Cotton Wool Spots Flashcards
What is considered a high BP
140/90
Ask about chest pain and breathing
Most common causes of CWS
HTN ret
DM
BRVO
CMV
Prehypertension
120-139 and/or 80-89
Hypertension is defined as
140/90 or higher
When should treatment be indicated for pt over 60 with HTN
SBP 150 or >
DMP 90 or >
When should treatment fir HTN in pts under 60 be initiated
140 or >
90 or >
Risk of HTN increases with
Age FamHx Race Obesity Diabetes Smoking Excessive sodium intake
HTN retinopathy occurs when
Resutls from chonric or acutely elevated (malignant) systemic BP. Chronically elevated BP alters the ability of retinal arteries to autoregulat their vessel diameter based on changes in BP, leading to breakdown of the BRB. BP should be checked in cases of suspected HTN ret to aid in the diagnosis
Grade 1 HTN ret
Mild to mod diffuse narrowing of the retinal arteries (but no focal constrictions)
Grade 2 HTN ret
Stage 1 plus focal constriction of the retinal vasculature (AV nicking) and exaggerating of the arterial light reflex
Grade 3 HTN ret
Stage 2 plus retinal hemorrhages, CWS (typically located within 3DD of the ONH), hard exudates (likely in a star configuration within the OPL layer, radiating away from the fovea), and retinal edema. Diastolic BP at this stage is usually 110-115mmHg
Grade 4 HTN ret
Grade 3 plus papilledema (malignant HTN)
Pts with malignant HTN
Must be hospitalized immediately due to high risk of stroke. BP is usually >220/120mmHg
Vision loss secondary to HTN ret
Rare unless the HTN changes resutls in a macular star, serous RD, or papilledema
Elschnig spots
Focal areas of choroidal atrophy that develop from nonperfusion, they represent past episodes of acute HTN.
Siegerst streaks
Linear hypopigmented areas over choroidal vessels. Recall that the choroidal vessels do not have the same ability to autoregulate their diameter compared to retinal vessels
Cat scratch findings
CWS
Unknown unilateral retinopathy
Mac star
Diff between CR and HTN ret
HTN is more likely to present with a “dry” retina (few hemorrhages, rare edema, rare exudates, and multiple CWS)
DR is more likely to present with a “wet retina” (multiple hemorrhages, multiple exudates, more edema, few CWS), with less artery attenuation
HTN ret secondary complications
Vein occlusion
RAMA
NAION
Causes of CWS
HTN Ischemia: DM Infections: bartonella, AIDS Meds: interferon Neoplasm: leukemia and lymphoma
CBC, physical, look at medications if seeing CWS
BRVO and CWS
HTN and DM are risk factors for BRVO. CWS will occur in the area of the occlusion
CMV and CWS
Most common ocular infection and the leading cause of blindness in patients with AIDS; it affects 40% of patients with AIDS, and is msot common in patients with CD4 counts less than 50
-CMV infection results in a hemorrhagic retinitis with thick, white-yellow patches of necrotic retina, vascular sheathing, retinal hemorrhagesm and CWS
Myelinated nerve fibers and CWS
Usually unilateral, feathery, yellow-white patches of myelination that typically follow the normal course of the RNFL. Can also appear as peripapillary myelination or isolated peripheral patches and may cause condition for papilledema or CWS on a cursory exam
- does not typically start until the ganglion cell axons are posterior to lamina cribrosa
- pts most often asymptomatic, but may have VF defect
What are CWS
Ice bc is, edematous, opaque areas within the nerve fiber layer that develop secondary to arteriolar-cap occlusion. Recall that flame shaped hemes are also lcoated within the nerve fiber layer. Hard exudates are located in the OPL. Dot hemorrhages are most often located in the INL
What warrants and immediate referral to the ER for HTN
A diastolic BP reading of 110-120 or symptoms of chest pain, difficulty breathing, HAs, nausea, a change in the patietns mental status, and/or decreased vision secondary to papilledema
F/u for HTN ret
Every 2-3 months initially, then every 6-12 months thereafter. Treatment of the underlying HTN results in resolution og the retinal findings; CWS almost always disappear within 5-7 weeks
Treatment of CMV retinitis
IV gancyclovir, foscarnet, or cidofovir. Pts need followed with a CBC if given IV gancyclovir (due to suppression of bone marrow), or with BUN/creatinine for IV foscarnet (nephrotoxicity)
-vitrasert is an intravitreal gancyclovir implant that can be considered treatment for initial unilateral episodes of CMV retinitis; pts are often treated with oral for systemic CMV prophylaxis
Drugs associated with AION
Viagra
Imitrix
Amiodarone
How to tel; NAION vs optic neuritis
Only way to tell is with MRI on certain cases
Side effects of BBlockers
DED Bradycardia Bronchoconstriction Impotence Depression
