Posterior Chamber and Retinal Disorders Flashcards Preview

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Flashcards in Posterior Chamber and Retinal Disorders Deck (80):
1

What are 8 posterior chamber/retinal disorders?

Central Retinal Artery Occlusion
Central Retinal Vein Occlusion
Amaurosis Fugax
Optic Neuritis
Retinal Detachment
Giant Cell Arteritis
Papilledema
Macular Degeneration

2

What is the primary event that leads to retinal detachment?

a retinal tear

3

What is the pathology behind detachment?
2

1. Fluid vitreous passes though the tear and lodges behind the sensory retina (between neural retina layer and outer pigmented layer)
2. Combined traction and pull of gravity results in progressive detachment (pull sensory layer away from pigmented layer)

4

Predisposing factors are?
6

Age – 50-75
Myosis
Cataract extraction
Trauma
Family history
Advanced diabetes

5

Retinal detachment is also called?

posterior vitreous detachment

6

Signs and symptoms of retinal detachment?
4

Blurred Vision
Floaters
Flashing lights(photopsias)
NO PAIN OR REDNESS

7

What are the flashing lights in retinal detachment caused by?

the tugging on the retinal surface by the separating vitreous
(last less than a second)

8

What will cause the retina to die quickly?

Lack of oxygen, retina is one of the most highly metabolically active tissues in the body. High oxygen uptake

9

Treatment for retinal detachment?
4

Cryotherapy (freezing)
Scleral buckle
Intravitral gas
Vitrectomy

10

What happens in a central retinal artery occlusion (CRAO)?

Emboli enter and occlude the retinal artery

11

Prediposing factors for central retinal artery occulsion (CRAO)?
6

Age – mean is 60-80, can happen earlier
Carotid artery disease
Atrial fibrillation
Hypertension
Diabetes
Temporal Arteritis

12

In CRAO what will the area that the blocked vessel is supplying look like?

Whiteish yellow region/area

13

Signs and symtpoms of a central retinal artery occlusion?
3

1. Sudden profound monocular visual loss (seconds, minutes, perm) aka amarousis fugax
2. Painless
3. What happens to visual acuity
-Can detect hand movements but can’t count fingers

14

What does the fundoscopic exam reveal about CRAO?
6

1. Pallor of the optic disc
2. Ischemic retinal whitening
3. Cherry red spot on macula or fovea
4. Arteriole narrowing
5. “boxcar” segmentation of the retinal veins
6. Marked afferent pupillary defect

15

What can happen if we don't catch CRAO right away?

Very poor prognosis for vision (particularly if not resolved within 90 minutes)!
REFER, REFER, REFER immediately

16

Treatment of CRAO?
3

Ocular massage
Anterior chamber paracentesis
Revasularization techniques
--Thrombolysis (clot busting)

17

What color will the retina appear in diabetes or hypertensive retinopathy?

yellow or pink

18

Why are you at risk for retinal detachment if you have myosis?

Retina is thinner and easier to tear apart

19

Where does vision loss is a retinal detachment start?

superior temporal area and expands fairly rapidly.

20

When do you have no hope for recovery of vision is a retinal detachment?

When the macula has peeled off

21

What will you see in a fundoscope exam for a retinal detachment?

wrinkled area. like bubbled wallpaper
Grey cloud with fluid shifting maybe

22

What is another way to describe CRAO?

Stroke of the eye

23

What is the cherry red spot in CRAO pathology?

The macula. the retina itself is a light color so it makes the macula look darker

24

Where does the emboli start in CRAO?

How could we prevent this early?

probably starts in the carotid and moves to the central retinal artery

Listen for bruit in the carotid before it goes to the brain

25

Temporal arteritis can cause CRAO. How do we treat it?

IV steriods

26

What do retinal vein occlusions cause?
3

dilated veins and leaky hemorrhages
cotton wool spots- little microinfarcts (dead areas of the retina)
optic disc swelling

27

Systemic etiologies of central retinal vein occlusion?
4

Increasing age
HTN
Coagulation disorders
Diabetes

28

Ocular etiologies of central retinal vein occlusion?
2

Raised intraocular pressure (> 25 mmHg)
vein inflammation (vasculitis)

29

Signs and symptoms of central retinal vein occlusion?
3



How can the diagnosis be made?

