Final Exam Flashcards by Matthew Hendricks

How can you tell the difference between drusen and exudates

Drusen are round and have dull borders.

Exudates are angularly shaped and have sharp defined borders

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Location of drusen vs exudates

Drusen: between RPE and bruch’s

Exudates: OPL

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What is flecked retina?

White, pisciform lesions that occur on a beaten-bronze colored macula in Stargart’s dystrophy

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What’s the one green retinal finding we learned about in the basics lecture?

Choroidal neovascularization

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What’s the one orange retinal finding we learned about in the basics lecture?

Lipofuscin

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How common is Toxoplasmosis? How common are its retinal findings?

There is serologic evidence that 30-70% of people carry the infection. Less than 1% develop retinitis. However, over 80% of congenital cases develop retinitis.

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Toxoplasmosis ocular symptoms

Blur
Floaters
Red eye
No pain
VF loss if papillitis present, or if scar in area of retina that corresponds to visual field area

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Toxoplasmosis diagnosis

-Based upon clinical findings
-Serologic findings are supportive but not diagnostic
-ELISA - for detection of toxo specific IgG and IgM antibodies
-FTA-ABS to r/o syphilis
PPD/CXR to r/o TB

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Indication to treat toxoplasmosis

Active lesion
Lesion threatens ON or macula
Lesion is large, regardless of location
2 line drop in VA
Hemorrhage
Persists > 1 month

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Toxocariasis ocular signs

Round, raised white granuloma in posterior pole ~ 1DD in size, often with RPE hyperplasia and fibrotic bands radiating from lesion
Possible anterior uveitis and vitritis
Possible RD

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Toxoplasmosis ocular prognosis

Good, so long as macula is not involved

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Toxocariasis ocular prognosis

Guarded to poor: can involve a macular scar, and can reactivate

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Histoplasmosis ocular signs

Circumpapillary choroidal scarring
Peripheral choroidal “punched-out” histo spots
Macular compromise secondary to neovascular net
No anterior uveitis or vitritis

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Amsler grid is good at monitoring which infectious ocular disease? Idiopathic/viral complication?

Histoplasmosis (POHS)

Multifocal choroiditis

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Syphilis ocular signs (acquired)

Multiple, non-elevated yellowish grey, ill-defined chorioretinal lesions  heals  chorioretinal atrophy with hyperpigmentation
Anterior uveitis – unilateral or bilateral, recurrent
Posterior uveitis
Vasculitis
Maculopathy
RD
SRNM
Conj involvement
Corneal involvement
Glaucoma
Retinal necrosis
Optic neuritis

THATS A LOT!

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Syphilis ocular signs (congenital)

“Salt and pepper” fundus
Glaucoma

Hutchinson’s triad:

Interstitial Keratitis
Deafness
Notched incisors

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TB ocular signs

Rare but possible

Anterior uveitis – unilateral or bilateral, granulomatous
Posterior uveitis/vitritis
Choroiditis - yellow white nodules (tubercles)
Periphlebitis
Phlyctenular keratoconjunctivitis (PKC) ?

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Lyme ocular signs

Stage one - conjunctivitis (11%) and periorbital edema

Stage two - granulomatous anterior uveitis (rare manifestation - may occur in late stage), retinal vasculitis and choroiditis

Stage three - episcleritis, stromal keratitis

Other ocular presentations:

Vitreous inflammation -“spider web”
Ocular motility problems
ON inflammation

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Sarcoidosis ocular signs

Lacrimal gland disorders 70%
Granulomatous, alternating anterior uveitis 40%
Posterior uveitis
Nodules – iris, conjunctiva
Periphlebitis (“candle wax drippings”)
Vitreous opacities (“string of pearls”)
ONH edema
Choroidal granulomas
Conj granulomas/conjunctivitis
Keratitis
Macular edema
Lid granules

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Sarcoidosis #1 systemic manifestation

Fatigue

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Can you cure sarcoidosis?

No, but can manage symptoms with prednisone

SLE retinal disease

Main problem is retinal vascular disease in about 10% of patients with SLE

More common: retinal hemorrhages and cotton wool spots (CWS)

Rare retinal vein and artery occlusions

Less common: retinal vasculitis, periphlebitis (sheathed narrow retinal arterioles with white exudates adjacent to the vessels)

Neurological, choroidal, scleral complications

Pars Planitis retinal findings

Asymptomatic, or floaters and hazy vision
Usually no pain, redness or photophobia

Objective/Signs:

Initial dirty, yellow exudates aggregate near vessels in extreme periphery
“Snowballs” – coalesced infiltrates in vitreous
“Snowbanking” - exudates may coalesce & break off into the vitreous
CME
Cataract
Periphlebitis

VKH ocular findings

Granulomatous anterior uveitis
Multifocal choroiditis
Detachments of sensory retina
Vitritis/posterior uveitis
Retinal hemes
“Sunset glow”: choroid depigmentation 3-4+ months after uveitis, associated with systemic disease

What is the most important sign of an endophthalmitis?

