Cotton Wool Spots

Question 1

What is considered a high BP

Answer 1

140/90

Ask about chest pain and breathing

Question 2

Most common causes of CWS

Answer 2

HTN ret
DM
BRVO
CMV

Question 3

Prehypertension

Answer 3

120-139 and/or 80-89

Question 4

Hypertension is defined as

Answer 4

140/90 or higher

Question 5

When should treatment be indicated for pt over 60 with HTN

Answer 5

SBP 150 or >

DMP 90 or >

Question 6

When should treatment fir HTN in pts under 60 be initiated

Answer 6

140 or >

90 or >

Question 7

Risk of HTN increases with

Answer 7

Age 
FamHx
Race
Obesity
Diabetes
Smoking 
Excessive sodium intake

Question 8

HTN retinopathy occurs when

Answer 8

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

Question 9

Grade 1 HTN ret

Answer 9

Mild to mod diffuse narrowing of the retinal arteries (but no focal constrictions)

Question 10

Grade 2 HTN ret

Answer 10

Stage 1 plus focal constriction of the retinal vasculature (AV nicking) and exaggerating of the arterial light reflex

Question 11

Grade 3 HTN ret

Answer 11

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

Question 12

Grade 4 HTN ret

Answer 12

Grade 3 plus papilledema (malignant HTN)

Question 13

Pts with malignant HTN

Answer 13

Must be hospitalized immediately due to high risk of stroke. BP is usually >220/120mmHg

Question 14

Vision loss secondary to HTN ret

Answer 14

Rare unless the HTN changes resutls in a macular star, serous RD, or papilledema

Question 15

Elschnig spots

Answer 15

Focal areas of choroidal atrophy that develop from nonperfusion, they represent past episodes of acute HTN.

Question 16

Siegerst streaks

Answer 16

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

Question 17

Cat scratch findings

Answer 17

CWS
Unknown unilateral retinopathy
Mac star

Question 18

Diff between CR and HTN ret

Answer 18

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

Question 19

HTN ret secondary complications

Answer 19

Vein occlusion
RAMA
NAION

Question 20

Causes of CWS

Answer 20

HTN
Ischemia: DM
Infections: bartonella, AIDS
Meds: interferon
Neoplasm: leukemia and lymphoma 

CBC, physical, look at medications if seeing CWS

Question 21

BRVO and CWS

Answer 21

HTN and DM are risk factors for BRVO. CWS will occur in the area of the occlusion

Question 22

CMV and CWS

Answer 22

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

Question 23

Myelinated nerve fibers and CWS

Answer 23

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

Question 24

What are CWS

Answer 24

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

Question 25

What warrants and immediate referral to the ER for HTN

Answer 25

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

Question 26

F/u for HTN ret

Answer 26

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

Question 27

Treatment of CMV retinitis

Answer 27

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

Question 28

Drugs associated with AION

Answer 28

Viagra
Imitrix
Amiodarone

Question 29

How to tel; NAION vs optic neuritis

Answer 29

Only way to tell is with MRI on certain cases

Question 30

Side effects of BBlockers

Answer 30

DED
Bradycardia
Bronchoconstriction
Impotence 
Depression