Ординатура / Офтальмология / Английские материалы / Pediatric Opthalmology_Mukherjee_2005

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Thickness of the retina is not uniform through out, it is thickest at the optic disc7 and thinnest at the centre of the fovea. The outer border of the fovea is the thickest area of the retina.7 In the ora, the arterioles and venules look to have same diameter and colour.8

The ora serrata is represented by an imaginary line joining the attachment of the four recti on the scleral surface. In adults it is 6 mm away from the limbus. The equator is 6-8 mm away farther behind the ora.

Functionally the retina can be divided into two areas, the central and peripheral. The central area is 5 mm to 6 mm in diameter which has dense cone population and less rod population, hence it is meant for day vision, fine vision and colour vision. In the centre of the central arc is the macula. Number of cones fall fast on the periphery. The peripheral retina is used for coarse vision, night vision and peripheral field of vision.

The macula is a relatively large area as compared to optic disc. It is an area 5.5 mm in diameter without any definite anatomical demarcation. It lies lateral to the optic disc between the superior and inferior temporal retinal vessels. Its medial border is very close to the lateral border of the disc. It subtends an angle of 15° on the nodal point, the disc subtends an angle of 4.5°. The centre of the macula is 2 disc diameter away from the lateral margin of the disc and 0.8 mm below the horizontal meridian. The macula looks darker than the rest of the retina because it contains xanthophyll, which is lipid soluble carotinoid in nature with yellow colour.

The pigment epithelium is more pigmented under the macula than rest of the retina. The macula is packed with cones. About 10 percent of all cones are located in the macula. The ratio between rods to cones in the macula is 1 : 2. The number of rods increases on the periphery and there is proportionate reduction in number of cones on the periphery.

The macula is sub divided into four zones—Foveola, fovea, para fovea and peri fovea.

The foveola is innermost 0.2 mm area. This is little depressed than rest of the macula. The fovea contains only photo receptors and their nuclei. This makes the retina thinnest at the foveola. The second and third neurones are displaced circumferentially.

The fovea—The surrounding area 1.5 mm in diameter is called fovea. The cones in the fovea are more elongated than in other areas. In contrast to foveola which is thinnest part of the retina, the outer border of the fovea is the thickest part of the retina which is 2.5 mm in diameter and called para fovea, the remaining part of the macula constitutes the peri fovea. The central 0.4 mm to 0.5 mm area of the fovea is devoid of retinal capillaries and called foveal avascular zone (FAZ), which is demonstrated on fluorescein angiography. The explanation for absence of capillaries in the foveola is as follows : The retina has dual blood supply.

The inner part up to inner nuclear layer gets blood supplies from the retinal capillaries. The remaining outer layers get blood supply from chorio capillaries. As the inner half of retinal layers are absent in the fovea, the capillaries do not exist at this place.

In a cross section of the retina, through the fovea, following points are noted9—

There are hardly any rods, the cones are covered directly by internal limiting membrane without other layers in between. The cones are tallest at fovea and are densely packed. The cones are arranged vertically all over the retina except the foveola where they are placed obliquely.

In the macula each cone is connected to a single bipolar cell, which synapses with single ganglion cell. This arrangement is the cause of higher visual threshold and best colour

sense at the macula, both of which fall on the periphery. The macula contributes one third of all fibres to the optic nerve. The macular fibres enter the lateral part of the optic nerve in a straight line and immediately assume the central part of the optic nerve.

One of the landmark that denotes location of macula is insertion of the inferior oblique on the sclera.

Layers of Retina

The retina develops from the two walls of the optic cup with a potential space in between. This potential space divides the retinal layers in two distinct structures -

1.The outer leaf called retinal pigment epithelium (RPE) that is firmly attached to the Bruch’s membrane and is single layered.

2.The inner leaf called sensory retina is multi-layered.

Functionally the sensory retinal layers are arranged in three strata10 -

1.Visual cells (rods and cones)

2.Bipolar cells

3.Ganglion cells

Histopathologically the retinal layers are arranged in following ten layers:

1.Retinal pigment epithelium (RPE)

2.Photo receptors

3.External limiting membrane

4.Outer nuclear layer

5.Outer plexiform layer

6.Inner nuclear layer

7.Inner plexiform layer

8.Ganglion cell layer

9.Nerve fibre layer

10.Internal limiting layer

Retinal pigment epithelium layer

This is the outermost layer of the retina closely attached to the Bruch’s membrane. It is continuous with pigment epithelium of the ciliary body as a single layer of cells. The pigment epithelial cells are cuboidal in shape. They rarely undergo division. Hence their number remains almost constant throughout the life. On a flat preparation, the cells have hexagonal outline. There are micro villi on the inner surface of the pigment epithelium that anchor the outer segment of the photo receptors firmly to the pigment epithelium. The pigment epithelium contains melanin granules, phagosomes and lysosomes. The melanin increases the efficiency of the cones by absorbing scattered light. In albinos these granules are colourless. The RPE forms the blood retinal barrier and help in storage and transport of vitamin A11

Layer of photo receptors

The nine sensory layers of the retina are separated from the RPE by a potential space. The photo receptors are located next to this potential space and deepest to other eight layers.

