Ocular Disease III: Lecture 1: Normal Retina/Retinal Potpourri

Question 1

Layers of the Retina

1. Anterior to Posterior: Name them!

Answer 1

1. ILM
2. Nerve Fiber Layer
3. Ganglion Cell Layer
4. IPL
5. INL
6. OPL
7. ONL
8. ELM
9. Rods and Cones
10. RPE

Question 2

General Topography of the Retina

1. Photo = ?
2. Cross Section = ?
3. Retina has 10 Layers and many cell types = ?
4. It’s organized into regions CENTRAL to PERIPHERAL and each Cellular Layer also has its own Organization

Answer 2

1. ACROSS
2. DOWN
3. Down-Cross Section
4. Across

Question 3

Retinal Landmarks (KNOW)

1. Optic Nerve
   a. Disc Diameter in size? (ALWAYS THIS)

b. How many MICRONS is about .33 DD
c. So what is the size of the ONH?
d. Normal (mm Length x width)

2. VESSELS (KNOW)
   a. the 1st VEIN is about what size (Microns)?
3. Degrees to mm Conversion: 1 DEGREE = how many Micrometers

Answer 3

1. a. 1 DD
   b. about 500 microns
   c. 1.5-2 mm in size
   d. 1.86 x 1.75 mm
2. a. 120 um (microns)
3. 1 degree = 288 um

Question 4

Dimensions

1. Foveola: Floor of the Foveola (mm)?
2. Fovea Rod Free Zone?
3. FOVEA length Across?
   a. what is it?
4. Parafovea: What cells are HIGHEST here?
5. Perifovea: Thickness of Ganglion Cells here?
6. MACULA: Length across?
7. Posterior Pole (degrees)
8. Ora to Ora Length (mm)?
9. Fovea is how many degrees TEMPORAL from the disc?

Answer 4

1. 0.35 mm
2. 250-750 um
3. 1.5 mm ACROSS
   a. Shallow depression in the Center of the Macula
4. Retinal Bipolar and Ganglion Cells (0.5 mm)
5. Ganglion Cells are 4 cells thick to where they are 1 cell thick (1.5 mm)
6. 4 mm ACROSS
7. 45 degrees
8. 32 mm
9. 11.8 degrees

Question 5

Bruch’s Membrane

1. Posterior to Anterior (5 Layers)

Answer 5

1. Basement Membrane of Choriocapillaries
2. Outer Collagenous Layer
3. Elastic Lamina
4. Inner Collagenous Layer (DENSE LAYER and where DRUSEN 1st ACCUMULATES)
5. Basement Membrane of the RPE

Question 6

Choroid

1. Anterior to Posterior (3 Layers)

Answer 6

1. Choriocapillaries (Single layer of Capillaries and they’re FENESTRATED)
2. Sattler’s Layer (Small Vessels)
3. Hallers Layer (Large Vessels)
   * Posterior

Question 7

Normal Retinal Blood Supply (MEMORIZE: WILL BE ON THE TEST)

1. Starting with the COMMON CAROTID ARTERY: Describe the Track that leads to the Blood Supply of the Retina and what each thing supplies.

Answer 7

1. Common Carotid Artery –> Internal Carotid Artery –> Ophthalmic Artery
   a. Opthalmic Artery –> Central Retinal Artery (CRA) –> SUPPLIES INNER RETINA
   b. Ophthalmic Artery –> Anterior Ciliary Artery –> SUPPLIES ANTERIOR UVEA & Anterior Choriocapillaris
   c. Ophthalmic Artery –> Posterior Ciliary Arteries
   i. Short: SUPPLIES NASAL/TEMPORAL Choriocapillaris
   ii. Long: Supplies PERIPHERAL Choriocapillaris

Question 8

Retinal Blood Supply (KNOW)

1. CRA:
   a. Branches run in what Layer?
   b. It has ADHESIONS to WHAT LAYER?
   c. Superficial Capillary Network runs in what 2 Layers?
   d. Deep Capillary Network runs in what?
   e. Overall: It supplies what 5 layers? (what do we call it?)

