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vascular and retinal disorders Flashcards

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1
Q

progressive chronic retinal disease affecting aging eyes (central vision loss)

leading cause of vision loss globally, with adults > 50 years old

idiopathic

blurred central vision

distortion of images

scotomas (dark spots)

declining visual acuity (unable to read, distinguish faces)

A

macular degeneration (ARMD)

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2
Q

neovascular, exudative

more severe and faster progressing

10% of cases

A

wet macular degeneration

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3
Q

atrophic, geographic, non vascular, non exudative

yellow cellular debris (drusen)

90% of cases

A

dry macular degeneration

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4
Q

advancing age, female, white race, tobacco abuse, heavy alcohol use, increased sunlight exposure, cardiovascular disease, hypertension, hyperlipidemia, family history, farsightedness, light iris color

A

macular degeneration risk factors

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5
Q

new blood vessels grow up from the choroid (neovascularization) behind the retina which can leak exudate and fluid and cause hemorrhaging and fibrosis

onset more rapid and severe

A

“wet” ARMD

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6
Q

cellular debris (drusen) accumulates between retina and choroid leading to scarring and atrophy

atrophy in retina

gradual progressive bilateral visual loss of moderate severity due to atrophy and degeneration of outer retina and retinal pigment epithelium

A

“Dry” ARMD

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7
Q

macular degeneration diagnosis

A

snellen test (should see reduced visual acuity compared to previous tests)

amsler grid

opthalmolgy for definitive diagnosis

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7
Q

dry armd treatment

A

pegcetacoplan and avacincaptad pegol (inhibit complement pathway) injections

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8
Q

macular degeneration treatment

A

vitamins and STOP SMOKING

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9
Q

wet armd treatment

A

inhibitors of vascular endothelial growth factors (VEGF)

ranibizumab, bevacizumab, afilbercept injections

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10
Q

cause regression of choroidal neovascularization with resorption of sub retinal fluid and improvement or stabilization of vision

A

inhibitors of vascular endothelial growth factors (VEGF)

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11
Q

separation of neurosensory retina from underlying retinal pigment epithelium

considered medical emergency (vision loss)

can be primary or secondary

curtain vision loss

A

retinal detachment

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12
Q

most common predisposing causes for retinal detachment

A

age
nearsightedness
previous cataract extraction

also:
ocular trauma
smoking
diabetic retinopathy

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13
Q

caused by entry of liquid vitreous into subretinal space through retinal break

secondary to increasing age (>50 years old)

shrinking leads to pulling on retina (tear)

retinal detachment primary

A

rhegmatogenous detachment

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14
Q

accumulation of subretinal fluid
wet armd
choroidal tumor
fluid trapped behind retina –> detachment

A

exudative retinal detachment

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15
Q

preretinal fibrosis (scarring of retina)

proliferative retinopathy due to diabetic retinopathy

retinal vein occlusion

complication of rhegmatogenous retinal detachment

scars pull on retina –> detachment

A

traditional retinal detachment

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16
Q

acute onset

“tunnel vision” or loss of peripheral vision “curtain like”

recent onset or increase in floaters and photopsias (flashes of light)

central vision remains intact until macula becomes detached

A

retinal detachment

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17
Q

opthalmoscopic exam

retina may be seen elevated with irregular surface

retina appears gray or cloudy

superior temporal quadrant MC

A

retinal detachment diagnosis

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18
Q

when you have retinal detachment you do urgent referral to ophthalmologist. During transport how is patients head positioned?

A

patient head positioned so retinal tear is placed at lowest point of eye to minimize extension of detached retina. also try to minimize movement of eyes (patching)

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19
Q

retinal tear inferior

A

keep head upright

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20
Q

retinal tear temporal

A

keep temporal side of head down

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21
Q

retinal detachment treatment (primary)

A

closing retinal holes and tears
- laser photocoagulation
- cryopexy
- pneumatic retinopexy (gas injected into vitreous cavity)

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22
Q

retinal detachment treatment for more complicated detachments (traction)

