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0V2022 Introduction to eye diseases > macula and choroid > Flashcards

macula and choroid Flashcards

1
Q

what are maculopathies ?

A

conditions that affect the macula and the choroid

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2
Q

what are the different types of maculopathies ?

A
  • acquired

- hereditary

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3
Q

what are hereditary conditions ?

A
  • macular dystrophies
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4
Q

what are acquired conditions ?

A
  • AMD
  • central serous retinopathy (CSR)
  • macular hole
  • cystoid macula oedema (CMO)
  • myopic maculopathy
  • choroidal neovascularisation
  • epiretinal membrane (ERM)
  • diabetic maculopathy
  • drug-induced maculopathies
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5
Q

what are the symptoms common to all maculopathies ?

A

. reduced vision especially at near

. positive scotoma - smudge or a visible blur at centre of vision

. distortion ( metamorphopisa)
- complain that straight lines appear wobbly or that door frames look crooked

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6
Q

what are rare symptoms of maculopathies?

A 
- micropsia (rare)
. increased spacing of foveal cones 
e.g.  caused space occupying lesion 
- macropsia (rare)
. reduced spacing of foveal cones
e.g.  caused oedema

. the patient will complain of distortion in central vision

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7
Q

what investigation to carry for diagnosis for maculopathies ?

A
  1. BCVA
    - near vision both monocularly and binocularly
  2. Amsler grid - to record and measure distortion
  3. pupils light reaction
    - expect to be normal
    - differentiates from optic nerve lesions
  4. dilated fundus examination using SL-BIO which helps look at subtle changes
  5. OCT - visualise the inner layer
  6. fundus autofluorescence
  7. HES- fluoroscein angiography
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8
Q

what are the characteristics of fundus autofluorescence imaging ?

A

. blood vessels are fluorescing

. optic nerve head is fluorescing

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9
Q

what are the characteristics of fluorescein angiography ?

A

. fluorescein is injected to a vein and the fluorescein flows around the vasculature and series of photographs are taken and blood vessels are filled with fluorescence

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10
Q

what is central serous retinopathy (CSR)?

A
  • a type of maculopathy
  • also called central serous choroidal retinopathy
  • exudative detachment of sensory retina in macula area
  • subtle pigmentary changes and shallow area of sub-retinal fluid
  • common cause of centra vision loss ( 4th most common retinopathy after AMD, DR and RVO)
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11
Q

what is the pathogenesis of central serous retinopathy ?

A
  • poorly understood
  • due to multiple leaks in extrafoveal RPE
    . FA ‘’ smoke stack’’ or ‘‘ink blot’’ appearance
    . active choroidal leakage
    -ICG
  • impaired choroidal circulation
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12
Q

what is the epidemiology of central serous retinopathy ?

A 
. incidence 10 per 100,000 in M
. M to F 6:1 to 10:1 ratio
. 25-50 year age group
. unilateral (80%)
. 30% recur
- in ipsilateral or contralateral eye
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13
Q

what are the risk factors of central serous retinopathy ?

A

. type A personality
. elevated testosterone levels
. systemic steroid use

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14
Q

what are the symptoms of central serous retinopathy ?

A

. sudden onset reduced VA/blurring

  • VA 6/9 to 6/18
  • possible hyperopic shift due to elevation of retina

. positive scotoma - interruption to central vision
. metamorphopsia- distortion
. micropsia

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15
Q

what is the clincal presentation of acute central serous retinopathy ?

A 
.detachment of sensory retina with serous fluid between RPE and photoreceptor outer segs
- oval/round elevation
- shallow
. absent/attenuated foveal reflex
. pigment changes
. PED

. 30% Px will have recurrence within a year
. multiple recurrence lead to chronic central serous retinopathy

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16
Q

what is the clinical presentation of chronic central serous retinopathy ?

A

. RPE atrophy

. risk of CNV

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17
Q

how to differentiate between chronic CSCR and wet AMD?

A
  • patients with CSCR are younger than patients with wet AMD
  • CSR resolves on its own accord
  • wet AMD progresses
  • differentiation with wet AMD based on age of onset and progression
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18
Q

what is the optometric management of CSR ?

A 
. reassure patient
. CSR tends to resolve spontaneously within 2-3 months
. VA recovers approx 90% of patients
. subtle metamorphopsia may persist
. refer to ophthalmologist
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19
Q

what is the ophthalmological management of CSR ?

A 
. confirmation of diagnosis
. observation
. tapering of systemic steroids
. PDT or focal laser 
- hastens resolution but does not affect visual outcome
. Anti-VEGF?
. guarded prognosis if recurrent/chronic
20
Q

what are the different types of macular holes dependent on ?

A
  • refers to extent of retina that is involved
21
Q

what is a full thickness macular hole?

A
  • this is a hole that goes from the internal limiting membrane all the way through to the RPE
22
Q

what are the clinical features of full thickness macular hole?

A

. edge of hole

  • pseudocysts ( small intra retinal spaced )
  • edge of fovea is thickerthan normal

. ‘punched out’ circle appearance at macula

. pseudocysts at edge

. pigment changes at base of hole

. edges may appear sl.raised

23
Q

what is partial thickness macular hole or lamellar macular hole?

A
  • photoreceptors are intact
  • loss of layers of retina
  • irregular foveal contour
  • retinal cells are still attached to the posterior vitreous face known as operculum
24
Q

what is an operculum ?