Answer 8

1. a. NFL
   b. ILM
   c. NFL and GCL
   d. INL
   e. ILM, NFL, GCL, IPL, INL (INNER RETINA!)

Question 9

Retinal Blood Supply (KNOW)

1. Posterior Ciliary Arteries
   a. What does it supply blood to?
   b. This in turn supplies what 5 layers?
   c. Number of SPCA (short)?
   i. Supplies what area of the Retina?

d. LPCA (Long): Number of them?
i. Where are they found?
ii. What part of the retina does it supply?

Answer 9

1. a. Choriocapillaris
   b. OPL, ONL, ELM, Photoreceptors, and the RPE!
   c. 10-15
   i. Supplies the Posterior 2/3 of the OUTER RETINA
   d. 1-2
   i. 1 is Nasal, and 1 is Temporal
   ii. the Anterior 1/3 of the OUTER RETINA

Question 10

Regulation of Retinal BF (KNOW!)

1. Does the Neural System regulate this?
2. How is it Regulated then?
   a. What happens if CO2 INCREASES above threshold?
   b. If CO2 DECREASES below threshold?
   c. What happens if the PRESSURE GETS to be TOO HIGH?

Answer 10

1. NO!!!
2. Via AUTOREGULATION in the INNER RETINA!
   a. VESSELS DILATE, causes Increased Flow and Decreased Resistance
   b. Vessels CONSTRICT, results in Decrease Flow, Increased Resistance, Increased Pressure
   c. Vessels will CHANGE TONE (MYOGENIC RESPONSE) to RESIST the Change in IOP!

Question 11

Retinal Arteries and Veins

1. Arteries
   a. It’s a TRUE ARTERIOLE; Where do they lie?
   b. Are they Strong or Weak?
   c. Muscle type?
   d. Elastic Lamina?
   e. Hemorrhages?
2. Veins
   a. True Venule; Thick or Thinned Walled?
   b. 2 things about them: ALLOWS for SVP (Spontaneous Venous Pulsation)

Answer 11

1. in NFL or GCL
   b. STRONG
   c. Smooth Muscle
   d. NO
   e. Pre-Retinal Hemorrhages
2. a. THIN Walled
   b. DISTENSIBLE and COMPRESSIBLE

Question 12

Pre-Retinal Hemorrhages

1. Where are they located?
   a. Where do they come from?

b. How fast do they Clear up?
c. It’s a sign of what 2 types of diseases?
d. Does it OBSCURE underlying vessels?
e. Can you see the Choroid or Retina?

Answer 12

1. POSTERIOR to the ILM and ANTERIOR to the NFL
   a. from the SUPERFICIAL CAPILLARY BED
   b. CLEARS FASTEST of ANY HEMORRHAGE
   c. Peripheral Vascular Disease and Arterial Disease
   d. YES. OBSCURES UNDERLYING VESSELS!
   e. BLOCKS NFL DETAIL and VISION. so NO!

Question 13

Flame Shaped Hemorrhages

1. Where does it Come from?
2. What does it FOLLOW?
3. Also CALLED what kind of HEMORRHAGE?
4. Duration?
5. MOST COMMONLY ASSOCIATED with what 2 THINGS!!?

Answer 13

1. Post-Arteriolar Superficial Capillary Bed
2. Contours of the NFL
3. NFL Hemorrhage
4. Short usually (6 weeks)
5. RETINAL VEIN OCCLUSIONS and HYPERTENSIVE RETINOPATHY

Question 14

Dot and Blot Hemorrhages

1. Where does it come from?
2. Located in WHAT LAYER?
3. Tells us that it’s what kind of DISEASE?
   a. Most ASSOCIATED with what 2 things?
4. What does it BLOCK on FA?
5. How long does it take to Resolve?