A

vitrectomy

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23
Q

about 90% of uncomplicated primary detachments can be cured with ____ __________

A

one operation

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24
retinal detachment worse prognosis
macula detaches detachment of long duration
25
poorly controlled diabetes
diabetic retinopathy
25
damage to retina due to chronic systemic conditions (diabetes and hypertension) can be acute or ongoing leading cause of vision loss and blindness early detection and management are crucial
retinopathy
26
leading cause of vision loss worldwide among adults aged 25-74 years
diabetic retinopathy
27
percentage of patients with retinopathy by 20 years after diagnosis. type 1:
99%
28
percentage of patients with retinopathy by 20 years after diagnosis. type 2:
60%
28
diabetic retinopathy present in about ____% of type 2 diabetic patients at diagnosis
20% should be referred to ophthalmology for baseline exam with new diagnosis of type 2 diabetes
29
nonproliferative microaneurysms, retinal hemorrhages, exudates* no changes in vision - no immediate treatment required
background retinopathy- asymptomatic
30
two main categories of diabetic retinopathy
nonproliferative proliferative
30
growth of new vessels and fibrous tissue on surface of retina (neovascularization) extends into vitreous chamber consequence of severe capillary occlusion --> retinal ischemia --> release of VEGF stimulates the new vessel growth with vision loss from pre retinal hemorrhage, fibrosis, and retinal traction vision usually normal until macular edema, vitreous hemorrhage, or retinal detachment occur
diabetic retinopathy classification --> proliferative
31
diabetic retinopathy management
control of blood glucose, blood pressure, kidney function, and serum lipids examine every 3-4 months*
32
proliferative macular edema and exudates blurry vision, decreased acuity, visual distortion, scotomas most common cause of legal blindness in type 2 diabetes
maculopathy- symptomatic
33
diabetic retinopathy diagnosis
ophthalmology referral - baseline fundoscopic exam at diagnosis of type 2 - type 1 diabetics should be screened 5 years after diagnosis if visual symptoms and acuity not sufficient - annual dilated* eye exam
34
nonproliferative retinopathy management: macular edema
intravitreal administration of VEGF inhibitor* (mainstay of treatment for macular edema) (ranibizumab, bevacizumab) laser photocoagualtion intravitreal administration of corticosteroid vitrectomy
35
nonproliferative retinopathy management: severe nonproliferative retinopathy
panretinal laser photocoagulation prophylactically
36
disease of vessels supplying the retina and choroid secondary to severe acute or chronic uncontrolled systemic hypertension usually not symptomatic primarily seen in older patients
hypertensive retinopathy
37
can be encountered in any age group sudden severe elevation in BP major RF: degree of elevation of BP
acute malignant hypertensive retinopathy
38
older patients secondary to long standing HTN+ atherosclerosis major RF= duration of increased BP
chronic hypertension retinopathy
39
As BP increases, blood flow is maintained over wide range of pressures because blood vessels will constrict to maintain constant blood flow
autoregulation hypertensive retinopathy
40
with severe or sustained elevations in BP, the walls of the blood vessels must thicken to maintain blood flow
atherosclerosis hypertensive retinopathy
41
typically seen in patients in hypertensive crisis (secondary HTN): BP > 200/110 damages vasculature of retina and choroid leading to ischemic necrosis cotton wool spots dot blot and flame hemorrhages papilledema
acute hypertensive retinopathy
42
acute hypertensive retinopathy diagnosis
fundus abnormalities are hallmark of hypertensive crisis with retinopathy -- requires emergency treatment
43
hypertensive retinopathy over time
loss of autoregulation arteries/arterioles become ischemic hemorrhages, exudates, cotton wool spots, copper wiring, etc
44
acute hypertensive retinopathy treatment
treat underlying cause caution --> do not reduce BP too quickly or suddenly
45
acute hypertensive retinopathy common complications
retinal detachment optic neuropathy
46
accelerates development of atherosclerosis --> if advances far enough, visual acuity decreases focal/uniform narrowing or arterioles AV nicking/crossing* (hallmark of chronic hypertensive retinopathy) hemorrhage (flame, dot blot) copper/silver wiring macular star (advanced disease)- retinal exudates
chronic hypertensive retinopathy
47
chronic hypertensive retinopathy risk factors
high sodium diet obesity tobacco alcohol family history
48
occlusion of central retinal artery (eye stroke) sudden monocular vision loss no pain no redness
central/branch retinal artery occlusion
49
in patients > 50 years with central retinal artery occlusion consider
giant cell arteritis
50
branch retinal artery occlusion presents in a similar way to central retinal artery occlusion but...
smaller portion of visual field
51
may be due to embolism or thrombosis emboli may arise from: - atherosclerotic plaques (carotid artery stenosis) - atrial fibrillation - endocarditis thrombosis less common cause of retinal artery occlusion but can be seen with: - various acquired/inherited thrombophilic disorders such as SLE and giant cell arteritis
retinal artery occlusion
51
etiologic factors for retinal artery occlusion
diabetes hyperlipidemia hypertension young patients - migraine - oral contraceptives
52
fundus signs of retinal swelling sometimes adjacent cotton wool spots limited to area of retina supplied by occluded artery extent of arterial non perfusion is best seen with fluorescein angiography
branch retinal artery occlusion diagnosis
52
pale swelling of retina with cherry red spot at the fovea retinal arteries are attenuated and "box car" segmentation of blood in arteries or veins (RBCs separate from serum when blood flow is slowed or arrested) retinal swelling subsides over 4-6 weeks, leaving pale optic disk with thinning of inner retinal on optical coherence tomography scans
central retinal artery occlusion diagnosis
53
requires ophthalmology referral color fundus photography and fluorescein angiography
retinal artery occlusion diagnosis
54
once retinal artery occlusion diagnosis is made
carotid doppler echocardiogram (similar work up as stroke)
55
giant cell arteritis diagnosis
ESR, CRP, platelet count
56
what do you worry about with younger patients and retinal artery occlusion
blood clotting disorders
57
retinal artery occlusion treatment
urgent referral to ER for imaging and clinical assessment to prevent subsequent stroke lay patient flat, ocular massage, high concentrations of inhaled oxygen, IV acetazolamide, anterior chamber paracentesis early thrombolysis
58
occlusion of central or branch retinal vein (branch 4x more common) initial presentation: no pain or redness branch occlusion my present in variety of ways - sudden loss of vision at time of occlusion of fovea is involved - more gradual with development of macular edema - retinal abnormalities confined to area drained by obstructed vein
retinal vein occlusion
59
RF of retinal vein occlusion
similar to artery occlusion glaucoma major risk
60
retinal vein occlusion pathogenesis
virchow's triad for thrombogenesis - vessel damage - stasis - hypercoagulability central retinal vein and artery share common sheath at AV crossing
61
retinal vein occlusion diagnosis
ophthalmology referral
62
widespread retinal hemorrhages retinal venous dilation and tortuosity retinal cotton wool spots optic disk swelling
ophthalmoscopic signs for central
63
retinal abnormalities are confined to the area drained by obstructed vein
ophthalmoscopic signs for branch
64
retinal vein occlusion treatment: macular edema
intravitreal injection of VEGF inhibitors (branch or central) and refer
65
retinal vein occlusion treatment: neovascularization
pan retinal laser photocoagulation for retinal or anterior segment neovascualrization and refer

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