A

retinal cells are still attached to the posterior vitreous face known as operculum

25
what are the causes of macular hole ?
1. traction - this is where retina is lifted from RPE pump - causes macular oedema 2. idiopathic 3. trauma to eye 4. inflammation
26
what is the prevalence of macular hole ?
. 1 in 3,300 . 6th and 7th decades . typically female . bilateral in 10-30% of cases
27
what are the symptoms of macular hole ?
- painless loss of vision - full thickness macular hole the VA is 6/60 - partial macular hole vision may be better - positive scotoma - metamorphopsia
28
what is the treatment of macular hole ?
. self resolving - no treatment required . not urgent referral . put px under observation . new full thickness macular may require surgery
29
how is the surgery of macular hole carried out ?
- vitrectomy and peel - post-operative positioning - sitting with face down to allow retina to adhere - visual outcome depends on presenting VA - risk of cataract
30
what is cystoid macular oedema ?
- cystoid macular oedema causes a painless loss of central vision (6/12-6/60) - result of fluid accumulation ( cysts ) at OPL and INL of fovea - fluid accumulation is a result of breakdown of blood-retinal barrier
31
what is the short term result of cystoid macular oedema ?
- may not be serious | - can improve without treatment
32
what happens if cystoid macular oedema becomes chronic or severe ?
- can be difficult to treat - may cause permanent drop in central vision - cysts may coalesce/merge to form a lamellar hole
33
what are the clinical signs of cystoid macular oedema ?
- loss of foveal depression - cysts may be visible with an OCT- appear as hyporeflective ( dark ) spaces within the retina - FA ( fluorescein angiography ) typical 'flower-patel' pattern of late hyperfluorescence ( due to dye accumulation with time in the OPL cysts )
34
what are the causes of cystoid macular oedema ?
- post surgery - diabetes - wet AMD - fluid leakage from the blood vessels results in cystic spaces being formed can cause cystoid macular oedema - retinal vein occlusion - uveitis - epiretinal membran - radiation retinopathy - choroidal tumours - retinitis pigmentosa - prostaglandin analogue eyedrops for glaucoma - macula telangectasia - coats disease
35
what is irvine-gass syndrome ?
- it is cystoid macular oedema which follows cataract surgery - occurs 1-3 months post-op - clinically significant CMO affects 10% after routine cataract surgery ( but 25-40% show CMO on FA)
36
what happens when a patient has cataract surgery ?
- they are invited to an appointment 6-12 weeks after surgery, during which they have an OCT to identify if there is any element of cystoid macular oedema
37
what happens to diabetic patients post-cataract surgery ?
- in diabetes, post-cataract surgery CMO occurs in 32% without DR ( diabetic retinopathy ) , and 81% of diabetics with DR - pre-existing diabetic macular oedema should be treated before cataract surgery whenever possible
38
what is the treatment of Irvine-gass syndrome ?
- topical non-steroidal anti-inflammatory drugs (NSAIDs) - topical corticosteroids - anti-VEGF
39
what does pathological/degenerative myopia cause ?
- degenerative changes in sclera, choroid and RPE - > -6D - AL ( axial length) greater than 26mm - significant cause of visual impairment in working population
40
how prevalent is pathological/degenerative myopia ?
- 2 to 10% population | - race dependent
41
what are the systemic associations of high myopia ?
. down syndrome . marfan syndrome . prematurity . ehlers-danlos syndrome
42
how does myopic fundus look like ?
1. pale tessellated ( tigroid) fundus - diffuse attenuation of RPE ( RPE is thinned ) with increased visibility of choroidal vasculature 2. focal chorioretinal atrophy - patchy areas where choroid ( and possibly ) sclera visible due to elongation of globe 3. anomalous optic nerve head - small, large or tilted appearance ( edges more blurred on one side ) 4. peripapillary chorioretinal atrophy - atrophy surrounding optic nerve head - common - includes peripapillary intrachoroidal cavitation = small yellow-orange area inferior to disc - can cause visual field defect 5. acquired optic disc pit - due to expansion of peripapillary area over time 6. Lacquer cracks 7. subretinal haemorrhages ( may develop from lacquer cracks ) 8. choroidal neovascularisation 9. Fuch's spot
43
what are lacquer cracks ?
. linear breaks in RPE-bruch's membrane complex - fine yellowe lines, criss-crossing - stretching and degeneration of the choroid from elongation of globe - associated with CNV( choroidal neovascularisation ) in 82% of eyes
44
what is the prevalence of choroidal neovascularisation ( CNV) ?
. CNV in 10% highly myopic eyes - CNV located between neurosensory retina and RPE - minimal sensory retinal elevation . typical onset 40-50 years . better prognosis than with CNV in AMD . location is mostly subfoveal in 60% . juxtafoveal ( to the side ) in 30%
45
what does myopic CNV lead to in the advanced stages ?
. advanced stages: leads to Fuch's spot - macular scar with pigment clumping - raised, follows reabsorption of sub retinal bleed - treatment : anti-VEGF
46
what other changes that can occur in myopic eye ?
. staphyloma - peripapillary or macular ectasia of posterior sclera due to focal thinning . lattice degeneration . retinal tears and breaks . retinal detachment . macular retinoschisis - possible in eyes with staphyloma due to macular traction . macular hole - spontaneous or after trauma
47
what are other myopia complications ?
. premature lenticular opacities - PSC or early onset nuclear sclerosis . lens dislocation - may be associated with systemic conditions . primary open angle glaucoma - increased prevalence

0V2022 Introduction to eye diseases (22 decks)

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