common retinal disorders
DESCRIPTION
Basic common retinal disorder for medical studentsTRANSCRIPT
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Dr. Jatushan NG-Pooresatien;M.D.Department of OphthalmologyChonburi hospital
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1. basic anatomy of the retina and vitreous
2. symptoms, signs, principles of treatments, sequelae and prevention of common retinal diseases
3. significance of the floater and/of flashing symptoms
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1. Basic anatomy of the retina and vitreous2. Symptoms, signs, sequelae, principles of
treatments, and prevention of common retinal diseases, eg.
2.1 Retinal vascular diseases 2.2 Macular degeneration 2.3 Retinal detachment
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion
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2.2 Macular degeneration2.2.1 Age related macular degeneration2.2.2 Myopic macular degeneration
2.3 Retinal detachment2.3.1 Rhegmatogenous2.3.2 Exudative2.3.3 Tractional
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Anterior segmentPosterior segment
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กระจกตา(cornea)
เปลือกตา (eye lid)
ขนตา(eye lash)
เยื่อบุตา(conjunctiva)
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Anterior ติดกับ posterior lens capsule
posterior ติดกับ ILM of neurosensory retina
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pars plana เรยีก บรเิวณนี�วา่ vitreous base
retinal vessel optic nerve ; Weiss ringmacular
มบีรเิวณท่ีติดแน่นกับ retina ได้แก่
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MacularFoveaEquatorial retinaperipheral retina ; ora serrata
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Rod and cone cell external limiting membrane outer nuclear layer (photorecepter cell body )
outer plexiform cell
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inner nuclear layer ( bipolar cell ) (1st order neuron)
inner plexiform cell ganglion cell layer nerve fiber layer ( The axons of the ganglion cell layer)
internal limiting membrane
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The ocular exit site of all retinal ganglion cell axons
Location nasal site of fovea 3-4 mm
Size V*H= 1.7*1.5 mm
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Is the neural connection between the neurosensory retina and the lateral geniculate body
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No photoreceptor cell
Absolute scotoma (Blind spot of Mariotte)
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The ocular exit site of all retinal ganglion cell axons
Location from fovea to nasal site 3-4 mm
Size V:H 1.7:1.5 mm
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degenerative process เชน่ Age related Macula Degeneration (AMD)
abnormal metabolic process เชน่ Diabetic retinopathy
Vascular occlusive diseases เชน่ โรค central หรอื branch retinal vein หรอื artery occlusion หรอื การเปล่ียนแปลงท่ีเราอาจพบได้ของ
เสน้เลือด เชน่ใน hypertensive retinopathy
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systemic drug toxicity เชน่ การได้ยา Chloroquine derivatives หรอืยาใน กลุ่ม Phenothiazines
inflammatory process เชน่ uveitis หรอืการอักเสบของมา่นตา
infection เชน่ CMV retinitis
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อาการตามวั โดยหากมจีอตาสว่น macula ผิด ปกติ ก็จะท้ำาใหม้ี central visual acuity ลดลง
แต่ในกรณีท่ีเป็นความผิดปกติของจอตาสว่นท่ีเป็นperipheral retina ก็จะท้ำาใหม้ผีลต่อการมอง
เหน็ด้านนอก หรอื การลดลงของความกวา้งในการ มองเหน็ (peripheral visual field defect)
ตาบอดกลางคืน(Nyctalopia) โรคของจอตาจะไมม่อีาการปวด เนื่องจากไมม่ี
pain receptor ท่ี retina
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy
- Branch retinal vein occlusion (BRVO)
- Central vein occlusion (CRVO)
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Grade 0 no changes Grade 1 Barely detectable arterial
narrowing Grade 2 Obvious narrowing with focal
irregularities Grade 3 Grade 2 plus retinal
edema/hemorrhage and cotton wool spot Grade 4 Grade 3 plus disc swelling
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Vasoconstrictive stage
vasospasmGeneralized arteriolar vasospasm
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Sclerotic stage
•Intimal thickening•Hyperplasia of medial wall•Hyaline degeneration
•Severe generalized and focal arteriolar narrowing•AV nicking or nipping•Copper wiring
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Exudative stage
•Disruption of blood-retina barrier•Necrosis of smooth m. & endothelium
•Microaneurysm•Hemorrhage•Hard exudate•Cotton wool spot
Cotton wool spot
hemorrhage
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Severe elevated blood pressure Swelling of optic disk
Malignant HT
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion
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CRA compressed the CRV in the vicinity of lamina cribosa , leading to turbulence, endothelial damage, and subsequent thrombus formation
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10% have history of CRVO /BRVO
Systemic abnormalities association
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Systemic associationArterial hypertensionDiabetes mellitusHyperviscosityIncrease intraocular pressure
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Dilated and tortuous retinal vein
swollen optic discRetinal hemorrhagemacular edemacotton wool spots
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Non-ischemic (perfused) form Ischemic (non-perfused) form
capillary dropout of at least 10 disc area
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Neovascularization of optic disc or retina
Neovascularization of Iris Vitreous hemorrhage
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Treatment for associated medical conditions eg:Hypertension: Diabetes: Hyperlipidemia
Vasodilator drug ??? Steroid ??? Aspirin for decrease platelet
