 All right you guys ready for retina, but first We have to go to Barcelona So I don't know if you ever saw when the tour to France Finished when you know did a little bit around in Barcelona once they did a bunch of laps around here So this is the National Museum up there on the hill and I'm not sure what these two pillars do But they're pretty cool and there's a bunch of bikes racing around them. It looks it looks cool So that's the National Museum and This is from the Walkway if you go up there, it's kind of nice because Barcelona's it's on the water But it does has some hills around it So it's got the look of a little bit of a valley and it's got quite a bit of green around it So this is kind of looking down to where there's two pillars were you can see they've got a little stadium down here where they do They do temporary concerts and things the proverbial lions, you know garden the stairway when you go up And this is looking out into the city so this is the Fortress on top of Montjuic and You guys are too young to remember the 92 Olympics, but that's where the 92 Olympics were when they had you've heard of the dream team You know, that's where the dream team play. Is there a pointer in here anywhere? I Didn't bring my Yoda pointer, so I Don't think that's a pointer All right, very good Okay, we're gonna talk about retina And you know when we talk about the retina there's going to be a theme that keeps bouncing back over and over and over and ophthalmology and The question that I put out is what do ogre's onions and retinas have in common? Layers exactly so we're going to pound the layers of the retina So when we look at the retina first thing is you want to look at some definitions And so when you look at the definitions of the retina the definition of the macula Basically what retina people call it is the macula is the area within the arcades But if you look at it pathologically the macula is also The area where you have more than one ganglion cell and so to a pathologist. That's the macula Fortunately most of these line up and so really the area within the arcades is the area that pathologists call the macula All right, so when we're starting on the layers We want to start first at the vitreous and then work our way down to the sclera So we're going to just go around the room and you can't hide back there Renee So it doesn't matter. I'll still find you so we're going to start on the vitreous side So first layer of the retina Reese Interlimiting membrane Eileen They're fiber layer who's back there Julia right Renee who's next Niko? In a nuclear layer Outer pucks one. I don't know you All right, so outer nuclear layer you guys are That's it that's that's good with somebody who knows all All right, so we had left at the outer nuclear layer. So what do we call this layer right here? See they put pressure on you now. They said you do everything. So that's the hard part That's what the photoreceptors are exactly so this is the photoreceptor layer Okay, and then you can see the photoreceptor layer is kind of divided into an inner segment and an outer segment So inner segment outer segment and then this layer right here. Oh John good timing here Right little pigment epithelium. All right, so we're going to come back down here again. What layer is that right there? Coriocapallaris and then you go to the medium vessels and the larger vessels of the coroid and then eventually the sclera So when we look at a little bit of a higher power here What we want to do is we want to trace a photon of light So it comes through the cornea it's refracted it comes through the lens it's refracted more it goes through the vitreous You know the retina is really upside down because light has to go all the way through the retina To get to the rods and cones which are furthest away So, you know first you think you the retina should have been designed with the rods and cones on the outside You know facing the vitreous, but that's the furthest away from its nutrients So the reason that the retina evolved this way I'm sorry Ted Cruz one yesterday the reason that this was designed intelligently this way is That you want the rods and cones to be near their blood supply because they're very highly metabolically active And so the rods and cones are actually down here. So photon of light has to go all the way through So photon of light comes through it hits What part of the rods and cones that starts the actual mechanism that lets you see light? All right, so where does the rhodopsin live? Exactly so the outer segments here you've got it's like a stack of coins if you look at it on an EM and on that membrane Out there is the rhodopsin and so photon of light hits it It does the flip from cyst to trans and then what that does is that starts? hyperpolarization that eventually starts an electrical cascade going and so the rods and cones Start the cascade going now the inner part of the rod and cone cell This is where the cell nuclear. This is where the cell has its Lights it's um, you know activity that are there, you know, it's got mitochondria in there It's got all kinds of things in there and then of course this layer right here in the outer Nuclear layer is where the cell body of the rods and cones lives Okay, so then that signal then Leaves the you know first layer right here and it goes to the Outer Plexiform layer and what happens there Eileen? Okay, let's let's do the cascade first and then we'll worry about the other cells so So with the bipolar cells so the bipolar cells and so it synapses with the bipolar cells The bipolar cell bodies are here in the inner nuclear layer and then that signal leaves out the axons here and synapses in This layer right here with what cells? Ganglion sounds okay, so then the axon of that ganglion cell leaves the ganglion cell Renee, where does it go from there? Exactly so that axon that leaves this ganglion cell goes all