1. Visual impairment is commonly first noticed upon waking
2. Usually a sudden monocular loss of vision
3. PAINLESS


Diagnosis can be made with ophthalmoscopic exam


Refer ALL to ophthalmologist

30

What do we find in a fundoscopic exam with someone who has central retinal vein occlusion?
6

1. Minimal APD (afferent pupillary defect)
2. venous tortuosity / dilatation
3. Retinal hemorrhages
4. variable cotton-wool spots
5. mild to moderate disc edema
6. macular edema
SWOLLEN EVERYTHING

31

What should patients with central retinal vein occlusion be screened for?
4

diabetes
systemic hypertension
hyperlipidemia
glaucoma

32

What are patients with central retinal vein occlusion at high risk for?

develop neovascular glaucoma
proliferative retinopathy

33

What is neovascularization?
and what surgery is good for it?

new little tiny vessels bleeding into the space will raise intraocullar pressure and lead to gluacoma
lazer surgery good for that

34

Whats amaurosis fugax?

Monocular loss of vision lasting a few minutes with complete recovery

35

What is amaurosis fugax caused by?

caused by retinal emboli from ipsilateral carotid disease

36

How is vision loss described as in amaurosis fugax?

a curtain passing VERTICALLY across the field of vision leading to complete loss of vision and then a similar curtain effect as the vision returns”

37

How would we diagnose amaurosis fugax?
2

1. MUST have evaluation of carotids by doppler ultrasound or CT/MRI angiography
2. ALL MUST also have EKG to ensure A. Fib is not cause of emboli

38

In all cases how would we treat amaurosis fugax?

In ALL CASES, place them on low dose ASA

39

Whats the differential diagnosis for amaurosis fugax?
5

1. Impending central retinal artery/vein occlusion
2. Impending OPHTHALMIC artery occlusion (total retinal blanching)
3. Carotid stenosis (bruit)- thinking strokes
4. Temporal arteritis (GCA)
5. Ocular migraine (slower onset, “scintillating scotoma”)
-migraine with aura

40

Labs to order to diagnose and treat amaurosis fugax?

CBC
Fasting blood sugar
ESR and CRP
Lipid profile

41

In amaurosis fugax patients, how do we evaluate for embolus source?
2

1. Carotid dopplers
2. cardiac evaluation including echocardiogram

42

How should we treat amaurosis fugax patients?
3

1. Ocular massage is

43

What does ESR and CRP tell us in the diagnosis of amaurosis fugax?

They are both fairly nonspecific tests. If these tests are normal then its not amaurosis fugax. But if they are irregular it could be a number of different things

44

When we see a young patient with vision loss and no immediate obvious exam findings what should we think?

optic neuritis

45

Signs and symtpoms of optic neuritis?
3

1. Unilateral decreased vision over 1-3 days
2. Occasional pain with eye movement
3. Age 18-45 female

46

Etiology of optic neuritis?
3

1. Multiple sclerosis (MS)
-optic neuritis is often the initial
manifestation of MS
-30% risk at 5 years
-Check MRI - consider IV steroids
2. Idiopathic
3. Viral infections,
-TB,
-sarcoidosis

47

What kind of vision is often lost in patients with optic neuritis?

What other sign is often seen?

color vision

affernet pupillary defect

48

What should we see in a fundoscopic exam in a patient with optic neuritis?
5

1. Optic nerve usually has a normal appearance acutely
2. Can have swollen disc, but less common
3. Relative afferent pupillary defect (RAPD)
4. Decreased color vision
5. May get worse with exercise or temperature increase (Uhtoff’s sign)

49

Differential diagnosis for optic neuritis?
5

1. Ischemic optic neuropathy (sudden Vision loss, no pain, pale nerve, older patient, hemifield defect)
2. Papilledema (bilateral, no decreased Visual acuity)
3. Severe HTN
4. Intraorbital or intracranial mass
5. Toxic (ETOH, malnutrition, heavy metals)

50

Work up and treatment for optic neuritis?