aggregation ??? Laser PRP for prevent neovascular glaucoma
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More common in those with a history of systemic hypertension
10% of BRVO develop in second eye
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Usually occur at an arteriovenous crossing
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As CRVO in the distribution of blocked vessel
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As CRVO
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion
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1:10000 out patient ophthalmic visit
caused emboli phenomenon: thombosis: inflammation: systemic hypotension
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Artherosclerosis related thrombosis at laminar cribosa
Emboli from carotid artery or heart
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sudden painless severe vision loss
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Retina become opaque edematous
cherry red spot
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Glove(digital) massageAnterior chamber paracentesisO2+CO2(carbogen) combination inhalation therapy
Oral vasodilator systemic anticoagulant
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sudden painless severe vision loss in part of visual field of the affected eye
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Superficial retinal whitening is seen in the distribution of the fundus supplied by the vessel
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Generally not given It is not particularly effective and prognosis is relatively good
Medical work up is important
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion
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2.1 Retinal vascular diseases2.1.3 Diabetic retinopathy
- Nonproliferative- Proliferative- Diabetic macular edema
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Is essentially a microangiopathy affecting the retinal precapillary arterioles,the capillaries, and the venules
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Is unknownแต่เชื่อวา่การม ีhyperglycemia นานๆ เป็นสาเหตขุอง vascular endothelial damage
Pericyte cell loss
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Increase platelet adhesiveness aggregation
Decreased deformability of red and white blood cell
Increase basement formation in the retinal cappiaries
Loss of autoregulation in the retinal vessels
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Pericyte cell lost
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Microaneurysm Retinal edema Hard exudate
Dot blot hemorrhageNPDR
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Cotton wool spotsArteriolar narrowing
Venous change :- dilatation; looping;
beadingNPDR
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NeovascularVitreous hemorrhage
Tractional retinal detachment
PDR
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NPDR (Non Proliferative Diabetic Retinopathy)
PDR (Proliferative Diabetic Retinopathy)
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CSME (clinical significant macular edema)
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Medicine control blood glucose control lipid control blood pressure
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Laser pan retinal photocoagulation (PRP)focal or grid laser
Surgery par plana vitrectomy
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Type 1 หลังวนิิจฉัยโรค 5 ปีType 2 as soon as
possibleThen every year
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ผู้ป่วยท่ีเป็น diabetes retinopathy อาจมคีวามชดัของตา
ปกติ แมอ้ยูใ่นระยะสดุท้าย Early detection and timely treatment can prevent vision
loss
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2.1 Retinal vascular diseases2.1.1 Hypertensive retinopathy2.1.2 Venous retinopathy2.1.3 Diabetic retinopathy2.1.4 Retinopathy of prematurity (ROP)2.1.5 Retinal arterial occlusion
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A vanguard of mesenchymal cell initial growth outward in the nerve fiber layer from the region of the optic disc starting at 4-5 month of gestation
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These mesenchymal cells give rise to retinal cappillary endothelial cells which then form the cappillary system
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เสน้เลือด ท่ียงัไมถึ่ง periphery ได้รบัoxygen ในความเขม้ขน้ท่ีสงูกวา่ในครรถ์ เกิด vasoconstricttion and vasoobliteration และหยุดการเจรญิเติบโต
peripheral retina เกิดภาวะ relative hypoxia จงึมกีารสรา้ง angiogenic factors
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Gestation 4 m36 wk to nasal 40 wk to temporal
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Prematurity Low birth weightExcessive oxygen administration
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Stage 1 defined as a thin structure with in the plane of the retina that separates vascularized from avascular retina
Stage 2 represents an elevated ridge that has extend beyond the plane of the retina
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stage 3 there is extraretinal fibrovascular proliferration or neovascularizationat the ridge
Stage 4 there is a partial traction-like retinal detachment
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stage 4A indicates extramacular retinal detachment
stage 4B indicates macular involvement
Stage 5 is defined as a total retinal detachment
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significantly dilated and tortous retinal vessels in the posterior pole
vitreous haze iris vessel engorgement poor pupillary dilation
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Indicates extensive vascular incompetence
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Zone 1 circle 60 degree around disc
Zone 2 circle to nasal siteZone 3 remain temporal site
