VASCULAR OCCLUSIONS AND HYPERTENSIVE RETINOPATHY

Question 1

what is the inner retina supplied by

Answer 1

the retinal artery and veins

Question 2

what is the outer retina supplied via

Answer 2

the choroidal vasculature

Question 3

which circulation does the cilio retinal artery come from and how many % of people have one

Answer 3

choroidal circulation

10-20%

Question 4

name 2 types of artery occlusions

Answer 4

Retinal artery occlusion

Cerebrovascular

Question 5

list 4 types of retinal artery occlusions

Answer 5

1. Central retinal artery occlusion
2. Branch retinal artery occlusion
3. Transient ischaemic event – Amaurosis Fugax
4. Cilioretinal artery occlusion

Question 6

what type of artery occlusion does this demonstrate and what type of field defect would this px have

Answer 6

CRAO

this px has a cilio retinal artery - the fovea will still remain perfused hence can still see centrally as coming from the choroidal circulation

Question 7

what type of artery occlusion does this represent

Answer 7

superior hemi retinal artery occlusion

superior trunk is affected

Question 8

which type of artery occlusion does this represent

Answer 8

superior branch temporal artery occlusion

Question 9

what type of elderly px’s are affected with a cilio retinal artery occlusion and which type of young px’s

Answer 9

elderly with GCA

young - usually a flow problem as opposed to an occlusion

Question 10

what does this photo signify

Answer 10

CRAO cherry red spot with retinal and macula thickening/oedema

the fovea is not thickened hence the difference in colour

Question 11

list 5 risk factors of a CRAO

Answer 11

• Age
• Cardiovascular risk factors
• GCA
• IVDU - drug takers
• Cosmetic fillers

Question 12

list 5 GCA symptoms

Answer 12

• Headache – temporal
• Temporal tenderness
• Jaw claudication / ‘angina’
• Weight loss / loss of appetite
• PMR - shoulder aches

Question 13

where should a px presenting with a CRAO be referred to

Answer 13

Refer to stroke team
GP/A&E

Question 14

what 5 actions should be carried out for a px with a CRAO acute <4 hrs

Answer 14

Thrombolysis
re-breathing bag
ocular massage
Diamox
paracentesis

Question 15

what is the management of someone presenting with a CRAO >4 hrs

Answer 15

Manage risks – refer stroke team/TIA clinic

Question 16

list 3 variants of a BRVO

Answer 16

• Hemi
• Quadrant – superior temporal, inferior temporal, inf nasal, sup nasal
• Macular branch

Question 17

list the 5 effects of a vein occlusion

Answer 17

• Venous outflow is reduced
• Flow within the retinal vessels reduced
• Resistance to arterial flow into the occluded system – (see video)
• Results in overall poor circulation within the affected area
• Retinal cell injury - Ischaemia - VEGF - which causes oedema

Question 18

what is this FA image showing

Answer 18

BRVO

Question 19

what can a cilio retinal artery be secondary to

Answer 19

secondary to CRVO

Question 20

what condition does this OCT image show

Answer 20

CRVO

OCT shows thickening and hyper reflectivity in that region

Question 21

in which type of patients will you see a Central Retinal Vein Occlusion (CRVO) with associated cilioretinal artery occlusion and what type of prognosis will you expect

what will you want investigated for as a possible underlying cause for this px

Answer 21

Usually in young patients with CRVO

Good outcome in young patients - vision eventually recovers ~ in 6 months

Blood investigations - thrombophilia screen, vasculitis screen e.g. for suspect behcets disease

Question 22

what does this FA show

Answer 22

Retinal Vein Occlusion – macular BRVO

can see vessels above the fovea are tortuous with aneurysm which leak

Question 23

list 4 risk factors of a vein occlusion

Answer 23

Hypertension
Hypercholesteraemia
Age
Thrombophilia/inflammatory (in younger patients)

Question 24

name 2 complications from a retinal vein occlusion

Answer 24

• Macular oedema
• Neovascularisation

Question 25

In history taking, what question will you ask an older px and what 5 things will you ask a younger px

Answer 25

Older px: Cardiovascular risk factors – BP, cholesterol, CVA, MI Young patients • DVT/PE • Miscarriages • contraceptive pills • family history • oral ulcers

