Friedman posterior segment Flashcards
DDx causes of exudative RD
V: HTN, glomerulonephritis, eclampsia/pre-eclampsia
I: uveitis (VKH, SO, pars planitis, posterior scleritis)
T:
A:
M: hypoTH
I: CSR, Coat’s
N: retinal capillary hemangioma/VHL, choroidal hemangioma, choroidal malignant melanoma
Characteristics of exudative RD
>located inferiorly >display shifting fluid >smooth appearance >chronic exudative RD can lead to NVG >important to perform depressed exam and R/O RRD
In contrast, traction RDs are usually taut and immobile with a CONCAVE surface that does not extend to the ora serrata
Work-up for Exudative RD
FA: evalute tumor (intrinsic vasculature, feeder vessels) and vascular abnormalities
ICG: superior to FA to show intrinsic vascularity, hot spots, wash-out phenomenon for tumors*
B-scan: confirm shifting fluid, evaluate choroidal thickness, evaluate for masses
A-scan: evaluate internal reflectivity if mass is found
OCT: verify thickened choroid using enhanced depth imaging techniques in uveitic conditions, image SRF and/or CME
Rarely necessary: orbital imaging
*Wash-out phenomenon: rapid increase in hyperfluorescence, which peaks around 3 to 4 min. In the late phases of the ICG angiogram, a “washout” effect with reduction of the initial hyperfluorescence is observed secondary to the outflow of dye from the hemangioma
Choroidal hemangioma Rx
Individualized, based on:
> extent of Sx
>loss of vision
>potential for visual recovery
Aim: induce tumor atrophy with SRF resolution and reduce foveal distortion without destroying retinal function (NOT to obliterate the tumor)
Rx: laser photocoagulation (moderately intense, white reaction on tumor surface to eliminate serous exudation)
cryotherapy
PDT with verteporfin (visudyne) using standard treatment parameters
transpupillary thermotherapy
I-125 plaque brachytherapy
low-dose XRT
Choroidal hemangioma Px
visual loss can be progressive/irreversible if fovea involved in chronic cases
Poor VA results 2/2 fluid resolution from chronic macular edema/photoreceptor loss
Serous RD over macula DDx
CSR (central serous chorioretinopathy)
inflammatory choroidal disorders (VKH syndrome)
uveal effusion syndrome
ON pit (no leakage)
choroidal tumor
vitelliform macular detachment
PED from other causes including CNV (+leakage)
Serous RD over macula work-up
OCT: characterize features present along with the obvious SRF
>checking for macular schisis or ON excavations seen with an ON pit
>thickened choroid seen in VKH, CSR and uveal effusion syndrome or the characteristic OCT appearance of vitelliform lesions
FA: useful to R/O CNV and to visualize the early hyperF with late pooling of a PED and the SRF
If both of these tests fail, ICG can show hyperF with late staining in CSC, vascularity with tumors, and R/O CNV
CSR Rx
observation initially since most cases resolve spontaneously over 6 weeks
laser Rx or verteporfin (Visudyne) ocular PDT can be considered for pts who require more rapid visual recovery 2/2:
> occupational reasons
>poor vision in fellow eye 2/2 CSC
>no resolution of fluid after several months
>recurrent episodes with poor vision
>severe forms of CSC
Rx reduces the duration of Sx but does not affect the final visual acuity. Experimental use of oral rifampin and mifepristone (RU486) has been suggested in chronic/bilateral cases.
ARN DDx
ARN PORN syphilis CMV toxoplasmosis sclopteria lymphoma sarcoidosis amnioglycoside toxicity
ARN exam findings
possibly:
granulomatous anterior uveitis
vitritis
retinal vasculitis
Lab tests for ARN
PCR tap for HZV, HSV, CMV
blodo testing for HZV and HSV type 1 and 2 IgG and IgM
immunocompetent (ARN)/immunocompromised (PORN)
ARN Rx
systemic IV acyclovir until resolution of retinitis then PO for 1-2 months.
