be
A U-shaped, horseshoe tear surrounded by laser retinopexy
Retinal holes have a different pathogenesis - they are round atrophic defects in the retina that can occur without
posterior vitreous detachment. They may occur in eyes with lattice
degeneration, a thinning of the retina associated with myopia.
Round holes can lead to retinal detachment but it is not proven that
retinopexy reduces this risk. In the past they were usually
treated, but this is becoming less common. Symptomatic retinal
tears should be seen by an ophthalmologist the same day, whereas
atrophic round holes picked up during a routine optician examination
can be referred routinely. Asymptomatic retinal tears should be
seen by an ophthalmologist semi-urgently (1-2 weeks). Provide all patients with a retinal detachment warning,
advising them to present immediately if they develop flashes, floaters, or a visual field defect.
detachment is usually occurs when a posterior vitreous detachment pulls
a break in the retina, and vitreous fluid passes into the potential
space between retina and RPE (retinal pigment epithelium). Detached
retina does not see so the patient experiences an enlarging visual
field defect. If the detachment extends to involve the macular (a
macular-off retinal detachment), then visual acuity drops
Occasionally, retinal detachments are asymptomatic.
A superior macular-on retinal detachment
involves one of three strategies: pneumatic
retinopexy, cryobuckle surgery, or vitrectomy/laser/gas. Pneumatic
retinopexy is reserved for a small number of straightforward
detachments; it has the advantage that it is a simple procedure, but it
has a fairly high failure rate, with about 30% of cases going on to
require cryobuckle or vitrectomy. Cryobuckle involves the use of
scleral explants to indent the sclera/RPE in apposition to the retina.
The retina-RPE are then sealed together with a laser
or cryoprobe. Vitrectomy involves removal of the vitreous gel,
and a gas bubble to push the retina onto the RPE from within the eye,
and again, laser or cryoprobes are used to seal the break.
Because of the gas bubble patients have certain restrictions
after surgery and these are outlined in the patient information sheets
posted elsewhere on this website. Occasionally,
retinal detachments are detected during routine optician
and these can be referred to an opthalmologist semi-urgently (1-2
weeks), however in all other situations patients require same-day
ophthalmology review and shoud be kept nil by mouth. Refer to a
with a Vitreoretinal Service, such as King's College Hospital.
Macular hole The exact
pathogenesis of macular holes is not known but the end result is a
full-thickness defect centred on the fovea. As expected this
produces a central visual defect with blurred vision and distortion.
Macular holes seen on OCT (left) and a fundus photograph (right).
treatment only a small
minority of macular holes resolve and surgery is usually recommended,
unless the macular hole has been present for a very long time (2 years
of more), when the visual prognosis is guarded. Surgery involves
vitrectomy and gas, and leads to hole closure in 80-90% of eyes. Not
all eyes with closure of the hole have visual
improvement, but most have an appreciable improvement. Fully normal
vision is seldom achieved. Patients should be referred to a
Vitreoretinal Surgeon, routinely. Patient
Epiretinal membrane An epiretinal
membrane is a thin layer of scar tissue on inner surface of the
retina. It usually occurs at the macula. Contraction of the
membrane causes corrugations in the fovea that distort the patient's
vision, with straight lines appearing bent or bowed. It can occur in
isolation or in association with other eye disease such as
peripheral retinal breaks, posterior uveitis, and trauma.
Treatment involves surgical removal with vitrectomy and membrane
peel. This usually, but not always, improves the distortion.
The effect on visual acuity may be less marked but some benefit
is common. Sometimes the membanes recur and repeat surgery is
required. Patients should be referred to a Vitreoretinal Surgeon on a routine basis.