Question 26

list 6 investigations you will want to carry out on a suspect Vein Occlusion

Answer 26

• VA • RAPD • IOP • gonioscopy • Inflammation • central venous pressure

Question 27

which 2 types of imaging will help with assessing a vein occlusion and why

Answer 27

• OCT DRIL (Disorganization of Retinal Inner Layers) CMO • Angiography (FFA) Confirm diagnosis Assess perfusion – ischaemic/non-ischaemic

Question 28

what is the 2 management options for ischaemic crvo

Answer 28

- monthly anti VEGF injections for 6 months and observe or - if very ischaemic , prophylactic PRP can be considered

Question 29

what will significantly large areas of ischaemia / non-perfusion result in - when seen in a crvo

Answer 29

high risk of neovascular complications >10DA in the posterior pole

Question 30

what 3 signs will you usually but not necessarily see in your clinical examination of an ischaemic crvo

Answer 30

RAPD VA <3/60 multiple deep blot haem throughout retina

Question 31

what anterior segment sign can you seen from an ischaemic crvo and what can this lead to

Answer 31

Iris - rubeosis Angle – causes neovascular glaucoma

Question 32

when is anti VEGF tx given to a person with ischaemic crvo and what needs to be controlled first

Answer 32

Given in NVG but control IOP before injecting

Question 33

what is the longer lasting tx option for neovascularisation due to ischaemic crvo

Answer 33

panretinal photocoagulation

Question 34

what is a common complication of ischaemic crvo

Answer 34

macula oedema

Question 35

what are the 2 tx options to treat macula oedema for a crvo and possible tx for a brvo

Answer 35

intravitreal steroids anti VEGF possible macula laser for brvo

Question 36

name 2 types of intravitreal steroidal injections used to treat a crvo

Answer 36

Ozurdex IVTA

Question 37

what is the outcome of taking Intravitreal anti-VEGF to manage macula oedema due to ischaemic crvo

Answer 37

50% - 15 letter improvement

Question 38

what is the outcome of someone taking Intravitreal dexamethasone to treat macular oedema due to ischaemic crvo and name 2 disadvantages

Answer 38

40% - 15 letter improvement Risk cataract (30%) / IOP rise (12-15%)

Question 39

name 3 signs of mild Hypertensive Retinopathy

Answer 39

Focal arteriolar narrowing AV nipping Copper wiring

Question 40

name 2 signs additional of moderate Hypertensive Retinopathy

Answer 40

Haemorrhages and cotton wool spots in addition to Focal arteriolar narrowing AV nipping Copper wiring

Question 41

name the 3 main signs of MALIGNANT Hypertensive Retinopathy

Answer 41

Haemorrhages CWS & disc swelling

Question 42

in which types of patients will you find Hypertensive choroidopathy name 3 conditions they can be suffering from

Answer 42

Usually in young patients with acute hypertension Eclampsia/pre-eclampsia Renal hypertension Phaechromocytoma

Question 43

what causes Ocular Ischaemic Syndrome and what vessel is this a disease of

Answer 43

Poor perfusion to eye Carotid artery occlusive disease • >90% closure • Reduces perfusion by 50%

Question 44

name 6 ways ocular ischaemic syndrome can be presented/detected

Answer 44

Sudden vision loss (41-66%) Gradual vision loss (28%) Amaurosis fugax (15%) ocular pain (13%) Bright light amaurosis (20%) Incidental finding

Question 45

list 7 anterior signs of ocular ischaemic syndrome

Answer 45

AC activity Iris atrophy NVI/NVA/NVG Corneal oedema Cataract Dilated episcleral vessels IOP: 4-60mmHg - either v low or v high

Question 46

list 6 posterior signs of ocular ischaemic syndrome

Answer 46

Mid-peripheral ret haem Venous dilataion Mas Easily inducible arterial pulsation Arteriolar narrowing NVD

Question 47

what 4 signs does FA show in an eye with ocular ischaemic syndrome

Answer 47

Patchy choroidal filling Increased AV transit time Capillary non-perfusion Late leakage from arterioles

Question 48

what signs does an ultra sound show in ocular ischaemic syndrome

Answer 48

Reversal of flow / retrograde flow