Acquired Macular Disease

Question 1

Age-related macular hole ( FTMH)

1. Who are prone? Male or Female?
2. Age?
3. How do they present with?

Answer 1

1. Usually female
2. In 60s or 70s
3. Present with

• severe impairment of central vision
• asymptomatic deterioration, first noticed when the other eye is closed

Question 2

Age-related macular hole

Pathogenesis ? What structures involved?

Answer 2

Photoreceptors are displaced due to centrifugal force, probably c/b abnormal attachment of the vitreous and fovea

Traction occurs pulling anterior and posteriorly

Question 3

Age-related macular hole

Stages?

Answer 3

Causes several stages

1. a. Impending
   b. Occult
2. Early
3. Established
4. Greater than 400μm

Question 4

Macular hole

stages Stage 1a - Impending

Characteristics?

(3)

Answer 4

Characterized by

• flattening of the umbo
• yellow foveolar spot
• loss of the foveolar reflex.

Rarely seen clinically

Usually detected in a patient with a FTMH in the other eye

Question 5

Macular hole – stages Stage 1b - Occult

1. Vision defect?
2. What do you see around fovea?
3. Will it resolve?

Answer 5

1. Patient c/o mild decrease in VA or metamorphopsia
2. Yellow ring seen around the fovea
3. About 50% of stage 1 holes resolve following spontaneous separation of the vitreous and fovea

Question 6

Macular hole – stages Stage 2 – Early FTMH

Size of defect area?

How long does it take to progress from stage 1 to 2?

Answer 6

Defect area is less than 400μm in diameter

Can take 1-2 weeks to several months to progress from stage 1 to 2

Question 7

Macular hole – stages Stage 3 – Established FTMH

Size of defect? Thickness?

Answer 7

Stage 3 – Established FTMH

Full thickness defect more than 400μm in diameter

Question 8

Macular hole – stages Stage 4 – Greater than 400μm

Size of defect?

Appreance?

Effect on VA?

Answer 8

• Round defect more than 400μm in diameter
• Yellowish deposits within the round defect
• VA eventually stabilises as the hole reaches its maximum size

Question 9

Macular hole - diagnosis

1. Name of simple test diagnosing macular hole? ( Gross diagnosis)
2. Procedure
3. How patients with macular hole report?

Answer 9

1. Watzke-Allen test
2. Projecting a narrow slit beam over the centre of the hole both vertically and horizontally
3. Patient with a macular hole will report that the beam is thinned or broken
   Patients with a pseudohole or cyst see a beam of uniform thickness which is distorted or bent

Question 10

Macular hole - diagnosis

What is the most useful diagnosis tool?

Answer 10

OCT is useful to diagnose and determine the stage of macular holes

Question 11

Is FFA useful in diagnosis of Macular hole? Why?

Answer 11

Macular hole - diagnosis

• FFA
• Not so useful
• Shows hyperfluorescence which looks similar to:

–Cysts

–Pseudo-holes

Question 12

Central Serous Retinopathy (CSR)

1. Aka?
2. Definition?
3. Pathogenesis?
4. Affect one or both eyes?
5. Nature of this condition?
6. Who does it mainly affect?
7. Aggravated ( worsen) by?

Answer 12

1. AKA: central serous chorioretinopathy
2. Sporadic ( infrequent, periodic) disorder of outer blood-retina barrier
3. Sensory retina around the macula becomes detached
4. Usually affects one eye only
5. Self-limiting
6. Mainly affects young/middle-aged men with “type A personality”
7. Aggravated by

–Emotional stress

–Hypertension

–Alcohol

–Reflux

Question 13

CSR - signs

Answer 13

Round/oval detachment of sensory retina at the macula

OCT shows elevation of the retinal layer from the RPE

Separated by optically empty zone

Question 14

CSR - course

Short - Prolonged - Chronic

Answer 14

Question 15

CYSTOID MACULAR OEDEMA

1. Caused by?
2. Any short term effect?
3. If long standing, can cause what?
4. Damange reversible?

Answer 15

1. C/b accumulation of fluid in the outer plexiform and inner nuclear layers of the retina
   Fluid-filled cysts form
2. No short-term effects
3. If long-standing, can lead to large cavities at the fovea
4. Irreversible damage to central vision

Question 16

CMO - presentation

1. Patient presentation depends on ?
2. VA affected?
3. Patient c/o?

Answer 16

1. Patient presentation depends on aetiology
2. VA could be affected by a pre-existing condition which has caused the CMO
3. If no pre-existing disease:
   patient c/o:

• impaired central vision &
• positive central scotoma

Question 17

CMO – Slit-lamp signs ?

Fovea?

Retina?

Answer 17

On slit-lamp examination you see:

• loss of the foveal depression
• thickening of the retina
• multiple cysts

Question 18

CMO – OCT signs

Retina?

Macula?

Fovea?

