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medical retina > Acute Vitreoretinal Pathologies > Flashcards

Acute Vitreoretinal Pathologies Flashcards

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USMLE® Step 1 flashcards
1
Q

what is this and where in the retina does it take place

A

pre retinal haemorrhage

in the sub hyaloid space

between the post hyaloid and internal limiting membrane

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2
Q

what are the 2 causes of a vitreous haemorrhage

A

Damage to normal blood vessels

or

Growth of abnormal blood vessels

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3
Q

how does damage to normal blood vessels cause a vitreous haemorrhage and name 2 examples

A

Retinal blood vessels that are damaged through injury or trauma can cause a vitreous haemorrhage.

Posterior vitreous detachment
Retinal tears

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4
Q

how does growth of abnormal blood vessels cause a vitreous haemorrhage and name 5 examples

A

Abnormal retinal blood vessels are typically the result of neovascularization due to ischemia in diseases such as:

diabetic retinopathy
sickle cell retinopathy
retinal vein occlusion
retinopathy of prematurity
ocular ischemic syndrome
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5
Q

what is this a sign of

which type of px is it more commonly found in

what type of symptoms will the px experience

and where in the retina is this found

A

Retinal macroaneursym

more common in elderly hypertensive women

haemorrhaging of the arteriole macroaneurysm presents acutely with rapid visual deterioration

multi layered involving the - vitreous, pre retinal, intra retinal and sub retinal spaces

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6
Q

describe how a Rhegmatogenous retinal detachment takes place

A

This results when a hole, tear, or break in the neuronal layer allows fluid from the vitreous to seep between and separate sensory and RPE layers

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7
Q

describe how a Traction retinal detachment takes place

A

This results from adhesions between the vitreous gel/fibrovascular proliferation and the retina

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8
Q

describe how a Exudative (serous) retinal detachment takes place

A

This results from exudation of material into the subretinal space from retinal vessels – ocular tumour

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9
Q

which type of retinal detachment is not present with a vitreous haemorrhage

A

Exudative (serous) retinal detachment

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10
Q

how does a gas bubble procedure to treat a retinal detachment work

when is it not suitable to do this tx

what is expected of this px after the procedure

A

The gas bubble keeps the retinal tear dry while the healing takes place . The gas disappears after a few weeks

cannot to is a px is going to travel in air due to air pressure

px is expected to lie face down for a 5-8 days, so the gas bubble floats up and keeps the retina dry

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11
Q

explain how scleral buckling works as a treatment for a retinal detachment

A

the explant or buckle pushes the outside layers of the eye against the retinal tear to allow it to heal, and to stop the flow of fluid behind the retina

any remaining fluid is then absorbed by the outer layers of the retina

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12
Q

explain how a vitrectomy is carried out

A

A vitrectomy instrument is used to drain fluid that is behind the retina

a fibre optic light is used to aid this

in order to keep a steady IOP, fluid goes into the eye through a cannula to replace the vitreous that is removed

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13
Q

Name this condition

A

acute retinal necrosis ARN

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14
Q

with Acute Retinal Necrosis

In 1994, the Executive Committee of the American Uveitis Society refined the definition of ARN based on clinical characteristics and disease course to include what 5 signs

A

1) one or more foci of retinal necrosis with discrete borders located in the peripheral retina;
2) rapid progression in the absence of antiviral therapy;
3) circumferential spread;
4) evidence of occlusive vasculopathy with arterial involvement
5) a prominent inflammatory reaction in the vitreous and anterior chambers

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15
Q

what are the anterior 4 signs and 2 symptoms of someone with Acute Retinal Necrosis

A

photophobia and pain

anterior chamber inflammation
secondary KPs
episcleritis and scleritis
corneal oedema

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16
Q

what are the 4 posterior signs and 2 symptoms of someone with Acute Retinal Necrosis

A

flashes and floaters

vitritis - hazy appearance
vascular/arterialitis - haemorrhages
peripheral retinitis - white patches
swelling of the optic disc

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17
Q

how is acute retinal necrosis ARN treated

A

anti virals

given intravenously, orally or intravitreally e.g. aciclover, ganciclover

after the antivirals - given steroids to dampen down the inflammation

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18
Q

what is this condition

A

porn - progressive outer retinal necrosis

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19
Q

what is the difference between porn - progressive outer retinal necrosis and ARN - acute retinal necrosis

A

with porn - there is no haziness, you get a clear view of the retina because the inflammatory response is not to the same degree as ARM