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Number of clock hour involve
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Cryopexy and /or laser indirect ophthalmoscopy
Scleral bucklingPars plana vitrectomy
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Low birth weight <1500 gm
gestational age < 32 wkage 4-6 wk
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2.2 Macular degeneration2.2.1 Age related macular degeneration2.2.2 Myopic macular degeneration
2.3 Retinal detachment2.3.1 Rhegmatogenous2.3.2 Exudative2.3.3 Tractional
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Caused of legal blind in people over 50 years old
more than 200000 new cases are reported each year in the united states alone
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An accumulation of undigested products of RPEcells under the basal
lamina of Bruch’s menbrane
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Is characterized by Drusen , which appear as yellowish
concrescences beneath RPE, and by degenerative change
s in Bruch’menbrane and RPEcells
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Non neovascular AMD (Dry type or Atropic type)
Neovascular AMD (WET AMD)
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Produces progressive atrophy of pigment epithelium and the choriocappillaris
No neovascularization
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An exudative macular detachment is caused by leakage from CNVM or form RPE detachment
subretinal fluid often is hemorrhage and hard exudate
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Decrease central vision may be sudden or chronic
Metamorphopsia
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SunglasssupplementsLaser for NeovascularPhotodynamic therapyAnti-VEGF
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In very large eyes the retina and
choriocapillaris are thin
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Thinning of macular pigment epithelium
Peripapillary atrophyTilting of the optic disc
Early finding
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Breaks in Bruch’s membrane ( lacquer cracks)
Posterior staphyloma Small macular hemorrhage Formation CNVMs Severe macular atrophy Macular hole may causes macular
detachment
Late finding
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Laser photocoagulation for CNVMs
Treatment for retinal detachment
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is characterized by progressive atrophy of the rods and cones. In most cases; there is associated migration of pigment epithelial cells into the retina
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สาเหต ุ เป็นได้ทั�ง AR ; X-linked recessive อาการรุนแรง เกิดเรว็ (early childhood) หรอื AD เกิดชา้ ( middle age)
อาจแบง่ออกเป็นสองกลุ่ม type1 rods ถกู affect ก่อนcones และ type2 cones ถกู affect ก่อน rods
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Clinical feature type1 scotopic vision and peripheral vision ลดลง สว่น central visual acuity ในระยะเริม่ต้นมกัจะดี ต่อมาลดลงเนื่องจาก macular atrophy; cystoid macular edema; typical posterior subcapsular cataract
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Fundus finding จะพบ vitreous cell and opacities; narrowed arteries; diffuse depigmentation of the RPE; and comma-shaped intraretinal proliferation of pigment cells ( bone spicules ) สว่น waxy pallor of the optic disc จะพบในระยะสดุท้าย
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Type2 มกัไมม่อีาการ night blindness จนกวา่ visual field จะลดลงกวา่ 10 องศา
photopic ERG is more severely effect than is the scotopic
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Photocoagulation Burn Photodisruption Burst
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Photocoagulation เป็น Thermal laser ใชห้ลักวา่ แสงเลเซอรถ์กู absorb โดย tissue แล้วเปล่ียนเป็นความรอ้นท่ีสงูพอจนท้ำาให ้ tissue เกิด coagulation หรอื denature cellular componants ใชร้กัษาพวก diabetic retinopathy หรอื sealing of retina holes (Argon laser)
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A seperation of the neurosensory
retina from the pigment
epithelium and choroid
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ภาวะที่มกีารแยกระหวา่ง neuro-sensory retinaและ RPE
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Rhegmatogenous Nonrhegmatogenous
•Exudative retinal detachment•Tractional retinal detachment
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Clinical course and pathophysiology of retinal detachment
Rhegmatogenous retinal detachment เกิดจากการม ีretinal break (retinal hole; retinal tear ) และ fluid ( liquefied vitreous )ท่ีเกิดจากการเสื่อมของ vitreous ไหล เขา้ potential space ระหวา่ง neuroretinal and pigment retinal epithelium จนท้ำาให ้มกีารแยกชั�น กันเกิดขึ�น
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R etin a l b reak L iq u e fied vitreou s
R h eg m atog en ou s re tin a l d e tach m en t
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R E TIN A L TE A R R E TIN A L H O L E
R E TIN A L B R E A K
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floa te r flas h in g V .A . d rop
sym p tom
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Close holeDrain subretinal fluidPermanent scar
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Exudative retinal detachment (Exudative; Hemorrhagic retinal detachment ) เกิดเน่ืองจากมกีารสะสม fluid ใต้ sensory retina ซึ่งสว่นใหญ่เกิดจากโรคของ RPE and choriod
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Tractional retinal detachment มกัเกิดจาก proliferative diabetic retinopathy; proliferative vitreoretinopathy; retinopathy of prematurity; ocular trauma.
Traction forces ท่ีดึง retina ออกจาก RPE อาจมาจาก vitreal; epiretinal or subretinal menbrane ซึ่งเกิดจาก fibroblast; glial and RPE cell
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