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KMK Ocular Disease > 13- Retina/Choroid1 > Flashcards

13- Retina/Choroid1 Flashcards

1
Q

Retinal vascular disease

-#1 cause always think

A

HTN

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2
Q

Central retinal vein occlusion (CRVO)

  • epidemiology
  • risk factors/etiologies
A

3rd most common vascular cause of vision loss (#1 DM)
~7% will have CRVO in fellow eye

Risks: HTN (61%), DM, CV dz, open-angle glaucoma
-up to 40-60% of pts with CRVO have POAG (kinks/compresses veins)

Young pts: oral contraceptives (DVTs), collagen vascular dz, AIDS

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3
Q

Retinal vein occlusions (C/BRVO)

-pathophys

A

HTN/DM -> artery compresses vein -> turbulent blood flow -> THROMBUS* -> VEGF
*thrombus stays where it’s formed

Central = @/near lamina cribrosa
Branch = @ A/V crossing
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4
Q

Sudden, painless vision loss DDX (5)

A 
Retinal occlusions: C/BRVO, C/BRAO
N/AAION
OIS
Optic neuritis
Stroke/tumor
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5
Q

Central retinal vein occlusion (CRVO)

-signs/symp

A

Signs: thrombus -> ischemia -> VEGF

  • retinal hemorrhages in all 4 quads
  • collateral veins
  • dilated, tortuous veins
  • CWS
  • disc edema

Symp: SUDDEN, UNILATERAL, PAINLESS VISION LOSS (esp in elderly)

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6
Q

Central retinal vein occlusion (CRVO)

-collateral vessels

A

Congenital - just not used normally
Become visible over several wks-mos
Often on disc, permit flow b/w retinal + choroidal circulation

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7
Q

CRVO + BRVO

-vision-threatening complications (2 major concerns)

A

Macular dz: ischemia, edema (#1 vision loss), intra-mac hemes

Neovascularization* -> NVG, preret/vit hemorrhage, tractional RD

  • DRVOS concerns!
  • NVG with CRVO = “90-day glaucoma”
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8
Q

Central retinal vein occlusion (CRVO)

-neovascular glaucoma

A

“90-day glaucoma”
-most likely in first 3 mo of dx

60% of ischemic cases develop iris neo, up to 33% NVG
6% of non-ischemic cases develop rubeosis or angle neo

Importance of gonio with suspected CRVOs
Treated with PRP

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9
Q

Central retinal vein occlusion (CRVO)

-ischemic vs non-ischemic

A

I: defined as 10DD+ NON-PERFUSION ON FA

  • 90% present with 20/200 or worse
  • poor prognosis: final VA at CF or worse, high risk for NVG

NI: majority (67%), up to 16% progress to ischemic

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10
Q

Branch retinal vein occlusion (BRVO)

  • epidemiology
  • risk factors
A

By far the MOST COMMON RVO dz

Risks: HTN (60%), CV dz, incr BMI at 20yo, open-angle glaucoma

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11
Q

Branch retinal vein occlusion (BRVO)

  • usual location
  • if they don’t occur at an A/V crossing
A

SUPERIOR-TEMPORAL (60%)

Check for vasculitis

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12
Q

Central retinal artery occlusion (CRAO)

  • epidemiology
  • risk factors
  • eiotiolgy
A

Elderly, 10% risk in fellow eye

Risks: HTN (67%), DM (33%), CAD (25%), cardiac valve dz (25%)

Young: IV drug use, contraceptives

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13
Q

Central retinal artery occlusion (CRAO)

-recall layers of retina CRA, choroid supplies for

A

CRA = inner 2/3: OPL -> ILM

Choroid (S/LPCA’s) = outer 1/3: RPE -> OPL
-cilioretinal can save macula

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14
Q

Retinal artery occlusions (C/BRAO)

-pathophys

A 
#1 EMBOLUS:
-Calcific = large, from calcified heart valves, esp in CRA near optic nerve
—more likely CRAO - gets stuck at lamina
-Carotid = smaller cholesterol plaques (Hollenhorst)
—more likely BRAO - gets past lamina, into branch artery

Other: GCA, acute elev in IOP
-IV drug use, oral contraceptives, sickle-cell, syphilis

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15
Q

Retinal artery occlusions (C/BRAO)

-pts with retinal emboli should be eval for

A

Underlying carotid artery and cardiac dz: carotid doppler and EKG/echo, respectively

25% with retinal emboli also have acute cerebral infarct

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16
Q

Central retinal artery occlusion (CRAO)

-signs/symp

A

Signs: superficial WHITENING* of inner retinal layers, narrowed vasculature, cherry red spot (VISIBILITY OF UNDERLYING CHOROID), APD (secondary to optic disc pallor)
*once perfusion is restored, color returns, function does does

Symp: ACUTE, PROFOUND VISION LOSS (20/400 or worse) unless cilioretinal artery is present (15-30%)

17
Q

Why NVG is rare in arterial occlusions

A

Retina dies too quickly to get VEGF released

18
Q

Branch retinal artery occlusion (BRAO)

  • pathophys
  • signs/symp
A

90% due to emboli (Hollenhorst #1, calcium, fibrin, platelet)

Signs: superficial WHITENING in distribution area (90% TEMPORAL), visible emboli in 62%
-like central, color returns, function does not (VFD is permanent)

