Midterm I Flashcards
Where are the two groups of blood vessels in the retina located?
- superficial nerve fiber layer
2. inner nuclear layer
Where does the outer plexiform layer and outward receive its oxygen and nutrients from?
choroid and choriocapillaris
What layers usually separate in a retinal detachment?
RPE and sensory retina
What are the five methods to view the retina?
- OCT
- BIO
- peripheral funduscopy
- 3 mirror funduscopy
- Optos optimap
What is the junction of the inner and outer photoreceptor segments called? 1. What does it show up as on the OCT? 2
- photoreceptor integrity layer
2. thin red line above RPE
What does the RPE look like on the OCT?
deep red layer
What landmarks define the peripheral retina? 1. Posterior pole? 2. Midperiphery? 3
- area between vortex veins and ora sorrata
- bound by arcades
- arcades to vortex veins
What is used to push the peripheral retina into view?
scleral indentation/depression
Does the optos optomap get to ora?
no
What is the Optos Optomap not adequate at displaying?
retinal breaks
What are the ways to view the vitreous?
- direct ophthalmoscope (add plus from retina)
- fundus lens
- BIO (shadows on retina)
- slit lamp
What is the “skin” around the vitreous which is tightly attached to the internal limiting membrane of the retina? 1. Where is it absent? 2
- hyaloid
2. optic nerve head
What are the stronger hyaloid attachments of the vitreous from weakest to strongest?
- macula
- blood vessels
- around ONH (tightest posterior)
- vitreous base (at ora and a little into retina)
What is the clumping of solids during the deterioration of the hyaloronic acid that holds the vitreous together called?
condensation or floaters
What are the disorders that can lead to vitreal change in consistency and transparency earlier in life than expected?
- systemic vascular disease
- myopia over about 4-5 D
- connective tissue disorders
- inherited disorders
- trauma
What are the systemic vascular diseases that can lead to early vitreal deterioration?
- diabetes
- sickle cell anemia
- leukemia
What are the connective tissue disorders that can lead to early vitreal deterioration?
- Marfan’s
- Pseudoxanthoma elacticum (PXE)
- Ehlers Danlos
What is the number one reason for retinal break/detachment in children?
Wagner-Jensen-Stickler’s (aka Stickler’s)
What are the major changes in the vitreous over time in order from most to least important structurally?
- loss of hyaluronic acid the maintains gel-like consistency
- hyaloid atrophies
- vitreous collagen breaks down
- liquid content increases
What is the term for the hyaloid tugging on the internal limiting membrane?
vitreal-retinal traction
What is the separation of the posterior hyaloid and the internal limiting membrane called?
posterior vitreous detachment (PVD)
What is usually the last portion of the hyaloid that separates from the internal limiting membrane? 1. What is this called? 2. What does this lead to? 3
- hyaloid around optic nerve head
- complete PVD
- Weiss ring or Vogts ring
What is it called when the hyaloid falls forward toward the crystalline lens following detachment?
PVD with collapse or syneresis
What are flashes of light associated with a PVD called?
photopsia
About how long does it take for a complete PVD to occur after the first detachment occurs?
3-6 months
What do the tails of the vitreous base predispose the retina to?
retinal breaks in the periphery
What is caused by breaks in the internal limiting membrane and the proliferation of cells on its surface?
epiretinal membrane (ERM)
What are the other names for an epiretinal membrane (ERM)?
- preretinal membrane
- macular pucker
- surface-wrinkling retinopathy
- cellophane retinopathy
What cells form the epiretinal membrane?
glial, muller or RPE cells
What are the ways to “catch” a epiretinal membrane?
- patient complaints of distorted vision following PVD
2. shinning or glimmering when looking at the retina
What are the causes of ILM breaks?
- vitreo-retinal traction
- vascular disease (hypoxic atrophy)
- retinal breaks
What are the treatments for an epiretinal membrane?
- remove vitreous (vitrectomy)
2. epiretinal membrane peeled off
What can a epiretinal membrane lead to?