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20
Q

which type of people does porn affect

A

people with compromised immune systems e.g. AIDS

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21
Q

what are the clinical signs of porn - progressive outer retinal necrosis and how is it treated

what risk is there with someone who has porn

A 
areas of:
haemorrhages
white areas of retinitis 
and 
sheathing of the retinal vasculature

Tx = antiviral agents given intravitrially

Risk of - retial detachment

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22
Q

what is this condition called

what 2 characteristics do you see and why do these occur

A

Neuroretinitis

optic nerve oedema
and
macula star/stellate maculopathy

because of inflammation due to increased permeability of the optic disc vasculature which causes a secondary macula star

this can be from infective causes of vasculitis

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23
Q

what 2 parts of the retina are inflamed with Neuroretinitis

A

optic nerve
and
neuroretina

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24
Q

what causes the characteristics of Neuroretinitis

A

optic disc swelling

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25
Q

list 7 infective causes of Neuroretinitis

A 
bartinella
cat scratch disease 
syphilis 
tuberculosis 
lyme disease 
leptospirosis
toxoplasmosis
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26
Q

what organism is in cat scratch disease which can cause neuroretinitis and how does this get transmitted

A

Bartonella hensela

transmitted from a flea to the cat and then to the human host

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27
Q

what condition is this

what is this caused from

what characteristics do you see

what is the visual prognosis

A

commotio retinae

caused by anterior segment trauma - that produces a contusion injury by a countertop mechanism / blunt trauma

transient well defined greyish/white opacification of the retina - it can involve large areas of the peripheral retina or be confined to the macula

vision can be normal if confined to peripheral retina unless the macula is involved

28
Q

which layer of the retina is damaged with commotio retinae

A

photoreceptor outer segments

29
Q

what is the term called if commotio retinae affects the macula

A

berlins macula oedema

30
Q

what is this condition called

what clinical characteristics does it have

A

Terson’s syndrome

presence of any intra ocular haemorrhages 
e.g. 
vitreous haemorrhage 
subhyaloid haemorrhage 
intra or sub retinal haemorrhages
31
Q

what is the lead pathogenesis/theory of Tarsen’s syndrome

A

intracranial pressure causing a rapid efflux of cerebrospinal fluid or haemorrhages into the optic nerve sheath into the orbit which compresses the central retinal vein, objecting the venous outflow and rupturing the smaller retinal venules.

32
Q

what is an alternative pathogenesis of Terson’s syndrome

A

acute IOP which can cause increased orbital venous pressure, leading to a back fill of blood into the retinal veins

33
Q

what systemic issue will a px with Terson’s syndrome have

A

intra cranial haemorrhage or traumatic brain injury

34
Q

what is the visual outcome of someone with Tersen’s syndrome

A

usually good depending on extent of haemorrhages

can take weeks or months for advanced haems to clear

35
Q

what is this condition called

name 3 clinical signs

A

Pertschur’s Retinopathy

haemorrhages
cotton wool spots
pertchur flacken - polygnal layers of retinal whitening with a clear demarcating line

36
Q

give examples of 3 traumatic and 5 non traumatic causes of Pertschur’s Retinopathy

A

Traumatic

  • head trauma
  • chest compressions
  • fracture of long bone e.g. femur such as from orthopaedic surgery or weight lifting

Non traumatic

  • acute pancreatitis
  • pancreatic adenocarcinoma
  • fat embolism
  • preeclampsia
  • globulinemia
37
Q

how many % of Pertschur’s Retinopathy is bilateral and what type of visual issues does a person have with it

A

60%

Reduced VA associated with VF loss, centrally, paracentral, or arcuate scotoma - peripheral VF is usually preserved

38
Q

list 4 types of vascular occlusions

A

Central Retinal Vein Occlusion CRVO

Branch Retinal Vein Occlusion BRVO

Central Retinal Artery Occlusion CRAO

Ocular Ischaemic Syndrome

39
Q

what is the incidence of CRVO

what % of CRVO px’s have the contralateral eye affected and within how many years

what mean age group of px’s are affected by CRVO

A

Incidence 2-8/1000

5-10% contralateral eye affected within 5 yrs

Mean age 60-70 years

40
Q

what is the aetiology of a CRVO

A

Multifactorial
• Compression by a sclerotic central retinal artery & cribiform plate