1. complete ophthalamic exam
2. complete neurologic exam/MRI and possibly IV steroids (never oral)
3. Do NOT use oral steroids!!!!!!!!!!!
4. Check BP
5. ESR/CRP/ temporal artery biopsy if you suspect giant cell arteritis (55+)

51

What specifically do we want to pay special attention to when we do a complete ophthalamic exam for optic neuritis?
4

1. pupils!!
2. color vision
3. decreased light brightness sensitivity with penlight
4. visual field test

52

Visual signs for optic neuritis?
2

color vision loss
central scotoma

53

Etiology of papilledema?
6

1. Intracranial tumors
2. Hydrocephalus (too much CSF)
3. Pseudotumor (young, obese females)
4. Subdural hematoma (trauma)-not intraocular pressure but brain pressure!!!
5. Brain abscess / Meningitis
6. bilateral usually thats how you know its intracranial and not inrtaocular

54

Signs and symptoms of papilledema?
2

1. Slow vision loss from increased ICP / optic nerve swelling
2. Can have acute attacks of vision loss when lying flat

55

Is papilledema usually bilateral or unilateral?

bilateral.
intracranial pressure not intraocular

56

What will the fundoscopic exam/patient experience look like in a papilledema patient?
3

1. disc margins blurred
2. Often peripapillary disc hemorrhages
3. may have double vision if CN VI plasy from increased intracranial pressure

57

How do we treat papilledema?

directed at underlying cause

58

Signs and symptoms of giant cell arteritis/temporal arteritis?
8

1. Patients >55 years old
2. Sudden, painless, non-progressive visual loss
3. Headache
4. Scalp tenderness
5. Jaw claudication (very much one sided)
6. Fever
7. Weight loss
8. Polymyalgia rheumatica association
--Muscle and joint aches

59

What kind of vision problems with GCA will you see?

usually painless in the eye
(tenderness/headache)

60

How will the pulse feel in temporal arteritis?

you wont be able to feel it

61

What lab tests will be high in temperal arteritis?
2

ESR
CRP

62

What will you see on a fundoscopic exam for GCA/temporal arteritis?
2

positive afferent pupillary defect
pale, swollen, optic disc

63

What lab is very specific to GCA?

ESR BUT go by symptoms!
ESR and CRP can be normal in 20% of patients

64

HOw do we make a definitive diagnosis in temporal arteritis?

Temporal artery biopsy
---need at least 2-3 cm of vessel specimen on bx (i.e. skip lesions)

65

What will the histology show on a temporal artery biopsy?

shows granulomatous infiltrate of internal elastic lamina of artery
occlusion of vessel lumen
giant cells present (you see big cells)

66

How should we treat temoral arteritis?

TREAT WITH STERIODS EVEN BEFORE BIOPSY IS DONE! (dont want to wait and have progresstion)

67

What is our treatment goal with temporal arteritis?

preserve visual loss in the other eye

68

If their is no symtpoms or mild symptoms what should we use to treat temporal arteritis?

60-90mg of prednisone po qd

69

If severe symtpoms or visual loss from temporal arteritis what should we treat it with?
2

1. 1gm Solumedrol IV q 6 hrs x 3-5 days, then SLOW taper off oral steroids over 2 weeks
2. Refer to surgery for biopsy

70

What is the most common type of age related macular degeneration?

dry kind

71

What happens in age related macular degeneration?
2

1. “wearing out” of retina / photoreceptors
2. Degradation products form “drusen” in retina

72

Risk factors from macular degeneration?
5

1. Age
2. Smoking (2x higher)
3. Family history
4. Caucasian
5. sun exposure

73

What are the two types of ARMD?

Dry and wet or exudative

74

Characteristics of dry macular degeneration?
2

gradual vision loss
Drusen

75

What do patients complain of when they have dry ARMD?

gradual loss of vision in one or both eyes

76

Characteristics of wet (exudative) ARMD?
3

1. sudden vision loss
2. subretinal neovascularization
3. Accumulation of fluid and blood

77

What do patients complain of when they have wet ARMD?
2

1. Acute distortion in vision, especially distortion of straight lines, or loss of central vision.
2. Symptoms usually appear in one eye, although the disease is generally in both eyes.

78

What is the worst kind of ARMD?

wet type

more rapid and more severe loss of central vision due to fluid between retinal pigmented layer and Bruch's layer

79

Mimizing effects of ARMD?
5

1. monitor with Amsler grid
2. Stop smoking
3. control cardiovascular disease
4. diet high in friuts and veggies lowers risk (folic acid and B12)
5. Antioxidants from foods might help

80

Treatment of ARMD?
6

supportive measures. Not much they can do
Vitamin C 500mg
Vitamin E 400 IU
Beta carotene 15 mg (non-smokers only)
Risk of lung CA associated with beta carotene
Zinc 80mg
Copper 2 mg