- metamorphopsia
- macular edema
- decrease in vision
What is a hemorrhage resulting from vitreo-retinal traction called? 1. What layers is this between? 2. Where in the retina does this typically occur? 3
- preretinal hemorrhage
- between internal limiting membrane and nerve fiber layer
- peripheral retina
What are the two possible reasons for a preretinal heme?
- vitreo-retinal traction
2. new blood vessel growth from systemic vascular disease
What should be done for a patient with a systemic vascular disorder and a preretinal heme?
refer to retinal ophthalmologist (NEVER monitor)
What is the common shape of a preretinal heme?
D-shaped or keel-shaped because of gravity pooling blood in that area of the “dome”
What is it called when the preretinal heme makes its way through the ILM, hyaloid and into the vitreous? 1. What might the doctor see upon fundus examination? 2
- vitreal heme
2. red blood or nothing at all (no retina seen)
What should be done for a patient that has a vitreal heme? 1. Why? 2
- refer (NEVER monitor)
2. large amount associated with breaks, possible significant traction, and can be retroneovscularization
What do patients often see when they have a vitreal heme?
red blood seen as sudden small shower of floaters
What is the shape of a vitreal heme? 1. What color does it turn with time? 2
- no normal shape and changes often
2. yellow then black
What is the problem that can occur from a vitreo-retinal traction that is the result of recurrent inflammatory reactions? 1. What does the patient see? 2
- transient macular edema
2. distorted vision
What are the two forms of retinal breaks? 1. What is the location in the retina that the break is often located? 2
- retinal hole and retinal tear
2. peripheral
What color is a retinal break? 1. Why? 2
- red
2. looking at choriocapillaris through full-thickness opening
What color is the choroid? 1. Why? 2
- purple-blue
2. melanin within
Is a retinal hole likely to lead to a retinal detachment? 1. Is a retinal tear? 2
- no (2-3%)
2. yes (30-50%)
What is the escape of pigment into the anterior portion of the vitreous due to the liquefied vitreous getting into the RPE and breaking the bonds between the RPE cells called? 1. What originally causes this to occur? 2
- tobacco dust or Shafer’s sign
2. retinal break
What is tobacco dust a probable sign of?
impending or active retinal detachment
What is the number one mechanism of retinal detachment?
liquefied vitreous getting into the RPE and breaking the bonds between the RPE cells
What are the two things that can surround a retinal hole?
- cuff of whiteish edema
2. RPE hyperplasia
What does a cuff of whiteish edema around a retinal hole indicate? 1. What should be done for a patient with this? 2
- vitreoretinal traction that creates intraretinal edema and mild sensory retinal detachment
- refer if edema is one disc diameter or more
What does RPE hyperplasia surrounding a retinal hole indicate?
lesion at least 3 months old
What is degenerative thinning of the peripheral retina called? 1. What can this lead to? 2
- lattice degeneration
2. atrophic hole (can also be from atrophy)
What is the type of retinal hole that is from vitreo-retinal traction and retinal thinning?
operculated
What is a portion of the retinal tissue that has detached and is now floating in the vitreous called?
operculum
If there is pigment adjacent to a operculated hole, how old is the hole?
at least 3 months
Which retinal hole type is generally worse at first: atrophic or operculated?
operculated
What are the major things to consider in managing a retinal hole?
- is the patient symptomatic?
- atrophic or operculated?
- peripheral or central (central worse)
- superior or inferior (superior worse)
- is there a cuff of edema, how large?
- Does the hole have a black pigment around it?
What are the differences in identifying retinal holes vs. retinal hemes?
- holes round, hemes usually not
2. holes have edema ring, hemes do not
What should be done for a patient with a retinal tear?
refer
What color is a retinal tear?. How often does it occur following a PVD? 2
- red with edematous white surrounding
2. 10-15%
What is the progression of a retinal tear allowing liquified vitreous to go through retina and enter the space between the RPE and sensory retina, causing separation called?
rhegmatogenous retinal detachment
What do the brighter portions of tissue that is on the edge of a retinal detachment?
elevated tissue that vitreous is pushing up
What procedure greatly increases the risk of a retinal detachment?
cataract surgery
What is the time period that a retinal detachment occurs following an acute retinal tear?
within 6 weeks
How long after a PVD occurs is it highly unlikely that a retinal detachment will occur because of the PVD?