the way back through the optic nerve through the chiasm Through the radiations all the way the lateral genicular body. That's a really long axon And so anywhere along that pathway that can be interrupted and can cause damage along this Very very long axon So the other thing when you look at the retina is there are Some other cells in there beside the cells that we just talked about and they are located Pretty much in this inner nuclear layer right here. And so Niko tell me a couple of other cells that live in that inner nuclear layer Okay, and what do they do all right? So the Miller cells live here and they're kind of a microglial cell if you will and they do some have some support They've got little foot plates that come all the way here and along here if you look at really low power those little Dots that are along there will form a membrane. They'll call that the outer limiting membrane It's not really a membrane But then also their foot plates will go all the way up here to to the inner limiting membrane which is between The retina and the vitreous and so that's not again not a true basement membrane, but it is a little membrane like structure Horizontal cells, what do they do? Yeah, they kind of they spread horizontally if you will and they touch multiple different Areas where the you know nerve 5 where the I'm sorry the bipolar cells interact And so these are the beginning of processing a vision right here And so they really do go out and Helga Cole who was a PhD here who's now retired Did some wonderful EM pictures that they colorized and made into Videos and she gave a proctor talk a few years ago of the interactions there So this is really where visual processing begins. It's not actually in the brain It's actually right here in the retina. So they start and there's one other cell layer here Or one other cell type we should say in there Amicron cells and you know amicron are kind of like bipolar They're the ones again. They think of them as big octopuses. They put their Tentacles out all over the place and they're involved in early processing of the image Now right now, where are we now? Let's I'll give you a break again Jen. All right more specific Exactly. So this means we're in the maculans. So if you look at the ganglion cell layer You see that there's multiple ganglion cell layers here and the other thing interesting is look at the fibers From the outer plexiform layer From the outer nuclear layer here through the outer plexiform layer. They are running horizontally instead of vertically What layer do we call that? Still John, sorry Well, there's a specific area in the macula where these start running horizontally instead of vertically That's the Henley's layer Henley's layer Oh, man. I sound like the guy on Jeopardy, you know, Art Trebek He always sounds like he's so smart because he knows all the answers anyway when they miss it He'll like he'll say it like he knows it. So you see how it's running horizontally here So if you think about why that is this is the center of the fovea and in the center of the fovea You want those light rays to come in unimpeded And so what happens is is you see that the retina really thins out here And you've got all these mostly cones here a few rods mostly cones stacked up here And so those have to connect to the ganglion cells over here And what happens is is that they have to run this way in order to do it And so you get the fibers running Horizontally instead of vertically and that's Henley's layer the reason that that's important is That is where you get sister macular edema. That's why it has that funny flower petal look to it when you look at it Now when you look at the fovea the fovea is responsible for fine vision and so The foveal cones bless you Have a one to one connection between the bipolar cells to the ganglion cells and so it's one to one to one So all of these cones Have to link to ganglion so all those ganglion cells over here get stacked up And that's why it's multiple cell layers there in the periphery of the retina You might have a hundred rods hooked up to one ganglion cell And that's important because the periphery is involved in summation And so your central fovea gives you fine vision It's what lets you have the detail of the vision we have but the periphery Helps you to see movement and to see things going on in the periphery. Why is that important? Well, you know when we were out on the the tundra and you know say we're two tigers are chasing us You want to see that movement out there? There's a survival factor in it Whereas the central fovea eventually developed as we became more dept at seeing fine near vision And that's what we think of as our good vision. So you look at it all these ganglion cells stack up here and they're connected I don't know bleak angle by the henlings layer And I think we've talked this to death. So we'll go here. All right So what we want to do now is get into specific diseases that can affect the retina and one of the most common Problems that you see a lot when you're looking at the retina is vascular diseases. And so we're going to think we came around All right back to Reese again All right, so this is a good picture because it kind of shows us a lot of different things going on So why do flame hemorrhages look like flames and why do dot blot hemorrhages look like dots and blots? Yeah, so that nerve fiber layer as the Accents come out of the ganglion cells they turn around the corner and then they run along The surface and then into the optic nerve. And so if you get hemorrhages Along that surface layer they're shaped like a flame if you get hemorrhages deeper Then they are called dot and blot hemorrhages Eileen what else do we see when we're looking at the vasculature here? Look at the Little sausages right there when the arterioles Cross the vein you'll just see that's sausageing that avi-nicking. What causes that? Exactly