Answer 18

Hyporeflective spaces within the retina

Overall macular thickening

Loss of foveal depression

Question 19

CMO – FFA signs

1. Arteriovenous phase?
2. Late phase?

Answer 19

1. Arteriovenous phase:
   Small hyperfluorescent spots
   Caused by early leakage
2. Late phase:
   ‘flower-petal’ pattern of hyperfluorescence
   Caused by accumulation of dye within cystic spaces

Question 20

CMO Causes

Answer 20

Question 21

High myopia

•What’s the definition of high myopia?

Answer 21

6.00D or more

Axial length greater than 26mm

Excessive elongation- changes to everything

Pathological myopia: elongating and stretching soccer ball into a football => Everything is afffected

Question 22

High Myopia
Pathological or degenerative myopia is characterized by ?

Secondary changes to which structures?

Answer 22

Pathological or degenerative myopia is characterized by:

progressive and excessive anteroposterior elongation of the globe

• Associated with secondary changes involving the: sclera, retina, choroid and optic nerve head

Question 23

Degenerative myopia

Answer 23

Tigroid appearance ( Tiger-stripe shape)

Brecks in Bruch’s membrane

Lacquer cracks

Due to diffuse attenuation of RPE with visibility of large choroidal vessels

Question 24

Sign?

Answer 24

Degenerative Myopia

Focal choroidal atrophy and titled disc

Optic nerve more rounded/ovally

white= sclera

Black= retinal pigment

Visibility of larger choroidal vessles and evetually sclera

Question 25

Sign?

Answer 25

Ruptures in RPE Brunch's membrane Choriocapillaris complex Fine, irregular yellow line branching & corssing @ Posterior pole Lacquer crack ?

Question 26

Sign?

Answer 26

Choroidal neovascularisation Atrophy Lacquer cracks

Question 27

Sign?

Answer 27

Subretinal coin haemorrhage

Question 28

Sign?

Answer 28

Degenerative myopia Fuch's spot

Question 29

Degenerative myopia Any impact on visual acuity

Answer 29

Impede on macula If out in periphery - not going to complain as much

Question 30

Angioid streaks 1. What is it? 2. Cause? 3. Apperance? 4. Location? 5. Pattern? in relation to disc?

Answer 30

Angioid streaks 1. **Crack-like ruptures in Bruch’s membrane** 2. Occurs as a result of ***thickened, calcified and abnormally brittle collagenous*** and ***elastic portion of Bruch membrane*** 3. Linear, grey/dark red lesions with irregular edges 4. Lie beneath normal retinal vessels 5. Communicate in a _ring-like way_ around the disc and _radiate outwards_

Question 31

Angioid streaks FFA sign? Cause by?

Answer 31

Angioid streaks **•Hyperflurescence** is seen on FFA * C/b **window defects** in the RPE * FFA is mostly used to detect CNV

Question 32

Angioid streaks Sign on fundus?

Answer 32

**•Optic disc drusen** are commonly found •**Choroidal rupture** following minor ocular trauma causes **subretinal haemorrhage** –Eyes with angioid streaks are very ***_fragile!_***

Question 33

Solar retinopathy 1. What is it? 2. Effect on VA?

Answer 33

Solar retinopathy 1. Retinal injury caused by **photochemical effects** of **_solar radiation_** by *directly or indirectly* viewing the sun (eclipse retinopathy) 2. Patient presents within 1-4 hours of solar exposure with **–unilateral or bilateral central VA ↓** **–small central scotoma**

Question 34

Solar retinopathy Sign on fundus? Resolve?

Answer 34

Solar retinopathy * Fundus shows **Small yellow** or **red foveolar spot** **Fades** within a few weeks Spot is replaced by a *sharply defined **foveolar defect*** with *irregular borders or **a lamellar hole***

Question 35

Sign?

Answer 35

**Phototoxic maculopathy** Yellow spot on macula Burned a hole in both fovea OCT below= resolve !

Question 36

**Case study** 62 y/o female 3/52 history of decreased VA VA RE = 6/18

Answer 36

**Stage 1B macular hole** Fundus shows cystic appearance at the fovea OCT shows elevation at the foveal level Remaining retina bridges over the fovea

Question 37

Case study 69 y/o female C/o decreased VA worse in the RE, for past few months VA RE = 6/60 Diagnosis?

Answer 37

**Full thickness macular hole** Full-thickness hole confirmed on OCT _•Loss of retinal tissue_ at the fovea

Question 38

Case study 42 y/o male C/o progressive central vision loss RE over past 1/12 Diagnosis?

Answer 38

**Central Serous Retinopathy** Dilated fundus exam shows **diminished foveal reflex** FFA shows **pinpoint leak inferior to the fovea**

Question 39

Patient with psuedo-phakic LE •VA LE = 6/9

Answer 39

**Drusen** Fundus exam shows drusen FFA shows late staining of the areas of drusen OCT shows altered foveal contour

Question 40

45 y/o female Referred for evaluation _central visual distortion_ in RE for 6/12 VA RE = 6/7.5 Diagnosis?

Answer 40

Angioid Streaks OCT shows normal **neurosensory retina** and **normal foveal contour** Choroid on the RHS shows **irregularity**

Question 41

60 y/o female C/o decreased VA RE 1/12 post cataract Sx & IOL insertion VA RE = 6/30 Diagnosis?

Answer 41

CMO