Answer 14

1. Pre-Venule DEEP Capillary Bed
2. OPL
3. Venous Congestive Disease
   a. DIABETIC RETINOPATHY and OSCULAR ISCHEMIC SYNDROME
4. NaFl
5. Slower to resolve

Question 15

Sub-Retinal Hemorrhages

1. It’s Secondary to what?
2. Cause? (Breakthrough of what)
3. Location?
4. How is it identified (by our ability to do what)?

Answer 15

1. to Choroidal Neovascular Membrane (CNVM)
2. of Deep Hemorrhages
3. B/w RPE and Sensory Retina
4. to see DISTINCT Retinal Vessels overlying the hemorrhaging area. (if you see the retinal vessels, then the hemorrhage must be beneath the retina)

Question 16

Sub-RPE Hemorrhage

1. Located b/w what 2 things?
2. Color normally?
3. Can you see retinal vessels above it?
4. Common in what DISEASE?

Answer 16

1. RPE and Bruch’s Membrane
2. Gray/Green/almost black
3. YES!
4. WET ARMD

Question 17

Vitreous Hemorrhage

1. Results from what?
2. Where is it located (2)
3. What will the patient complain of?
4. Results from what diseases?

Answer 17

1. Break in the ILM
2. VITREOUS BODY or RETROVITREOUS
3. Subjective FLOATERS and Possibly SEVERE VISION LOSS
4. NVD, NVE, PVD w/RETINAL BREAK, Macroaneurysm, and WET ARMD
   * If you see this, GET IT OUT of your OFFICE!! (send to a RETINAL OPHTHALMOLOGIST!)

Question 18

More BLOOD Vascular ANOMALIES

1. Microaneurysms
   a. Diameter?
   b. Reflects weakening of what?
   c. Or could be due to ACTIVE CELLULAR RESPONSE to what?
   d. Sets you up for further LEAKAGE: Creates what?
   e. FORMS in RESPONSE to WHAT?

Answer 18

1. a. 30-120 micron diameter
   b. of Capillary Cell Wall (weakened pericytes)
   c. to Hypoxia
   d. Intraretinal Edema
   e. to ISCHEMIA

Question 19

Venous Beading

1. What causes it?
2. Non-Specific Sign of what?
3. One of the STRONGEST PREDICTORS if a Patient will develop what?

Answer 19

1. Constriction/Dilation of Vein Lumen
2. of Ischemia
3. if a Patient will develop Neovascularization
   * SAUSAGES (due to diabetes mainly probably due to glucose fluctuations)

Question 20

IRMA (Intra Retinal Microvascular Abnormalities) (KNOW: He will ask a question or two)

1. It’s an Intraretinal Shunting thru Vascular Channels from what?
2. What do CAPILLARIES look like?
3. What does it INDICATE?
4. Likely GERMINATION BED for what?
5. Does this stay Retinal or does it Break thru the ILM?

Answer 20

1. from Pre-existing Capillary Beds
2. TORTUOUS CAPILLARIES
3. RETINAL NON-PERFUSION
4. for NEOVASCULARIZATION
5. Stays RETINAL!

(They’re basically SHUNTS)

*If we see an IRMA, do an FA, cuz chances are, there’s NEO underneath it!

Question 21

Drusen (1)

1. What do they look like?
2. Where are they found (Level and around what)?
3. It’s an ABNORMAL THICKENING of what?
   a. Basal Laminar Deposits?
   b. Basal Linear Deposits?
4. Do they affect Photoreceptors or VA?
5. What is DRUSEN essentially?

Answer 21

1. SMALL, Round, Yellow Lesions
2. RPE Level, around Macular Area
3. of Inner Bruch’s Membrane
   a. Lipid rich, Collagen Fibrils
   b. Phospholipid Vesicles
   * May see associated RPE Detachment
4. May no affect photoreceptors; No affect on VA
5. ACCUMULATION of METABOLIC WASTE PRODUCT of RODS RECEPTOR OUTER LAYER

Question 22

Drusen (2)

1. Small: (Size)
   a. What do they look like?
   b. Risk of AMD Development?
2. Intermediate: (Size)
   a. Risk of development of AMD?
   b. Greater risk of what 2 things?
3. Large: Size?