so you can actually almost see The arterial lining people will start calling this silver wiring or copper wiring And so when you get arterial sclerosis the arterial wall thickens The column of blood narrows and then you see as it crosses over the sheath where the vein is you'll get Sausaging of the vein Julia what is this right here? All right, so that's called heart exudates and and the reason they do that is Used to in the olden days even before I was a resident maybe when Crandall was a resident You know they had to distinguish between heart exudates and soft exudates and they used to call these little fluffy white things up here Soft exudates now we know now those aren't exudates. Those are actually Little focal spots of ischemia called cotton wool spots and so But these are called heart exudates and that's where you get leakage of not rbc's from the vessels But the actual serum so it's lipid rich. It kind of looks yellow and so those are heart exudates So what could the etiology of this be? Exactly this could be hyperdesin that could be severe diabetics too because diabetics can get looks like this But this is a severe hypertensive retinopathy So you see if you like this you want to be really, you know careful to measure the patient's blood pressure And and this is another patient with high high blood pressure and nico. What are we seeing? Um right here. What's the shape of those heart exudates? Yeah, you see those little radio lines people will call these they almost look like little starbursts or You know like little if you look at the sun valley sun, you know, it's got the sun rays coming out of it So you've got that appearance to it and again that's because those exudates are going out in henley's layer And so they kind of spread out in that little sunburst pattern. So heart exudates here You see these hemorrhages around the disc. Look at that disc. It looks kind of more congested than normal And so when you have hypertensive retinopathy you can actually get disc swelling along with it And so you look real carefully maybe the beginnings of some disc swelling right there And then of course, this is a severe Hypertensive retinopathy where you can actually get frank papillodema from from severe Hypertension. This was a patient. They actually came to clinic when I was a resident and we were worried. Oh my god We were going to work them up for CT scan of the head Because there were no MRIs then yet and we were going to do all kinds of scans to figure out why they had papillodema And a medical student said well did anyone check their blood pressure? Medical student. So we were all embarrassed. We pulled out that thing that you put on the patient's You know arm and that other thing you put in your ears and we Pumped it up and listened and it was two ten over one ten So this patient had a hypertensive crisis sent him immediately to the emergency room for treatment. And so this is severe you know grade five Hypertensive retinopathy All right, what do we see in right here All right, so this is an ischemic retina star for oxygen It's very white pale swollen. What is the cherry red spot? Exactly. So that's like a window defect So remember that the fovea gets its blood supply The deeper part of the fovea from the core right the core. It'll blood supply is still good And so you have that thinning of the superficial retinus So you can't have all that edema in there to block it off. So you actually see that Fovial blood supply shining through so that's a classic cherry red spot from a central retinol artery occlusion All right, chris. What do we see in here? So you see you've got ischemia in this area here. And so that's when you get a branch artery occlusion now our artery occlusions usually embolic or thrombotic Now you had a 50 50 chance Embolic embolic ah very good. Very good. So I was just saying with confidence Exactly you said it with confidence. So you're making a guess guess with confidence You get credit when we are another so It's actually most commonly embolic when you see that the branch artery occlusions And so you'll sometimes be able to see a little You know emboli of some kind either blood or cholesterol or whatever And so usually embolic when you see those Now what we're showing here is what chance to save yourself So first of all, where are we at these funny? Things all the way around here this artery and vein Renee did I skip you that last round? I think I did. I just realized that Renee Where are we not quite in the orbit yet? Where are we? Well? Yeah, I guess this technically is part of the orbit more specific Who said nerve? All right, this is the optic nerve and so remember when The central retin artery comes into the eye it comes through the center of the optic nerve But the central retinal vein runs right next to it So if you look right here, this is an extremely arteriosclerotic artery right here Look at all that lipid in there that artery is narrowed down to that right there. So this is Um, you know the guys from crown burgers, you know who eat lunch there every day And you can see all that pastrami stacked up in the artery there and look how narrow that is You've got that narrowed artery and so it's very susceptible to clots because it's narrowed down It's more susceptible to the clots and to emboli So the most common cause of a central retinal artery is arteriosclerosis that leads to emboli What's the most common cause of a central retinal vein occlusion? Again, Renee Exactly So you see the artery in the vein as they come in share kind of a common Adventure area around them. And so the most common cause of a central retinal vein occlusion is that fat cholesterol filled artery Pushing against it, which then causes stasis and not emboli but thrombi So central retinal vein occlusion is you get stasis and thrombi formation But it's arteriosclerosis next to it that causes it So this is the result of a