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Flashcards in Retina cases Deck (120)
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1

Macular hole DDx

macular pucker, CME intraretinal cyst >Pseudohole -Appearance of hole w/ steep walls -Caused by vascular tortuosity around macula >Lamellar Hole -Thin layer of retina lifted w/ walls “bulging out” -Maybe precursor or resolved macular hole

2

Macular hole history questions

previous trauma? previous eye surgery?

3

Macular hole exam

complete exam, especially of macula Perform Watzke-Allen test (slit beam and see if line broken/distorted): >distortion = pucker >broken = hole

4

Macular hole evaluation

OCT = preferred modality IVFA with early hyperfluorescence w/o leakage for hole

5

Macular hole stage 1 definition and Rx

Stage 1 = impending hole Rx: Observe, as 50% will resolve spontaneously

6

Macular hole stage 2 vs 3 definition and Rx

Stage 2: full thickness hole 400 um, + elevated rim Rx: vitrectomy +/- ILM peel if operated w/in 1st 6 mo can regain 1/2 visual loss. others operate up to a year. small portion of patients may benefit even if long-standing history of hole Education: low risk for RD, but must explain Si/Sx to patient

7

Macular hole stage 4 definition and Rx

Stage 4: hole with cuff and complete PVD Rx: vitrectomy +/- ILM peel if operated w/in 1st 6 mo can regain 1/2 visual loss. others operate up to a year. small portion of patients may benefit even if long-standing history of hole Education: low risk for RD, but must explain Si/Sx to patient

8

Bulls eye maculopathy DDx

chloroquine/hydroxychlorquine toxicity cone dystrophy macular degeneration (AMD) Stargardt or fundus flavimaculatus battens = (AR) lysozyme storage dz. H/o seizures and progressive dementia with retinal findings of pigmentary retinopathy

9

Bulls eye maculopathy history questions

Medications: chloroquine/hydroxychlorquine (dosages)? History: FH of retinal dz, Sx of photophobia, seizures, ataxia, dementia

10

New macular hole grading system?

Small 400um

11

Bulls eye maculopathy exam

BCVA, IOP, DFE with special attention to macular pigment changes, drusen, macular, or peripheral pisciform (fish-like) flecks, CNV Perform a neurologic exam

12

Bulls eye maculopathy evaluation

If: patient younger, no RA, not taking chloroquine/hydroxychlorquine then order ERG and IVFA If ERG shows a non-recordable photopic response I would suspect a Dx of cone dystrophy If IVFA shows silent choroid I would suspect stargardt

13

Bulls eye maculopathy A/P

need to evaluation medication dosages. Maximum daily dose of chloroquine

14

chloroquine/hydroxychlorquine toxicity education

once toxicity starts, it may continue despite stopping the medication: Baseline exam vision, fundus photos, HVF (red test) OCT MAC

15

NV fronds with exudates and hemorrhage in child ddx

sickle cell retinopathy (sea-fan shaped) sarcoid sea fan neovascularization diabetic retinopathy eales peripheral retinopathy of unknown etiology

16

NV fronds with exudates and hemorrhage in child: history and eye exam

medical history of: sickle cell, DM, sarcoid, IVDA look for in eye exam: uveitis, iris nodules, NVI, DFE

17

NV fronds with exudates and hemorrhage in child:

tests: sickledex, ACE, lysozyme, fasting blood glucose, CT of chest if sarcoid suspected. IV FA to assist evaluation and development of Rx plan

18

Sickle cell A/P:

NV --> needs PRP to ischemic area located anterior to sea fan RD: PPV precautions (avoid encircling SB or taking down EOMs, avoid epi in local anesthetic, ensure O2 & hydration) For pts with sickle cell history and no evidence of retinopathy - plan f/u exams q6-12 mo for patients who develop retinopathy, plan closer f/u q3-4 mo, performing PRP as needed

19

sickle cell education

SC worst ocular Sx (SC>Sthal>SS>SA) SS worst systemic Sx Avoid CAI variable Px. with good patient education and comprehensive interval f/u, patients can expect to maintain good visual potential. Also need to have PCP involved to discuss si/sx of systemic sickle crisis