Answer 22

1. 125 microns

a. Same as intermediate

Question 23

Drusen (3)

1. Hard Drusen
   a. What do they look like?
   b. Risk of Progression to CNVM?
2. Soft Drusen
   a. What do they look like?
   b. Associated w/what?
   c. Risk of Progression to CNVM?
3. Confluent
   a. type of boundaries?
   b. Risk of progression to CNVM?

Answer 23

1. a. Discrete, well demarcated
   b. Least risk
2. a. Amorphous, Poorly demarcated
   b. Thickened Bruch’s Membrane
   c. Moderate
3. a. Contiguous Boundaries
   b. Moderate +

Question 24

Exudates

1. Looks like what?
   a. What are they?
   b. What level?
2. Circinate Retinopathy: Indicates leaking of what?
3. Accumulations of Lipids that leak from what?

Answer 24

1. Lipid Soup
   a. Waxy, Yellow Lesions
   b. At the OPL
2. Indicates leaking of Microaneurisms or Choroidal Neovascularization
3. from Surrounding Capillaries and Microaneurysms

Question 25

1. DONT MISTAKE DRUSEN with EXUDATES: a. Where is DRUSEN FOUND? b. EXUDATES?

Answer 25

1. a. DEEP (Bruch's/RPE level) | b. Are at the level of NEUROSENSORY RETINA

Question 26

Cotton Wool Sports 1. Used to be called what? 2. What is the cause of it? 3. What does it INDICATE? 4. What are they essentially? 5. Blockage of what Arteriole? 6. Damning of what? 7. LOOK FOR CAUSE? Is it okay to have 1 CWS? 8. What 5 things can present with CWS?

Answer 26

1. Soft Exudates (THIS IS WRONG!!) 2. Focal Retinal Ischemia - Infarcted Retina 3. HYPOXIA 4. Arteriolar Microinfarcts in NFL 5. of Terminal Retinal Arteriole 6. Axoplasmic Damning 7. NO!! (but it's ok to have 1 Retinal Heme) 8. a. Diabetes Mellitus b. Retinal Venous Obstruction c. Systemic Arterial Hypertension d. Lupus e. AIDS

Question 27

RPE Window Defect (He was really quick with it.) 1. Color? 2. What do they look like? 3. Lesion RESULTS from ABSENCE of what? 4. Benign/Metastatic?

Answer 27

1. White to Yellow 2. Round, well-circumscribed areas in the with NO surround of Reactive RPE Hyperplasia 3. ABSENCE of MELANIN in the RPE 4. BENIGN, but can appear to increase in size over the years

Question 28

White Without Pressure 1. % of General Population? 2. 10x's more common in light/dark skinned peeps? 3. Uni/Bi? 4. What does the area look like? 5. Type of Borders? 6. Nearly ALWAYS Mistaken for what? 7. Flat/Elevated? 8. What does it represent? 9. DISORGANIZED what? 10. Closer to what in the Retina? 11. BENIGN?

Answer 28

1. 30% 2. Dark Skinned peeps 3. Usually Bilateral 4. GRAY-WHITE TRANSLUCENT AREA 5. Scalloped Borders 6. for RD by beginning Optometry Students 7. FLAT 8. an Abnormal Vitreoretinal Interface 9. DISORGANIZED RETINA 10. to the Ora 11. TOTALLY BENIGN

Question 29

Myelinated Nerve Fiber 1. Often Emanates from what? 2. May be isolated w/in what area of the retina? 3. Generally does NOT extend beyond what? 4. any CLINICAL or VISUAL SIGNIFICANCE? 5. AKA?

Answer 29

1. from the DISC 2. the Posterior Pole 3. the Posterior Pole 4. NO! 5. Medullated Nerve Fibers

Question 30

Chorioretinal Scar 1. Usually what Color? 2. What is it? 3. THe Scar may involve what layers? 4. What do you do?