central retinal artery occlusion and And john tell me a little bit about the blood supply to the retina Why do you have this picture if you've had a central retinal artery occlusion? Roughly, how much of the inner layers? Well, two-thirds of the whole retina. So that's a good way to remember it So the inner two-thirds of the retina gets its blood supply from the central retinal artery the outer third Gets its blood supply from the chloride So if you look at this You see that the ganglion cell layers totally wiped out almost all of the inner nuclear layers wiped out So you just got you know a tiny bit left there But then you see the outer nuclear layer and the rods and cones are still alive because they're getting their blood supply from the chloride So the outer third gets its blood supply from the chloride inner two-thirds from the central retinal artery All right, we are Back to Reese. Okay. So what do we see in here? So what do you think caused this? Exactly. So this is a central retinal vein occlusion. They call this the blood and thunder retina I have no idea what that means, but it means it's you know bad, you know, you look a lot of blood a lot of thunder So blood and thunder so you see that if you have a complete central retinal vein occlusion you get backup of blood all the way I mean, and so you see just diffused backup of blood and As opposed to this which is what is this right here? More of a branch vein now when the branch vein occlusion occurs, where does it usually occur? Exactly. So again, it's arterial sclerosis. So you see that silver wired Curial and where that vein crosses it where you had that Sausage, you can get stasis there and then you can get a branch vein occlusion So not only do you see blood, but what are these guys right here? Little cotton those spots you can get ischemia there too. So you can have central retinal vein occlusions Then you can have more focal branch retinal vein occlusions And this shows you what a central occlusion looks like in a globe that's been cut in half And you see that that blood goes all the way to the aurasurata from the optic nerve all the way to the aurasurata So it's just a diffuse Blockage and you get blood backed up everywhere And here you can see what the retina looks like you get Ischemic changes, but you get a lot of blood in the retina and you can even get exudate Here in the retinas so central retinal vein occlusion can cause a lot of damage Eileen what else do you worry about beside acute damage in a central retinal vein occlusion say several months out? And what causes that? Exactly so you can get chronic ischemia And then ischemia will produce these magic humors Which you know we call now like vegef among other things And so what happens is is these humors will make abnormal blood vessels grow So when you get a central vein occlusion and it is ischemic, what's the most common place that you get neovascularization? Actually, no Nico The iris okay, you got it that counts all right So the iris and so you know you can get neovascularization in the retina But what you really worry about when you got a ischemic central retinal vein occlusion you get neovascularization of the iris And so then you can get secondary neovascular glaucoma So you worry about that if you have lots of ischemia All right now Nico, we're kind of this almost looks similar to that first picture that we showed And tell me what you're seeing here All right lots of heart exudates Got flat flame Those are the cotton low spots so This isn't hypertension. What else causes it to look like this? Actually the most common um Most common What should I call it most common vascular disease That that can affect the eye Diabetes exactly. So this is diabetic retinopathy. This is a nice picture because this shows you All of the changes of background retinopathy dot blot hemorrhages heart exudates But when you start to see cotton low spots, that means ischemia is beginning So now it's phasing into pre-perliferative retinopathy. So this is a diabetic And the first thing that we see in in diabetics Brian Yeah, so so what we can do you can do what's called the trypsin digest You can take You know a piece of retina you can digest the stuff around it and leaves the vessels behind and you see the first Finding of diabetes is you can get these little micro aneurysms. So you start to have Parasites drop out vascular walls get weakened you get micro aneurysms eventually these can leak And cause some of the other findings that you see All right, what do we see in right here? Chris So you can see this is more macular heart exudate and so These are really difficult to treat because once you get that heart exudate in there. It's very lipid rich It can really disrupt vision. So you can't really laser that that destroys tissue just as badly And so you you really want to treat the diabetes get that under control and try to prevent that You know macular edema and macular exudate from occurring And here you can see this is exudated stains that nice pink color on h and e stain in the outer Plexiform layer the layer of Henley here. So macular heart exudate in in diabetes Renee, what do we see in here? Cut low spots and what did we say causes those? Of what layer? The nerve fiber layer and so here we have the nerve fiber layer you get some focal ischemia All those ganglion cells get swollen And you get that wispy cotton wool look because it's in the very surface layer And so it gives you that little cotton wool spot that's the it just kind of follows the way that the fibers run Now these can come and go because as the ischemia goes away It's not that that recovers you're left with a little dead spot right there, but it won't be swollen It's the swelling that you see And here's a close-up These are actually the ganglion cells here that are ischemic that become swollen. So that's what causes the Cotton wool spots and again, that's a