Hypopyon

Initial ocular presentation of HIV/AIDS

Cotton Wool Spots

What commonly causes CMV retinitis to manifest

Reactivation of latent CMV infection (very common) due to immunosuppression in HIV/AIDS. Usually not seen until CD4 drops below 200

Ocular CMV clinical features

- Necrotizing retinitis with or without hemorrhages is usual presentation - Patchy yellow-white areas with secondary hemorrhage along the edges - Occurs most frequently along the major vascular arcades or near the ONH - ALL retinal layers affected  full thickness retinal destruction - Spread centrifugally - direct extension from diseased to healthy retina

Types of CMV retinitis presentations

1) Hemorrhagic 2) Brushfire 3) Granular

CMV retinitis treatments

Anticytomegaloviral medications: HAART = highly active antiretroviral therapy Ganciclovir (Cytovene) - Inhibits viral DNA polymerase - Nausea, vomiting, neutropenia, thrombocytopenia - Vitrasert is an eye implant that delivers ganciclovir Foscarnet (Foscavir) - Inhibits viral DNA polymerase and reverse transcriptase - Anemia, renal dysfunction, hypo- and hyperphosphatemia, hypocalcemia Cidofovir (Vistide) - Inhibits viral DNA polymerase and reverse transcriptase - Renal failure

Typical CMV retinitis cocktail

1) IV Cidofovir 2) Intravitreal Vitrasert implant (ganciclovir) 3) Intravitreal injections of ganciclovir or foscarnet

Absorption and Emission peaks of NaFl

Absorption: 490nm - transmitted through excitation filter Emission: 520nm - transmitted through the barrier filter

What is caused when the transmission curves of the excitation and barrier filters overlap?

Psuedofluorescence

Complications to NaFl injection

Mild - Injection site reaction - Nausea - Vomiting Moderate - Urticaria - Shortness of breath - Vasovagal reaction - Skin necrosis Life Threatening - Anaphylaxis - Seizure - Cardiac collapse

Is NaFl angiography okay for pregnancy?

NO NO NO NO

Do you want to take some fundus photos before NaFl injection?

Yep - color and red-free-green!

NaFl angiography timing, in general

Fluorescein should start appearing in the eye in about 8-12 seconds - 8 seconds for younger individuals - 12 seconds for older individuals Take photos every 1.5-2 seconds in the transit eye for about 30 seconds until the initial transit is complete After, the fluorescein recirculates and the concentration of fluorescein begins to decrease Option of taking photos of fellow eye & periphery Wait (for late staining) ~3-5 minutes, take additional photo Option of taking 10 minute photo

NaFl angiography stages timing

Choroidal Flush: 8-12s after injection Arterial Phase: 2 seconds after Arteriovenous & Venous phases: ????? Mid Phase: 2-4m after injection Late Phase: 7-15m after injection

Be sure to compare hypofluorescence on the angiogram to the color fundus photo. If the hypo is the same shape as a finding on the color photo, then it's a "blockage." If there's nothing corresponding on the color photo it's a vascular filling defect

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How will hemorrhages appear on NaFal angiogram?

Hypofluorescence. It's old blood, so it's not full of the NaFl dye. Anything that would normally fluoresce that's being blocked by the heme won't shine through because of the density of the blood in the way

Name the two autofluorsescent things we learned about

1) Optic Disk Drusen | 2) Astrocytic hamartomas (tumors of astrocytes)

What has a petaloid appearance on FA?

CME

What has a smokestack or ink blot appearance on FA?

Central serous retinopathy

What has a light bulb appearance on FA, complete with gradual brightening over time?

Pigment epithelial detachment (PED)

How can you differentiate drusen and exudates on FA?

Drusen stain, exudates do not

How is are the anterior and posterior corneal stroma different?

Anterior is more disorganized Posterior is more uniform: will peel like an onion This is maybe true? I hope so. The notes are unclear

What process has make DALK better in recent years

Big Bubble

Most common cause of congenital cataracts

Rubella

Most common senile cataract

Nuclear

Least common senile cataract

Subcapsular (visually debilitating)