Though this layers is designated as layer of photo receptors i.e. cones and rods. The photo receptors structure wise are not exclusively localised in this layer. This layer consist only of peripheral processes of rods and cones. The layer of photo receptors in fact extends from the RPE to outer plexiform layer beyond which they are joined to bipolar cells, and horizontal cells. In between the pigment epithelium and outer plexiform almost mid way lies the external limiting membrane that divides the peripheral process from the nuclei of rods and cones.

General structure of photo receptors

Though the rods and cones have different distribution and function structurally, they have many common points:

Each photo receptor has an inner segment and an outer segment demarcated by external limiting membrane. Each photo receptor has a cell body, a nucleus, a cell process. The long axis of the receptor is at right angles to the retinal surface. The rods and cones derive their name from the shape of their outer segment. The rods have long cylindrical shape while the cones have short conical shape. The apexes of the outer segment of rods and cones are attached in the micro villi of the pigment epithelium.

The outer segments of the photo receptors consist of a set of lamellar disks made up of lipid proteins. The nuclei of the cones are larger and paler than that of rods. The synaptic end of the rod is called rod spherule and that of cone is called cone pedicle due to their difference in shape.

The rods are meant for scotopic vision and peripheral field of vision. The cones are meant for photopic vision, central vision and colour vision.

External limiting membrane

This is not a true membrane. It is a modified layer of plasma of photo receptors and Muller’s fibre. It is so stretched that the photo receptors seem to be suspended in it with peripheral part towards RPE. The external limiting membrane ends at ora serrata anteriorly, posteriorly it blends round the edge of the optic nerve.

The outer nuclear layer

This layer contains nuclei of photo receptors. The nuclei of cones are larger than that of rods and are situated near the external limiting layer. The nuclei of rods are smaller and placed away from the external limiting membrane. The nuclei are joined to the second order neurones. Each cone is joined to only one bipolar cell. This is not true for rods. Each rods spherule is connected to two to three bipolar cells.

The outer plexiform layer

Outer plexiform layer is a narrow space. It lies between the outer and inner nuclear layers, containing synapses between photo receptors, bipolar cells and horizontal cells. As it lies midway between the internal limiting membrane and RPE, it does not get sufficient blood supply either from choroio capillaries or retinal artery, hence it is more likely to suffer from metabolic disorder.

The inner nuclear layer

This layer consists of bipolar cells, horizontal cells, amacrine cells and Muller cell’s. The capillaries of central retinal artery reach up to this level.

The inner plexiform layer

In the inner plexiform layer the axons of bipolar cells, branches of ganglion cells and amacrine cells synapse. It also contains branches of Muller’s cells.

The ganglion cell layers

This layer contains neurologia in which lie the ganglion cells. It is four to five times thicker under the macula as compared to other parts of the retina. There are about 1.2 million ganglion cells each with an axon. All the axons ultimately get together to form the optic nerve. One ganglion cell serves four to six cones and about a hundred rods. The number of ganglion cells get reduced towards the periphery, they are densest at the posterior pole.

The nerve fibre layer

It is also called stratum opticum. It consists of axons of ganglion cells. The axons form the unmyelinated nerve fibre and the optic nerve. The nerve fibres are arranged parallel to the surface of the retina. The arrangement of the nerve fibres is not similar all over the retina. The fibres originating from the macula go straight to the temporal side of the disc and are collectively called papillomacular bundle. The fibres arising from the nasal retina travel in radial fashion to reach the disc. The nerves arising temporal to macula sweep over the macula to reach the disc in the upper and lower pole of the disc. The peculiar arrangement of nerve fibre layer is responsible for different shapes of field defect.

The internal limiting membrane

This is a true basement membrane that separates the vitreous from the nerve fibre layer.

Blood supply of the retina12

The retina has double blood supply. The inner layer up to outer plexiform layer, (the cerebral layer) get their blood supply from the retinal arteries. Rest of the retina gets its blood supply from the chorio capillaries.

The central retinal artery arises from the first part of the ophthalmic artery near the apex of the orbit. Its orbital part runs anteriorly under the dural sheath of the optic nerve as far as a point 10 mm behind the globe, then it takes an upward course, piercing the dural sheath, arachnoid covering of the optic nerve almost vertically to reach the subarachnoid space, this constitutes its inter vaginal part. It then passes through the substance of the optic nerve as inter neural part. After reaching the middle of the optic nerve its course is forward, as central retinal artery proper to supply the inner layers of the retina and the optic nerve head. Before terminating as artery of the retina, it give following branches - The pial branches, the recurrent retinal branch, the inter neural branches.

The central retinal artery divides into two i.e. the superior and inferior branches, each again dividing into temporal and nasal branches. These four branches are arranged in such a way that there is one branch for each quadrant of the optic nerve and corresponding retinal quadrant except the foveal a vascular zone. The rods and cones that are metabolically most important get their blood supply exclusively from the chorio capillaries. The retinal vessels lie superficially in the nerve fibre layer under the internal limiting membrane.

Generally there is no anastomosis between the retinal circulation and the chorio capil-

laries.