sign of pre perliferative retinopathy All right, john, what do we see in here? All right, so we see a diffuse hemorrhages, but there's something else besides just hemorrhages What's going on right here? Exactly so neo vascularization And so you're actually going now from pre perliferative to proliferative retinopathy. So now we're seeing neo vascularization and when we Divide up neo vascularization. We kind of divide it up into two Things we call it neo vascularization of the disc And neo vascularization elsewhere. So this is nv. This is elsewhere. This is peripheral neo vascularization And then of course here we have your classic neo vascularization of the disc Where you see the medusa's head remember medusa and Greek mythology with the snakes coming out of her head? And so this really does it looks like medusa here neo vascularization of the discs What was interesting is in the 1970s Lasers were just being invented and ophthalmologists were getting xenon arc lasers. These things were great I mean the laser was like the size of a vw van, you know, and it would put out these Thousand millimeter spot sizes, you know, you would just cook it and so people said well if this is a neo vascularization We should you know zap these these abnormal vessels with laser and it'll make them go away And so they would zap the heck out of the optic nerve head Well, they quickly found out that the patients would immediately go blind because you would kill off The whole you know Ratna around here, but at the same time they were taking these xenon lasers They were blasting the peripheral neo vascularization. What was happening is when they blasted the periphery The neo vascularization on the disc went away And so as people understood more what was going on You actually treat the peripheral retina to kill off ischemic retina in order to cause The neo vascularization to regress And so you treat the entire peripheral retina now with laser and that actually causes regression centrally So you don't treat the neo vascularization itself You treat the ischemic retina and then the neo vascularization goes away So they quickly realized you don't treat the optic nerve had you treat the periphery And this is what can happen when you don't treat it Right away. So I guess we'll start back again at that Reese. What are we seeing here? Put it through membrane and you can see here this This stock of gliotic Retinence so when you get hemorrhaging you can have stimulation of Gliosis you can get tractional retinal detachments. You can get all kinds of problems and Of course, you can get this Eileen. What do we see in here? And what shape do we call this? For both exactly good. I love that Too bad Custis our old fellow wasn't here. So So it's boat shaped exactly. So you see it's got a flat top because it's kind of Pre-retinal it's it's in front between the retina and the posterior vitreous And so you'll have a flat top on it and then kind of around bottom So boat shaped hemorrhage and so the idea is you want to prevent this from happening in the first place by Treating the ischemia and causing it to go away Niko so what happens if you don't treat the ischemia? All right, so what do we call this and people would call this rubiosus, you know red iris so rubiosus irritus We used to call it when it got this bad rupiosus because those big dilated vessels look like ropes. So this is rupiosus on neovascularization of the surface of the iris secondary to chronic ischemia And what can happen when when you see this? Let's go back to brian What do we see here? What do you should be looking at? So this is the iris and cross-investigation of the iris and then the pupil margin is turning Yeah, so you see that that posterior pigment theme is being pulled around the corner So what happens is when those vessels grow on the iris they have some contractile elements to it So they'll eventually contract and that pupillary border will get pulled around the corner and you'll get pigment epithelium There and so when you look at these they'll actually have a little black margin Around where the pupil is and so this is ectropion UVA What do we see in right here Chris? Yeah, so you see a closure of the angle there and what do we call that when it's it's like doing closure, but we call this a a peripheral anterior Sonechia or PIS we see that the angle is closed off as those vessels grow and then you get the peripheral iris Sticking to the cornea and so it closes off the angle so you get secondary angle closure again from ischemia From the retina causing the iris neovestigation Now there's one other thing that can that can happen to the iris and diabetics Rene exactly lacy Vaculization of the pigment epithelium and that's from the chronic ischemic changes And last but not least John. What part of the eye are we looking at here? Ciliary body good. What stain are we do using here? PAS and so what is this is showing us? Basal membrane and what do you make of that ciliary body basement membrane? It's very thick so diabetes can cause thick ciliary basement membrane So I took a picture very similar to this one I was a Dave Apple fellow and he took my pictures and he turned them into the board of ophthalmology And so when I took boards for real I looked and my picture was on there and I said wow diabetic You know the ciliary basement membrane man. I'm good. I can get this and then the question said And you guys will love it those of you haven't taken boards It's just a killer because it's a two-part question. They said a patient with this picture would have a you know creatinine clearance of You know b perineal nerve velocity of And so I what their diabetic they're going to spill creatinine their nerve velocity is going to be slowed down. I said women What's a normal creatinine clearance? What's a normal perineal nerve velocity? So that's how they separate wheat from chaff on boards and so even if you