Answer 30

1. White to Yellow 2. Intraretinal Fibrosis w/Accompanying RPE Hyperplasia 3. the Choroid thru the Retina 4. Monitor YEARLY. Carefully investigate for retinal tears.

Question 31

Chorioretinal Scar (2) 1. Very Common Cause? 2. May involve what? 3. Scar itself: Benign/Malignant? 4. what else?

Answer 31

1. TOXOPLASMOSIS 2. the Macula unfortunately 3. Benign 4. Pos-inflammatory or Traumatic; Retinal Atrophy or Fibrosis

Question 32

Fibrosis: NOT GOOD 1. Response to what? a. Some causes? 2. Gliosis: CNS Special a. Driven by what? b. Glial Cells proliferate with what cells? (Leading to what)

Answer 32

1. Response to INJURY! a. Mechanical vs. Hypoxia Driven; Inflammation and Ischemia; Degenerative Ds 2. a. Neovascularization/Angiogenesis Driven b. with Endothelial Cells, Leading to Fibrosis c. Trate; Neo; Proliferation of Fibroblast; DM, PVR, ROP, ARMD

Question 33

RPE Hypertrophy 1. Enlargement of what Cells? a. Usually what color? 2. Looks like what? a. Seen in what? 3. Describe them? 4. What is EXTREMELY DIAGNOSTIC of them? 5. If there are MULTIPLE LESIONS: Ask ABOUT WHAT 2 things?

Answer 33

1. of RPE cells a. usually VERY DARK 2. Bear Tracks a. Congenital Hypertrophy of the RPE (CHRPE)*** 3. WELL-DEMARCATED, round, solitary or multiple gray-brown or black lesions which have Flat or Scalloped margins 4. LACUNAE (Area where RPE is not Hypertrophy) 5. COLORECTAL CANCER, and FAMILIAL ADENOMATOUS POLYPOSIS (FAP)

Question 34

RPE HYPERPLASIA (know the difference b/w this and RPE Hypertrophy) 1. Represents what cells INVADING WHAT? 2. Response to WHAT? 3. Color? 4. What can it cause? 5. What is it essentially? 6. Visualization of Hyperplasia is Indicative of a process that's been ONGOING for how MANY DAYS? 7. SELF LIMITING, BUT must ASCERTAIN what?

Answer 34

1. RPE CELLS INVADING SENSORY RETINA 2. INJURY, retinal tear, retinal detachment, LATTICE DEGENERATION, etc. 3. Black 4. CHORIORETINAL SCARS 5. IRREGULAR SHAPED areas w/variable Size 6. for 60-90 DAYS 7. the CAUSE of the RETINAL INSULT

Question 35

Chorioretinal Scar 1. RPE Hyperplasia is a component of chorioretinal scarring. Should a differential diagnosis be Chorioretinal Scar vs. RPE Hyperplasia?

Answer 35

1. NO! because they're essentially parts of the same entity.

Question 36

Benign Choroidal Melanoma (Choroidal Nevus) 1. What type of tumor is it? a. From what? 2. Lesion represents an Accumulation of what? 3. Flat/Elevated? a. Color? 4. MONITOR if size is LESS THAN what? 5. What if it's more than 5 mm?

Answer 36

1. Benign Melanocytic Tumor a. of the Posterior Uvea 2. of Atypical but Benign Melanocytes 3. Flat a. Slate Grey Lesion of variable size 4. 2 mm 5. Assume MALIGNANCY (if 2-2.5 times the size of the Optic Nerve: Send IT OUT!!) * Put on R/G filter w/BIO, and this will DISAPPEAR!

Question 37

Choroidal Melanoma vs. Nevi 1. Nevi have what? 2. Melanoma has what? 3. Drusen = ? 4. Nevi are how thick? 5. Melanoma are how thick? 6. What can melanoma have in the TUMOR DOME?

Answer 37

1. DRUSEN 2. Lipofuscin 3. STABILITY 4. 2mm thick 6. Visible Blood Vessels