6 months
What is the main symptom of a retinal detachment?
increase in flashes and floaters
What is the procedure for follow up appointments after a PVD occurs with symptoms of flashes and floaters?
1 month, 1 month, 6 months
What should be told and documented to the patient following a PVD?
if they see a shower of flashes or floaters increasing in intensity they should come in immediately
What is required during the exam of a patient that has a PVD and has symptoms of flashes and floaters?
must get to ora in all 4 quadrants
What are the symptoms of a rhegmatogenous retinal detachment?
- flashes
- floaters
- curtains
- most are asymptomatic
What group of people do traumatic detachments mostly occur in? 1. Myopic detachments? 2
- young people
2. aged 25-45
What is more likely to cause a retinal detachment: a new break or an old break?
new break
How often should phakic retinal detachment patients be dilated for an exam?
every 6 months
How does a rhegmetogenous retinal detachment appear on examination?
- undulating with elevated ridges of retina that moves when eye moves
- opaque with time
Why does a rhegmetogenous retinal detachment look white?
- edema
2. tissue is dead/scarring
What is the pigment hyperplasia line at the posterior border that occurs after a retinal detachment is stationary for about 3 months?
demarcation line or high water mark
What occurs in a long-standing retinal detachment to the retinal tissue after a long period of time?
tissue becomes necrotic and see yellow intraretinal exudates
What happens to the IOP with a retinal detachment (and why)?
- IOP elevated (Schwartz syndrome)
2. IOP reduced (break gives route for uveoscleral outflow)
What must be done by the optometrist as far as management of a retinal detachment?
get same day consultation
What are the questions that will be asked when referring a patient for a retinal detachment?
- how big is it
- where is it
- is the macula on or off
What is the largest deciding factor of visual impact for a retinal detachment?
whether it’s macula-on or macula-off
What are the procedures for a retinal detachment that is not too large?
- laser treatment (scarring to reattach retina to RPE)
2. pneumatic retinopexy
What is the injection of an expanding bubble of gas into the vitreous to push the retina against the RPE and recreate adhesion called?
pneumatic retinopexy
What are the procedures for a retinal detachment that is large?
scleral buckling
What is the most common procedure for repair of a rhegmatogenous retinal detachment?
scleral buckle
What is a scleral buckle made out of? 1. What is the buckle sutured into? 2
- silicone
2. to sclera (explant) or within sclera (implant)
What are the procedures that often accompany scleral buckling?
- diathermy
- cryotherapy
- laser photocoagulation
What is sometimes done during the scleral buckling procedure to prevent increases in IOP?
drain subretinal fluid
What are the scleral buckling post-operative complications?
- glaucoma
- infection and extrusion
- choroidal edema
- cystoid macular edema
- epiretinal membrane (macular pucker)
- diplopia
- changes in refractive error
When does cystoid macular edema usually occur following scleral buckling surgery?
4-6 weeks
What is an extremely bad epiretinal membrane that is extremely thick and causes extreme distortion called?
proliferative vitreoretinopathy (PVR)
What can lead to diplopia following scleral buckling surgery?
- proliferative vitreoretinopathy (PVR)
- cystoid macular edema
- EOM rubbing
What are the problems in refractive error that can occur following scleral buckling surgery?
- more myopic
2. irregular astigmatism
What percentage of scleral buckling procedures result in anatomical reattachment?
90%
What percentage of patients with macula-on retinal detachments lose less than 2 Sellen acuity lines after scleral buckling?
90%
What percentage of patients with macula-off retinal detachment are worse than 20/50 after scleral buckling?
60%
What procedures are often done in conjunction with pneumatic retinopexy?
laser/cryotherapy
What is the procedure in which silicone oil is put into the back of the eye to push the retina against the RPE for re-adhesion and needs to be removed eventually?
silicone oil tamponade
When is silicone tamponade used for a retinal detachment?