know the answer you still don't get the answer right But it was kind of fun to see my own picture on the board exam. I love that. I went I took that picture. I know this So thickened ciliary body basement membrane in diabetes All right, so back to Reese again. What is this? Someone with measles, you know of the retina Those are laser spots exactly so we've treated the peripheral retina with laser panoramic photocoagulation and Basically the way the laser works is we still use mostly an argon laser mostly argon But the laser is absorbed by the pigment epithelium. It creates heat It kind of kills off this part of the retina here. You see the chorio capillaris seals off You get a loss of the retina there You have normal retina here and here and so you do the laser spots people have argued a long time about how the laser works It does definitely decrease Vegev and other vascular You know humors that cause vessels to grow but some people say they do it by You know allowing more oxygen to come through this area where you've cooked it with the laser Other people have argued said no, no, no, you just kill off ischemic retina. So there's less retina to make these bad humors Because I don't know the answer that this is what a laser spot looks like Eileen what the heck is this? So what are we looking at? What kind of study here? Yeah, they still do fluorescein now with all the octs. They actually do inject it still. Okay But so what's going on here? This is kind of a weird-looking picture Yeah, so you see this black area here. That means that there's no Fluorescent getting in there no blood getting in this. So it's not perfused and you've got this Neovascularization kind of at the interface they call this a C fan So what entities can you get this in? Sickle cell, yeah Now you could also get I think retinopathy of prematurity will sometimes look like this too But when you've got this C fan and then this area of non-profused periphery, this is a case of sickle cell And so this is a patient with severe sickle cell and this is a again just kind of showing you What it does to those blood vessels so chronic sickle cell can cause little micro vascular occlusions and cause this little beady Change to the vessels as you're there All right. Let's look at some other things here. Nico, what are we looking at here? Hole, yeah, exactly. This is a macular hole And so this is one of those pictures where I say it's really apparent because even the intern can get it So this is one of those inter maybe even a student would get this. I don't know But certainly the intern can get it. So there's a macular hole And then this is a close-up showing you that what is this Thing right here. Is that like a string of blood coming out of that hole? What is that? Trick question, sorry That's the little rod that that the person looks at when the photographer is taking the picture And so when you have a central defect you can't focus centrally So they tell you look at the end of that stick that said that's actually the artifact of the stick there So there you see that macular hole And you see that there's a little area of edema a little area of swelling around it And this is the only picture I could find I'm sorry because people don't You know take out macular holes and send them to us And this is an old old picture of a macular hole and then some of the edema around it And so we now know that it's A an area of traction that's around that that causes the hole to happen So the retina guys will go in peel off all the traction Put a bunch of gas in there have the patient sit face down for a period of time and hopefully seal that hole off A little bit more subtle right here Brian. What do we see in here? That's Exactly so this is probably an epirentinal membrane and this is a more Dramatic one even the student again could see this one So but you see right here that these vessels are being yanked into this you can actually see The epirentinal membrane on the surface of the retina, but sometimes these can be really subtle And you just don't don't see them as well. And so this is again. Here's that rod You know pointing down for the camera. What kind of picture is this? Brian yeah, yeah or a red free. I guess you would call it is so Yeah red for you red for you know, I knew what you meant So you can see right here red free picture and you see the vessels being pulled Into this little membrane on the surface and being stretched out And so that's an epirentinal membrane and you know when you look at it with the OCT nowadays you can really see A nice area where you've got that wrinkled membrane and you can get Focal areas where you actually get traction on the retina from the epirentinal membrane And here again you can see on the OCT That nice epirentinal membrane there on the surface Pathologically what causes an epirentinal membrane what kind of cells once again Brian what kind of cells cause it? Yeah, the the astrocytes And so you have in the retina a few little scattered Astrocytes and if they gain access to the surface of the retina they can grow and you'll see they cause this Irregular folding pattern on the surface. I like to think of it as like a wrinkled piece of cellophane When you get on the surface Chris, what are we seeing here? All right, so a bunch of drusen Where are drusen located? All right, so actually right under the RPE All right, so this is a good thing. I purposely left this until now There's one more layer that we didn't talk about so What is the membrane between the RPE and the coroid called? Brooks membrane and how many layers are in Brooks membrane? Renee five and what are the five? Based memory in the RPE Collagen layer elastic Another collagen Basement memory in the coro kepler. So the way you think of it is it's a turkey sandwich from upstairs at the judge You have the bread on both sides the RPE Basement membrane the coro kepler space membrane, then