Flashes And Floaters

Question 1

Things that cause flashes of light

Answer 1

PVD
RD
Ocular migraine
Occipital lobe infarction

Question 2

What is a PVD

Answer 2

Most common differential for flashes of light. Result from the detachment of the posterior hyaloid of the vitreous from the retina. HA and collagen complex in the victory’s is disrupted with age, resulting in the clumping of collagen into bundles. Liberated collagen fibers can contract within this complex, resulting in detachment of the posterior hyaloid from the retinal ILM; the detachment can be localized, partial, or total

Question 3

Why is the cause of the flashes of light in a PVD

Answer 3

Traction on the retina at the site of the vitreoretinal adhesion

Question 4

Stats on PVDs

Answer 4

More common in females, and the prevalence approximates age after 50 years.

• PVDs occur an average of 20 years earlier in myopes compared to emmetropia
• additional risk factors include DM, intraocular surgery, intraocular inflammation, vitreous hemorrhage, and trauma

Question 5

Signs of PVDs

Answer 5

Weiss ring and anteiror displacement of the posterior hyaloid membrane. May present with pigmented cells in the anterior vitreous (from the RPE, called Shaffer’s sign) and a vitreous hemorrhage

Question 6

What is the most common cause of retinal tears

Answer 6

PVDs and degenerative vitreous liquefaction causing vitreous traction

Question 7

Rhegmatogenous RDs

Answer 7

Result from retinal breaks (full thickness retinal defects)

• atrophic holes
• retinal tears

Question 8

Atrophic retinal holes

Answer 8

small, round, full-thickness defects caused by chronic atrophy of the sensory retina (NOT vitreoretinal traction); they are associated with low risk for a subsequent detachment. Most often in the temporal retina (superior>inferior), and are often associated with lattice degeneration

Question 9

Retinal tears

Answer 9

Caused by vitreous traction.

• flap tears: result of uneven vitreous traction; the vitreous traction often persists after the retinal tear occurs , leading to an increased risk of subsequent retinal detachment
• operculated tears: symmetric and the result of even vitreous traction; the traction no longer persists after the tear, reducing the risk of a subsequent retinal detachment. An operculum will be seen floating above the retinal tear

Question 10

Where are retinal breaks most likely ro occur

Answer 10

ST quadrant (60% of cases) in patients with an RD

Question 11

How likely is it that an eye with an RD will have more than 1 tear

Answer 11

50%

Usually located within 90 degrees of one another

Question 12

Nonrhegmatogenous RDs

Answer 12

NOT caused by retinal breaks, they include serous (exudative) and tractional RDs

Question 13

Exudative RD

Answer 13

Result from an accumulation of fluid underneath the sensory retina due to damage to the RPE. Examples of conditions that can cause this are ARMD, DR, inflammation, vascular conditions, neoplastic

Question 14

Tractional RDs

Answer 14

Most commonly caused by PDR, ROP, and sickle cell. The fibrous tissue associated with preretinal neo creates traction on the retina, leading to a detachment

Question 15

Who gets RRDs the most

Answer 15

Males over age 45

Question 16

Risk for RRD

Answer 16

Lattice degeneration 
Previous ocular surgeries
PVD
Trauma
Family Hx of RRD pre previous occurrence of RRD
Myopia

Question 17

Lattice degeneration as a risk of RRD

Answer 17

20-33% of eyes that develop RRD will have associated lattice; however only 1% of eyes that have lattice will develop RRD

Question 18

Symptoms of RRD

Answer 18

Can be asymptomatic, most present with symptoms of acute onset of flashes of light, floaters a shadow or curtain blocking vision, and/or decreased vision

Question 19

Signs of RRD

Answer 19

Retinal elevation (convex retina with folds) with an assocaited retinal break (atrophic hole or tractional tear), retinal movement with the eye movement, clear subretinal fluid that does not move with eye movement, pigmented cells in the anterior vitreous, hypotony, a mild iritis, and possibly an APD

Chronic RRDs are associated with a pigment demarcation line (takes 3m or longer to develop), intraretinal cysts (after 1 year), fixed folds, and/or subretinal precipitates

Question 20

Quadrant of symptoms in RDs

Answer 20

The quadrant that patients report the flashes of light are of no significant importance when determining where the RD is, but if there is a shadow or VF defect, it does correlate.

Question 21

Symptoms of ERDs

Answer 21

Usually asymptomatic unless the RD involves the macula; patients report symptoms that are similar to RRDs, but are more variable (vision loss can range from minimal to severe)

Question 22

Symptoms of TRDs

Answer 22

Often asymptomatic, unless macula is involved. Symptoms include decreased vision,flashes and floaters (rarely), and/or progressive VF defect (may remain stationary for months to years)

Question 23

Classical migraines

Answer 23

Preceded by a visual aura that develops over 5-20 minutes and lasts less than 60 minutes. The visual aura is most commonly bilateral and does not cross the midline. Patients often report photopsia, bright spots, zig-zags, jigsaw puzzle defects, tunnel vision, spreading scotomas, altitudinal defects, and other visual disturbances. These patietns will not have any vitreous or retinal abnormalities

Question 24

Focal occipital lobe infarction

Answer 24

Results in photopsia. Likely to occur in an older patient as a result of stroke

Question 25

Photopsia and retinitis

Answer 25

Flashes of light can also be a symptom of retinitis. Many patietns with RP report small, shimmering, blinking lights similar to the symptoms of a migraine visual aura. CMV retinitis May cause small peripheral retinal breaks that result in RD