Atlernatively if lesions are more peripheral then use PO therapy with valacycovir instead of IV therapy
Ganciclovir is alternative
Important to follow BUN and creatinine for nephrotoxicity
Both PO and topical steroids can be started s/p patient begins to respond to prevent inflammatory complications
ARN complications
high risk of RRD 2/2 holes/tears 2/2 retinal necrosis
important to observe fellow eye
Chronic vitritis DDx
V
I: infections/noninfectious uvetitis - birdshot chrioretinopathy, pars planitis, toxoplasmosis, syphilis, sarcoidosis, multifocal choroiditis, APMPPE, Behcets, TB, ARN
T
A
M
I
N: primary intraocular lymphoma (diffuse large B-cell non-hodgkin’s lymphoma)
chronic vitritis work-up
R/O uveitis: CBC, ESR, ACE, HLAB27 and 51, ANA, VDRL or RPR, FTA-ABS/MHA-TP
MRI to evaluate CNS involvement with LP for CNS cytology
If negative: Dx PPV: undilute vitreous biopsy (1 cc) should be sent for cytology, flow-cytometry analysis for B and T cell markers, kappa/lamda light chains
Measure: IL6 and IL10 (high IL10 to IL6 ratio is suggestive of intraocular lymphoma)
Intraocular lymphoma Rx
Intravitreal MTX and rituximab and orbital radiation if no CNS involvement (however majority of pts - [60-80% within 29 months] - develop CNS involvment) so usually Rx with blood-brain barrier disruption and high-dose systemic MTx
Poor Px if brain involvement
Need to complete metastatic survey (chest/abdomen) and bone marrow biopsy
Granulomatous uveitis DDx
V
I: Syphilis, TB, leprosy, brucellosis, toxoplasmosis, P. Acnes endophthalmitis, fungal infection (cryptococcus, aspergillus), HIV
T
A
M
I: sarcoidosis, VKH, SO, phacoanaphylactic rxn
N
Granulomatous uveitis findings
Ciliary injection AC cell and flare hypopyon iris nodules rubeosis synchiae increased/decreased IOP Cataract Pars planitis ON hyperemia chorioretinitis periphlebitis CME
Granulomatous uveitis work-up in pt with negative history/ROS/exam
CBC with differential ESR VDRL or RPR with FTA-ABS or MHA-TO ELISA or indirect immunofluorescence assay (IFA) for toxoplasma IgM and IgG ACE, lysozyme
+/- the following: ANA, RF, ELISA for LYme (IgM and IgG), HIV antibody test, CXR or CT (for TB/sarcoidosis), sarcroiliac radiographs and urinalysis
+/- HLA typing (HLA-A29 for birdshot)
if vasculitis present (ANCA)
Raji cell and C1q binding assays for ciruclating immune complexes (SLE, systemic vasculitides)
C3, C4, total complement (SLE, cryoglobulinemia, glomerulonephritis)
soluble IL-2 receptor
Toxoplasmosis chorioretinitis Rx
topical steroids and cycloplegics for anterior inflammation
Systemic steroids added for posterior pole lesions or those with intense inflammation
Small peripheral lesions: observe since they often heal spontaneously esp in immunocompetent pts
Rx with antibiotics if:
>Decreased vision
>moderate/severe vitreous inflammation or lesions that threaten the macular, papillomacular bundle, or ON
Rx with 4-6 wks with Abx to kill tachyzoites in the retina (Rx does not affect cysts) - Rx with Bactrim (TMP-SUF) For aggressive lesions or posterior pole lesions - use triple therapy: primethamine (daraprim) folinic acid (leucovorin) and one of the following: >sulfadiazine >clindamycin >clarithromycin >azithromycin >Atovoquone
IOFB classification
Inert (do not require removal) - glass, plastic, sand, stone, ceramic, gold, platinum, silver, aluminium
Reactive (cause inflammation/toxicity and must be removed) - copper (>= 85% severe endophthalmitis,
Chalcosis findings
mild intraocular inflammation
copper deposition in the anterior lens capsule (sunflower cataract) and DM (Kayser-Fleischer ring)
retinal degeneration
Iris may become green and the pupil sluggishly reactive to light
Siderosis findings