you have the turkey which up there is pretty collagenous So you got two collagenous layers and in the middle You've got your elastic american cheese layer in there. So Elastic in the middle two collagen layers and then two basement membrane So technically a drusen if you really want to be specific is actually intra Brooks And so it's actually underneath the RPE But still along what's left of Brooks there. So this is where drusen sits And this is a little bit of a bigger drusen. We call this a soft drusen And so you see it's a big drusen here, but look what it does it disrupts the RPE overhead Which then disrupts the retina because the retina gets its nourishment from there So it disrupts the retinal nourishment. So that's a drusen And these are again a picture of some Softer drusen. So the soft drusen are bigger. They don't have such a distinct edge to them And here you see RPE broken up Soft drusen right there Okay, what do we see in our eye here John? All right, so you've got some areas there where the pigment is clumped up here the RPE is clumped up, but look at the rest of it right here What do we call that when you get this Kind of RPE totally wiped out just a little bit left there Yeah, I'm sorry you guys in path. Don't see retina pictures. So This is called geographic atrophy. And so this is again a variation of macular degeneration You can get diffuse disruption of the RPE and eventually Leads geographic atrophy, which can cause loss of central vision And when you look at a patient with geographic atrophy, you see that here's Brooks membrane right here You can still see it But look the RPE is totally wiped out. There's some soft drusen here and here and look at the surface retina It's just wiped out. I mean there's just no retina left there. So that's diffuse geographic atrophy with macular degeneration All right, what do we see in right here? Will you yawn here Reese? Well, there may be a small pigment epithelial detachment, but what's going on right here? Why do you have that? Greenish gray color with elevation Yeah, so you've got some retinal neovascularization and technically when it's got that dark dark color to it It's actually probably even sub RPE neovascularization So it's neovascularization underneath the RPE, which gives you kind of that greenish tint to it And when you look right here, I had to get this out of a book because again, I don't have this beautiful picture But here is Brooks membrane core capillaries look right here These vessels from the quarry to broken through Brooks and they're spreading under what's left of the RPE there So sub retinal actually even sub RPE Neovascularization so for some reason in macular degeneration You'll get that focal break in Brooks and then vessels will come from the quarry and start growing under the RPE and eventually under the retina So what we used to do with these our treatment was that you would take a laser And you just blast the heck out of it where it was and that would seal it off And the patient would go from you know, 2200 to 2200 And you would say yeah, but we kept you from going to 2400. So It's like the old analogy they used to use in vietnam the generals They used to bomb the village so they could save it, you know Now we bombed it so we could save it, you know, so the communists wouldn't take it over So we used to bomb the retina to save what little of it was still left with with laser But now we can inject with anti-vegeta and actually cause that to shrink down before it gets to this point So this is a severe sub-retinol Which is the red and sub-RPE which is the darker hand mentioned So this is the kind of the end stage of a sub-retinal neovascularization and then What that can do Eileen is that can induce this change which is Don't you love when they try to help you and you go, what the hell is that? Lego blocks, you know coming together. What is that? Well, just step back when you don't say, god, what is that? What kind of tissue does that look like? Yeah, so it's like a connective tissue And so remember there's no fibroblasts there in the retina, but there are Atrocytes and so this isn't fibrosis, but it is Gliosis exactly. So if you have sub-retinal neo, you can eventually get sub-retinal Gliosis And this is what we call a discoform scar. So end stage Neovascularization for macular degeneration you get this discoform scar underneath there All right, Nico, what do we see in here? So some kind of focal lesions affecting the deep retina and the coroid and then here Where are we there? macula, so what could cause a picture like this where you've got Macular disruption and then some focal discrete round lesions in the periphery Infectious good What kind of infection? Not a toxo but a histoplasmosis And so this is a classic picture of histoplasmosis and you have to be Technically correct. They call it presumed ocular histo because by the time you see this You don't have any active beasts in there And so they just you know the blood tests show there was histo and people live in the proper area where histo lives And so you see these punched out lesions they call them In the coroid periphery and then you can have this macular lesions here. So this is presumed ocular histoplasmosis Now this is a little bit of a a different look to the macula here Brian, what do we see in here? I'll give you a hint. This was your last cataract patient at the Vaugh Exactly so this is the so-called cystoid macular edema and the reason they call it that is when you do the floor scene You get this late leakage and it has this flower petal Appearance as you get leakage of Fluid into henley's layer again into the outer tuxiform layer. So this is Cystoid macular edema and the most common cause that we see for this is post op You know, you can see this from chronic uveitis and other inflammatory diseases But usually post op is what the cause is for cystoid macular edema and here