  • Haemodynamic disturbances leading to stagnation and primary thrombus formation
  • Degenerative/inflammatory disease within the vein e.g. sarcoidosis
41
Q

list 6 systemic risk factors of a CRVO

A
  • Arterial hypertension
  • Cardiovascular disease
  • Diabetes Mellitus
  • Obesity
  • Hyperlipidemia
  • Smoking
42
Q

list 5 Thrombophilia causes of a CRVO

A 
Hyperhomocysteinaemia
Anti-phospholipid syndrome
Increased APC resistance
Increased haematocrit 
Increased plasma viscosity
43
Q

list 7 local/ocular risk factors of a CRVO

A
  • Glaucoma
  • Retinal vasculitis
  • Central artery occlusion
  • Drusen
  • Papilloedema
  • Arteriovenous malformation
  • Trauma
44
Q

list 4 Hyperviscosity (abnormalities in the blood) syndrome causes of a CRVO and what investigation should take place due to this

A

Polycythemia
Macroglobulinaemia
Myeloma
Leukaemia

a blood count should be done urgently

45
Q

list 3 investogations/tests to differentiate between ischaemic and non ishaemic CRVO

A

Visual acuity
RAPD
Fluorescein Angiography

46
Q

how can you investigate the extent the of blurred vision with a CRVO

A

Determine if macular oedema using OCT

47
Q

what 3 conditions does a medical work up from a CRVO look for

A

hyperlipidemia
hypertension
diabetes

48
Q

what 3 other ocular conditions should you look out for after seeing a CRVO

A

neovascularisation - 90 day glaucoma - from blockage of the trabecular meshwork

vitreous haemorrhage

retinal detachment

49
Q

which type of CRVO can cause 90 day glaucoma

A

ischaemic CRVO

50
Q

list 2 possible treatments for macula oedema from a CRVO

A

Anti VEGF

Intravitreal steroid - if don’t want to give anti VEGF to someone who has had a stroke
e.g. Ozurdex - longer acting steroid

51
Q

what test should be carried out with a CRVO to rule out ischaemia and why

A

FFA

as OCT alone does not tell us about the full perfusion of the retina

52
Q

what condition should you suspect if you see a CRVO like this and what clinical signs suggest this

A

Leukemia

haemorrhages around the optic disc with a white centre = underlying haematological disorder

53
Q

what types of VA do 90% of people with a CRAO get

A

CF to PL

54
Q

which type of artery occlusion does a px with NPL and no cherry red spot have

A

ophthalmic artery occlusion

55
Q

what causes a cherry red spot in a CRAO

A

a continued blood supply to the choroid from the ciliary artery = bright red colouration to the thinnest part of the retina at the macula

56
Q

list 6 causes of a CRAO

A 
Giant cell arteritis - in older patients
Embolus formation
Systemic hypertension
Diabetes mellitus
Cardiac valvular disease
Cardiac anomalies
57
Q

what is the most common cause of an embolism causing a CRAO

list 3 other less common causes

A

Cholesterol is the most common type

but it can also be from:
calcium, bacteria, or talc from intravenous drug use

58
Q

what is the leading cause of CRAO in patients aged 40-60 years and how many px’s with this type of cause does it account for

A

Atherosclerotic disease

Carotid atherosclerosis is seen in 45% of cases of CRAO

59
Q

what is a common etiology of CRAO in patients younger than 30 years

A

A hypercoagulable state

such as in patients with sickle cell anemia, polycythemia, or antiphospholipid syndrome or in those taking oral contraceptive

60
Q

name a secondary cause of a CRAO in young patients

A

Hyaluronic acid fillers

causes bilateral CRAO and brain infarction/stroke

61
Q

how to the retinal veins and arteries appear after a CRAO

A

“Boxcarring” appearance of the impaired blood column can be seen in both arteries and veins

62
Q

list 3 medical treatments that should be done as soon as a CRAO is detected and why

A

Ocular massage - to dislodge the embolus

Anterior chamber paracentesis - needle into ant chamber to reduce the IOP and facilitate perfusion of the retina

Medical reduction of intraocular pressure e.g. diamox & facilitate perfusion of the eye

63
Q

what can occur in 4-5 weeks after a CRAO event and in how many % of people

A

Neovascularization of the iris occurs in 20% of patients

64
Q

what condition is panretinal photocoagulation is effective in after a CRAO and in how many % of these patients

A

iris neovascularization in 65% of patients

65
Q

what is the mortality rate and over how many years in Patients with visualized retinal artery emboli, regardless of the presence of obstruction?
compared to how many in an age-matched population without retinal artery emboli?

A

56% mortality rate over 9 years

27% in an age-matched population without retinal artery emboli

66
Q

what is the life expectancy among patients with CRAO compared to an age matched population without CRAO

A

5.5 years compared to 15.4 years in an age-matched population

medical retina (17 decks)

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