Symp: often asymptomatic

  • VFD*, sudden unil painless vision loss
  • defect respects midline, mimics glaucoma - est VF for “new normal” once “healed”
19
Q

Diabetic retinopathy

  • think equals __
  • blood sugar levels of DM
A

Breakdown of BRB

> 126 fasting
200 oral
6.5 A1C

20
Q

Diabetic retinopathy

-exams/follow-ups

A

Initial:

  • DM1 = within 3-5 years after dx
  • DM2 = at the time of dx

Follow-ups:

  • no retinopathy = annual
  • mild-mod ret = 6-12mo
  • severe N/PDR = 2-4mo
21
Q

Diabetic retinopathy

-epidemiology

A

Leading cause of new cases of blindness in USA for 20-74yo

Most important risk factor = duration of dz

22
Q

Diabetic retinopathy

-pathophys

A

Loss of pericytes + damage to retinal capillary basement membrane -> breakdown of BRB

  • recall: pericytes = autoregulation (ret vessels, optic nerve)
  • recall: BRB = TJ b/w RPE cells and on ret vessels
23
Q

Non-proliferative diabetic retinopathy (NPDR)

-mild vs mod vs severe vs very severe

A 
Mild: 5% risk of progression to PDR in 1 year
Mod: 15%
Severe: 52%
Very severe*: 75% 
*meets 2+ criteria from 4:2:1
24
Q

Diabetic retinopathy

-4:2:1 rule

A

Diagnosis for SEVERE NPDR: pt meets 1 of 3 criteria

4: severe retinal hemorrhage in 4 quads
2: venous beading in 2 quads
1: IRMA in 1 quad

*very severe = 2+ criteria

25
Q

Diabetic retinopathy

-high risk characteristics (HRCs)

A

For pts with PDR who are at most risk for VISION LOSS

1) size + location: NVD >1/4 disc diameter within 1DD of optic nerve
2) hemorrhage: NVD/E with an associated vit/preret hemorrhage

26
Q

Diabetic retinopathy

-signs/symp

A

Signs: many, most important are macular dz + neo

Symp: often asymptomatic; blur, metamorphopsia

27
Q

Diabetic retinopathy

-macular disease

A

Ischemia: hypoxic = initially thickens -> thins + dies
-FA shows enlarged foveal avascular zone (hypofluorescent)

Edema: thickens (stays thickened), #1 loss of vision with DR, can occur at any stage

28
Q

Diabetic retinopathy

-CSME criteria

A

One need 1/3 for dx: key retinal THICKENING

1) retinal thickening within 500um (1/3DD) of foveal center
2) hard exudates within 500um of foveal center with adjacent retinal thickening
3) retinal thickening of at least 1DD within 1DD of foveal center

Recall: new/worsening caused by pioglitazone

29
Q

Diabetic retinopathy

-neovascularization threats to vision

A

DRVOS!
Preret/vit hemorrhage
NVG
Tractional RD

30
Q

Hypertensive retinopathy

  • pathophys
  • symp
A

Recall retinal vessels are autoregulated - this is altered at extremely high/chronically elev systolic pressures -> retinopathy
BP of at least 140/110 for latter stages to occur

Commonly asymptomatic; macular edema (star), papilledema, serous RD, vein occlusion

Recall: 130-139/80-89 is grade 1 HTN, >180/>120 is malignant HTN

31
Q

Hypertensive retinopathy

-signs/stages

A 
Bilateral, asymmetric
1: skinnery artery narrowing
2: stage 1 + A/V nicking
3*: stage 2 + 3 things: HEME, CWS, HARD EXUDATES (star config)
4: stage 3 + PAPILLEDEMA
  • stage 3 is when we start to see color (blood, CWS)
  • *elschnig spots: choroidal infarcts, occur in severe hypertensive ret
32
Q

Retinal artery macroaneurysm

  • epidemiology
  • signs/symp
A

Elderly women (70’s) with HTN, atherosclerosis

Signs: unilateral focal area of dilation in retinal artery (100-250um) with MULTI-LEVEL HEMORRHAGES from ruptured aneurysm

Symp: asymptomatic; gradual vision loss from edema or sudden from vit hemorrhage

33
Q

Ocular ischemic syndrome

  • epidemiology
  • pathophys
A

aka venous stasis retinopathy, part of DRVOS

Men, 50-80, HIGH CHOLESTEROL
-assoc with HTN, DM, cardiac dz

Occlusion of ICA and/or Ophthalmic artery (less common)
Usually secondary to atherosclerosis, may occur with GCA

34
Q

Ocular ischemic syndrome

-signs/symp

A

Signs: UNILATERAL (80%), dot-blot hemes of MID-PERIPHERAL fundus, dilated non-tortuous veins, narrow arteries, 67% PRESENT WITH NVI/NVA at time of dx

Symp: GRADUAL VISION LOSS (90%), dull periorbital pain/headache (40%), amaurosis fugax

35
Q

Ocular ischemic syndrome vs Venous stasis retinopathy

A

VSR: retinal findings (-)ant seg signs

OIS: retinal findings (+)ant seg signs

36
Q

Amaurosis fugax vs TIA vs stroke

A

AF: type of TIA, transient monocular vision loss, RETURNS TO NORMAL after event

TIA: TEMPORARY neurologic deficits due to loss of blood flow, perfusion restored in <24hrs (usually <15min), no permanent damage

Stroke: PERMANENT neurological deficits due to prolonged blood loss

KMK Ocular Disease (17 decks)

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