- patient doesn’t want pneumatic retinopexy
2. intractable case where detachemtn cannot be stopped
When is a vitrectomy used to treat a retinal detachment?
- PVR occurs
2. still areas of vitreo-retinal traction
What is essential in determining the stage of a macular hole?
OCT
What are the main features of a stage 1 macular hole?
- macular cyst
2. may leave dark red lamellar hole
During stage 1 of a macular hole with a macular cyst present, what is at the base of the fovea and is a yellow spot?
xanthophyll
What does a lamellar hole due to visual acuity?
around 20/40-20/60
What are the main features of a stage 2 macular hole?
- small hole (
What are the main features of a stage 3 macular hole?
- full thickness hole (1/2 to 1/3 DD)
- Very red
- surrounded by cuff of edema often
- yellow deposits in base of hole
What impact does a stage 3 macular hole have on visual acuity?
20/200 or worse
What are the main features of a stage 4 macular hole?
- full thickness hole like in stage 3
- all other features of stage three are same
- no hyaloid attachment is present
What are the ways to tell the difference between stage 3 and stage 4 macular holes?
- OCT
2. look for grey spot or clump directly over fovea (pseudo-operculum)
What is the thickened portion of the hyaloid that is detached from the fovea and can sometimes be seen following a stage 4 macular hole?
pseudo-operculum
What are the treatments for a macular hole?
- vitrectomy with pneumatic retinopexy
2. plasma enzyme (Ocriplasmin)
Following a vitrectomy with pneumatic retinopexy what is required of the patient?
need to lay face down most of the time for 10-14 days
What does the injection of the plasma enzyme (Ocriplasmin) due for a patient with a macular hole? 1. What procedure is it sometimes done with? 2
- dissolves attachments between hyaloid and internal limiting membrane
- vitrectomy
What are the yellow-white spheres of calcium soaps that are in the vitreous? 1. What is their impact on vision? 2
- asteroid hyalosis or Benson’s bodies
2. little effect on visual acuity and patient rarely notices them
What diseases are asteroid hyalosis associated with?
- diabetes
- systemic hypertension
- systemic atherosclerotic vascular disease
What are accumulations of flat crystals of cholesterol in the vitreous called? 1. When are they often seen? 2
- synchisis scintillans
2. blind or severely damaged eyes
What is the failure of regression of the structures of the primary vitreous, resulting in a dense vitreous called? 1. Who is it usually seen in? 2
- Persistent Hyperplastic primary vitreous (PHPV)
2. full-term infants
What other ocular anomalies is PHPV associated with?
- microphthalmos
- cataract
- prominent ciliary processes
What is the appearance of PHPV?
- white pupil (leukocoria)
2. may see hyaloid canal
What are the differentials when a white pupil (leukocoria) is seen in an infant or child?
- cataract
- retinoblastoma
- retinopathy of prematurity
- PHPV
What are the four essential aspects of isolated retinal lesions that lead to a differential diagnosis?
- location
- color
- border (well-defined and shape)
- size and elevation
What are dark grey/brown/black areas on the retina that are due to enlargement of RPE cells?
congenital RPE hypertrophy (CHRPE)
What is the typical location of CHRPE? 1. Description of border? 2. Elevation? 3
- peripheral
- fairly well-defined
- flat
What can form within CHRPE due to a blockage of blood supply to the RPE and can lead to scarring?
chorioretinal atrophy (lacunae)
What are the two variants of CHRPE (and what are the sizes of each)?
- multifocal (usually
What is the ocular effect of CHRPE?
benign but can create visual field defect (scotoma)
What disease has an association with CHRPE? 1. What presentation of CHRPE do they have? 2
- familial adenomatous polyposis (FAP)
2. irregular multiple unifocal CHRPE lesions (usually 4 or more)
What is the disease that presents with the development of polyps in the large intestines around puberty and often results in colon cancer?
familial adenomatous polyposis (FAP)
What must CHRPE be differentiated from?
malignant melanoma
What can CHRPE lead to (but is very rare)?
RPE adenocarcinoma