iris heterochromia (Hyperchromic on involved side) Mid-dilated minimally reactive pupil lens discoloration (brown-orange dots from iron deposition in lens epithelium, generalized yellowing from involved cortex) vitritis pigmentary RPE degenration vessel sclerosis retinal thinning atrophy
DDx for causes of cotton wool spots
MCC = DM and HTN
V: ischemic (RVO, ocular ischemic syndrome, severe anemia, pre-eclapmisa, carotid artery obstruction)
embolic (carotid embolic, cardiac emboli, deep venous emboli, WBC emboli - Purtcher’s retinopathy)
Blood disease (aplastic anemia, dysprotenimiea, perniciious anemia vitamin B12 deficiency),
Hyperviscosity syndromes (multiple myeloma, Waldenstrom macroglobulinemia), hypercoagualibity syndromes (factor V Leiden, prothrombin 20210A, hyperhomocysteinemia, protein C/S deficiency, antithrombin 3 deficiency, dysfibrinogenemia, factor 13 deficiency)
I:HIV, RMSF, Cat-scratch fever (b. henselae), toxoplasmosis, subacute bacterial endocarditis, leptospirossis, onchocerciasis
T: severe chest compression/long bone fractures, foreign bodies, amniotif fluid embolization
traumatic nerve fiber layer laceration (in which case CWS will not resolve)
Toxic (interferon, MTX), radiation induced
A: immune-mediated (SLE, sarcoidosis, dermatomysosis, scleroderma, cryogloublinemia)
M
I: ERM traction
N: neoplastic (lymphoma, leukemia, mtz carcinoma, Hodgkin’s dz)
cotton wool spot work-up
CBC with diff, platelet count
HgA1c
ANA
HIV antibody test
+/- cardiac valvular dz, carotid stenosis, Deep venous source of emboli
CWS resolve spontaneously in 1-2 months
Macular hole DDx
macular hole
psuedohole (Appearance of hole w/ steep walls
Caused by vascular tortuosity around macula)
lamellar hole Thin layer of retina lifted w/ walls “bulging out”; Maybe precursor or resolved macular hole
CME, ERM
solar retinopathy (usually bilateral)
CSR, wet AMD
Macular hole work-up
Clinical test?
Watzke-allen test (absolute scotoma in the hole)
Stages (antiquated)?
Stage 1: 1A (pseudocyst); 1B (outer layer loss)
50% spontaneously resolve (no surgery)
Stage 2: Full-thickness hole 400um + elevated rim
Stage 4: Hole with PVD
New grading system?
Small 400um
Risk factors for macular hole
CME, VMT, trauma, post-surgical, post-laser Rx and post-inflammatory disroders
Rx for macular holes:
Jetrea (if 250um) + ILMP (if >400um)
PPV Treatment success? 92% closure ; 50% if re-op short-acting gas (SF6 or 10% C3F8) ILMP (↑ closure) if >400um Face down (3 days; ↑ closure if >400um) Treatment for traumatic MH? Observation (no traction; spontaneous closure ~2 mo)
Px for macular holes
Good for recent onset & smaller diameter holes, as well as patients with good pre-operative visual acuity
Px: poor for holes > 1 year and > 400 um wide.
PVD exam
retinal tear (10-15% of PVDs) and RRD esp when pigmented anterior vitreous cells are present VH (seen in 7.5% of PVDs) from a torn vessel during vitreous separation (70% of a retinal tear)
Repeat DFE in 4-6 weeks
Risk factors for retinal tears
Age history of RD in fellow eye (15%) high myopia/axial length (7%) FH lattice degeneration trauma, cataract surgery (1% s/p ICCE, 0.1% s/p ECCE with intact posterior capsule) DM YAG for PCO
DDx for inflammatory disorders
white dot syndromes (birdshot, MEWDS, APMPPE)
pars planitis
PIC
sarcoidosis
infectious: TB, syphilis, DUSN, toxoplasmosis
masquerate process: ocular lymphoma, mtz dz, choroidal lymphoproliferative dz
Birdshot work-up
FA findings?
subtle compared with ophthalmoscopic appearance (mild hyperF early with active lesions my hypoF early) and late stianing
Late views: vascular incompetence with leakage
CME, 2ndary retinal staining
“quenching” (dye disappears quickly from vessels)
HLA-A29 (90-98%) although 7% of general population positive for HLA-A29
Other signs of birdshot
Mild vitritis; vascular attenuation & leakage Optic disc edema or atrophy; CME Painless eye Decreased scotopic ERG CNV is rare