we have what part of the eye are we in? Macular because look at the ganglion cell layer And sure enough out here in henley's layer is Exudate so this is chronic cystoid macular edema Chris, what do we see in here? Exactly. So kind of a bullseye pattern. So what's your differential when you see a bullseye in the macula? Yeah, nowadays it's placoidal toxicity and this is why we watch these patients so carefully because we don't want to let it Get to this point once it gets to this point. It may not be so reversible So we're doing tests on our placoidal people to find out signs of toxicity early Before you get to this final bullseye maculopathy and when you do a fluorescein angiogram How would you describe this? So it's not a leakage. It's just a focal Area of some of some staining that you see and it really demarks that bullseye pattern to it So you can get it from other medicines beside placoidal chronic Melaril toxicity can give it to you some antipsychotics can give it to you, but it's usually medicine induced Renee, what do we see in here? Yeah, so where are angioid streaks located? Yeah, so they're deeper this that first glad you say oh some funny vessels here, but if you look Here's the vessels up here. These are under the retina. So there breaks in brook. So what classically causes this? All right, and so this is the classic Plucked chicken look to the skin in a patient with pseudosanthoma elastica So it's a disease that affects the elastic tissue brooks membrane becomes brittle And it comes to have some focal breaks. And so you get the classic plucked chicken look to it What do we see in here? John Okay, so the problem is is when you're not sure what the answer is you tend to it's Slow and really quietly That makes it easier. So So there's a triad here and what I want to point out Look at the disc waxy powder of the disc Markedly attenuated arterioles and then there's Bony spicule pigment pattern in the periphery. Does that ring any bells? Uh-huh. What are bony spicules usually? Retinitis pigmentosa. So this is the classic picture of retinitis pigmentosa And this is more in the periphery. You see this bony spicule pattern and When you look at it what causes that is the rpe gets really disrupted the pigment goes up And it tends to deposit around the vessels which gives it the bony spicule look So this is retinitis pigmentosa All right back to Reese. What do we see in here? Okay, so what pattern does this fit what disease? All right, so this is the classic kind of sunny side up Yoke look to best disease now you can get this usually in kids, but in adults they can call it the teleform type dystrophy It's the same thing you get this this sunny side up egg look and you get these deposits Underneath the rpe and best disease or in the teleform dystrophy All right Eileen. What do we see in here? Yeah, so this is classic for stargarts or fundus flavy maculata and some people call these piece of form and I don't get it. They say these look fish like, you know, Pisces the fish. So from what language? From the greek, of course from the greek. So They call these pisiformer fish like so this is classic stargarts fundus flavy And what you see is you see these deposits In the rpe cells and what are those usually made of beside pigment? Lipofucin so you get lipofucin Stuffed into those rpe cells in in stargarts disease All right, Nico What do we see in here? Yes, you see this kind of Yellowish irregular thing now when you see a hazy fundus you look through there They call that the headlight and the fog because you're seeing the optic nerve head through this fogginess. What causes the fogging? Actually blood can do it, but in this case, it's inflammatory cells in the vitreous So you've got an inflammation that's spilling over in the vitreous and then you see This little lesion here now if you let it go and you look at it a few years later. It may look like this So what do you think could cause this look? You already said this once Uh-huh short-term memory Yeah, so this is toxo so toxa you get this classic later on you get these lacunar Areas where the everything's been wiped out coroid retinol You're seeing a sclera showing through and then you get this pigment around it here, but when it's acute You get it's a choreo retinitis And so you get this spill over into the vitreous headlight and the fog and This is the classic look at the end once it's settled down now There still may be some toxo cysts sitting in there and they can actually reactivate sometime later So it's toxoplasmosis and when you look at the retin in these cases Here's your rpe and your retin and you can see it wipes out the rpe and the retina from the toxo All right, brian, what do we see in here? All right, so this is your classic picture of cmv and people call this the tomato ketchup look or the pizza look So you'll have hemorrhages. You'll have exudates You'll have edema now. Fortunately. We're not seeing this as often now when the AIDS outbreak really came You know really came of age and I was a resident We saw this a lot because we didn't understand it but now with triple therapy and antiretrovirals and all We're seeing this much less frequently. In fact, the last cmv I saw actually wasn't an hiv patient It was a patient who'd had a bone marrow transplant and was immunosuppressed So chronic immunosuppression can give you this look, but this is chronic cmv seromego virus And when you look what's interesting is you can get intra nuclear Inclusions you can also get intracellular plasmid inclusions. So they get in the ganglion. So you get these big swollen ganglion cells from the cytomegovirus Okay, so that's from Mao's week Sitting there on a cold blustery day in Barthelona, and I think we've killed Barthelona if I'm not mistaken and so I'm going to have to come up with something different for next week. So next week is Optic nerve. So know you're optic nerve. All right