20

Sickle cell signs and stages

–Stage 1: peripheral arteriolar occlusion –Stage 2: peripheral AV anastomoses –Stage 3: preretinal sea fan NV (posterior border of nonperfusion; may autoinfarct and turn white) –Stage 4: Vitreous hemorrhage –Stage 5: Tractional RD Black sunburst (mid-peripheral pigmented lesion with spiculated borders) Salmon patch (IRH) Iridescent spots (intraretinal spots s/p resorption of salmon patch) angoid streaks (conjunctival comma-shaped capillaries in inferior fornix)

21

4 quadrants flame shaped hemorrhages following NFL, swollen ON DDx

CRVO DM Radiation retinopathy hypertensive retinopathy papilledema

22

4 quadrants flame shaped hemorrhages following NFL, swollen ON History

History Questions: HAs, transient visual obscurations glaucoma, thyroid eye disease, DM, HTN, radiation, hypercoagulable dz, vasculitis (lupus, syphilis, sarcoid) medications (OCP, diuretics, tetracycline, trenitoin), orbital tumors

23

4 quadrants flame shaped hemorrhages following NFL, swollen ON eye exam

VA pupils Hertel ocular motility gonioscopy (looking for NVI/NVA) IOP DFE looking for NVD and macular edema

24

4 quadrants flame shaped hemorrhages following NFL, swollen ON tests

IVFA to determine and define macular edema - whether condition is ischemic or non-ischemic IVFA will show non-perfused areas and the OCT macular swelling Check: BP, evaluate for DM (FBS, HgA1c) order screening labs (CBC, PT/PTT, ESR, lipid profile, homcysteine), sarcoid suspects (ACE, lysozyme, chest CT), atypical cases (FT-ABS, Lyme titer, ANA) Refer for cardiovascular and hypercoagulable work-up as needed

25

CRVO A/P

suspect ischemic CRVO if: 20/400 VA, APD, no pain Non-ischemic CRVO: usually has better VA and no APD Ischemic cases can develop NVI/NVA. Therefore I would follow monthly for 6 months performing eye exams and gonioscopy looking for NV. Should this develop I would initiate PRP to regress NVA/NVI. FOr macular edema I would discuss using IV triamcinolone or anti-VEGF

26

CRVO education

would discuss with patient that there is a 10% chance of contralateral eye developing a CRVO or branched retinal vein occlusion (BRVO)

27

retinal whitening with cherry red spot DDx

CRAO, Tay-Sachs, Niemann-Pick (presents in younger children)

28

retinal whitening with cherry red spot history questions

History of HTN, carotid dz, CV dz, sickle cell, hypercoagulable states syphilis, migraines, collagen vascular dz

29

retinal whitening with cherry red spot exam and evaluation

full eye exam: VA, pupils for APD, DFE to search for emboli Seek etiology of emboli as this can be helpful: (1) cholesterol emboli (hollenhorst plaque) = refractile bodies seen @ bifurcations arising from carotid artery atheromatous plaques (2) calcium emboli = white seen distally in retina and arise from cardiac valves (3) platelet -fibrin emboli = dull, white long arising from carotid atheroma CRAO can occur with GCA, evaluate for HA, scalp tenderness, jaw claudication, obtain immediate ESR/CRP.

30

Retinal vasculitis (CG pt as example)

Ddx for etiologies include embolus, in situ thrombosis, GCA, connective tissue disease, hypercoagulable state and less likely syphilis, Behcet's disease, Susac's, migraine, trauma. Plan: Control comorbidities, including BP Secondary risk stratification by PCP to include fasting BS, lipid profile, hypercoagulability workup Will obtain ESR/CRP, CBC with diff, Coag panel, FTA-ABS, ANCA, C3/C4, CXR, UA Provided h/o stroke and diffuse vascular disease, will obtain Carotid Doppler, cardiac echo RTC 5-6 weeks to review results, DFE and OCT Mac