Question 26

___ of patients with an acute symptomatic PVD will present with a retinal break. This number increases to _____ if there is an associated vitreous hemorrhage present

Answer 26

10-15% | 70%

Question 27

Vitreous hemorrhage

Answer 27

Can cause sudden painless low vision and/or black spots that may present with corresponding flashes of light. Mild VHs may still allow for visualization of the fundus, severe cases obscure the entire fundus, warranting a B scan to look for RDs behind the vitreous hemorrhage. Chronic VH appear yellow or gray yellow

Question 28

Which is more common, migraines with visual auras or without visual auras

Answer 28

Without visual auras - most migraines are not associated with visual auras and are termed common migraines (80%). Migraines with visual auras are termed classic migraines. Note that pts who have migraines with visual auras and normal behavioral risk factors related to stroke are at a higher risk for an ischemic stroke

Question 29

Lattice degeneration

Answer 29

Area of peripheral retinal thinning that us typically circumferential (often cigar shaped) nad concentric with the ora. The central area of the lesion is atrophy, and the outer margins have firm adhesions to the vitreous - is found in 6-10% of patients and is more common in myopic eyes. It is bilateral in 33-50% of cases and more commonly located temporally and superior - 12% of patients will have the classic pattern of crisis-crossed white sclerosed blood vessels

Question 30

____ of patietns with RRDs have lattice degeneration

Answer 30

20-33%

Question 31

Only ____ of lattice degeneration are associated with atrophic holes and only ____ will develop RRDS

Answer 31

25% | 1%

Question 32

Treatment for asymptomatic lattice degeneration

Answer 32

Does not require treatment. Prophylactive treatment is generally not indicated unless the fellow eye has had a lattice related RD

Question 33

When is prophylactic treatment considered in lattice degeneration

Answer 33

For patients with high myopia, aphakia, or a strong family Hx of RDs

Question 34

Treatment of symptomatic lattice

Answer 34

Should receive prophylactic treatment with cryopexy or laser photocoagulation

Question 35

Vitreoretinal tufts

Answer 35

Small, focal areas of vitreous traction located in the peripheral retina. They occur in 5% of the population and are secondary most common peripheral retinal lesion assocaited with an RD (lattice is number 1); less than 1% of pts with vitreoretinal tufts develop RDs. No prophylactic treatment needed

Question 36

What refractive shift is expected after RD surgery with a scleral buckle

Answer 36

Myopic

Question 37

Treatment of symptomatic retinal tears

Answer 37

With persistent traction (horseshoe tears, giant tears) have a high risk of subsequent RD and are generally treated promptly after dx

Question 38

Treatment for asymptomatic flap tears

Answer 38

Have a lower risk of RD, but are typically treated prophylactically

Question 39

Treatment for symptomatic operculated tears

Answer 39

Also have a lower risk of detachment; treatment depends on the retinal specialist.

Question 40

What types of retinal tears rarely require prophylactic treatment

Answer 40

Atrophic holes, asymptomatic operculated tears, and asymptomatic lattice.

Question 41

What location of retinal break is more dangerous

Answer 41

Superior because of gravity

Question 42

retinal breaks with subretinal fluid

Answer 42

Need managed aggressively

Question 43

How are retinal breaks treated

Answer 43

With laser photocoagulation or cryotherapy; these techniques create a strong adhesion between the retina and RPE so vitreous fluid entering the retinal break cannot spread and create a RD

Question 44

Visual potential in RDs

Answer 44

Directly related to the duration of the retinal detachment and the severity of macular involvement

Question 45

Treatment of chronic asymptomatic RD

Answer 45

Not required

Question 46

Treatment of mac off RD

Answer 46

Usually result in permanent reduction in vision even with timely and appropriate treatment; these RDs should bd treated urgently within 48-96 hours

Question 47

Treatment of mac on RDs

Answer 47

Immediately (within 24 hours)

Question 48

Types of surgical treatment for RDs

Answer 48

Pneumatic retinopexy Scleral buckle Vitrectomy

Question 49

Pneumatic retinopexy

Answer 49

An intravitreal gas bubble is injected to temporarily tamponade the retinal tissue against the RPE., this prevents additional vitreous fluid from entering the tear and allows the RPE to pump excess subretinal fluid into the choroid. Laser photocoagulation or cryotherapy is then used to permanently seal the retinal break. Pneumatic retinopexy is primarily used for superior retinal breaks; it has a high success rate and seals the retinal break without utilization of a scleral buckle

Question 50

Scleral buckle

Answer 50

Flexible silicone strip is permanently sutured on or within the sclera in order to indent the sclera and relieve vitreoretinal traction associated with the retinal break, cryotherapy or laser photocoagulation can then be used to create permanent adhesion between the retina and RPE. Side effects include induced myopia, pain, hemorrhages, infection, and diplopia

Question 51

Vitrectomy for RRD

Answer 51

Removal of the vitreous allows release of vitreoretinal traction. Intravitreal gas (retinopexy) or silicone oil is then utilized to tamponade the retina before applying laser photocoagulation or cryotherapy for permanent adhesion. Vitrectomy can be performed with or without scleral buckle. Common indicates for a vitrectomy with retinal breaks include the following - Inabiltiy to visualize the retinal break as a result of a cloudy vitreous - inability to close retinal breaks through tankard techniques, typically as a result of a very large break, posterior breaks that include a macular hole, and severe vitreoretinal traction

Question 52

Post opt complications of RD surgery

Answer 52

``` Elevated IOP Cataracts Hemorrhage Infection Post op positioning complications (pt should be face down) ```

Question 53

Treatment of exudative RS

Answer 53

Treatment of the underlying condition