NBEO Part 2 Flashcards
PVD w/ no retinal tear
Signs/Symptoms:
Treatment:
Follow up:
Signs/Symptoms: Flashes, floaters, Weiss ring
Treatment: N/A
Follow up: 6 months - yearly
- Inform pt PVD may occur in the fellow eye
PVD w/ suspected retinal tear
Signs/Symptoms:
Treatment:
Follow up:
Signs/Symptoms: flashes, floaters, Shafer’s sign, VH
Treatment: ultrasound if VH obscures retina,
Follow up: 2-4 weeks, 3-6 months, 6 months
- if pt has significant VH or shafer sign, refer to retina specialist the following day because of the high chance of a retinal break
- 8-10% of pts with symptomatic PVD have a retinal break
- VH >70% have a coexisting retinal break
Retinal break/tear
Signs/Symptoms:
Treatment:
Follow up:
Signs/Symptoms: flashes, floaters, shafer sign, “webs” or “spots” that changes position with eye mvmts, VH, PVD, retinal flap, operculum (above the retinal hole), curtain or shadow
Treatment: Refer within 24-72 hours for laser /cryotherapy and scleral depression (depending on risk of progression esp if the pt has horseshoe or operculated tear or acute traumatic break)
Follow up:
- treated retinal breaks: 1 week, 1 month, 3 months, 6-12 months
- retinal breaks that do not require treatment: 6-12 months
Chronic retinal breaks and atrophic holes
Signs/Symptoms:
Treatment:
Follow up:
Signs/Symptoms: asymptomatic, surrounding ring of pigmentation, line of demarcation, no symptoms
Treatment: Refer within 24-72 hours for laser /cryotherapy and scleral depression (depending on risk of progression esp if the pt has horseshoe or operculated tear or acute traumatic break)
Follow up:
- treated retinal breaks: 1 week, 1 month, 3 months, 6-12 months
- retinal breaks that do not require treatment: 6-12 months
Rhegmatogenous retinal detachment
Signs/Symptoms:
Description:
Treatment:
Follow up:
Signs/Symptoms: Flashes, curtain/shadow, peripheral or central visual loss or both, mild RAPD,
Description: SRF (subretinal fluid)
Treatment:
- Pts w/ acute RRD that threatens the fovea should be treated same day or ASAP
- Prognosis is significantly worse in detachments that involve the fovea. Surgical options include laser photocoagulation, cryotherapy, pneumatic retinopexy, vitrectomy and/or scleral buckle
- All RRDs that are mac off or tractional detachemnts that involve the macula should be repaired but not urgent (depending on the retinal specialist) but usually performed 7-10 days of the onset
- chronic mac off are treated within 1 week if possible
Follow up: Pts treated for RD are reexamined per retinal specialist, 1 day, 1 week, 1 month, 2-3 months, 6-12 months.
Chronic rhegmatogenous retinal detachment
Signs/Symptoms:
Description:
Treatment:
Follow up:
Signs/Symptoms: demarcation line at the posterior extent, intraretinal cyst, fixed foods, white dots underneath retina, or combination of these w/ VF defect
- no symptoms
Treatment: chronic mac off are treated within 1 week if possible
- chronic mac off are treated within 1 week if possible
Follow up: Pts treated for RD are reexamined per retinal specialist, 1 day, 1 week, 1 month, 2-3 months, 6-12 months.
Exudative/Serous retinal detachment
Signs/Symptoms:
Treatment/Workup:
Follow up:
Signs/Symptoms: minimal to sever VF loss, vary w/ changes in head position, mild RAPD
Treatment: B-scan, OCT, systemic workup (HTN, multiple myeloma etc)
- exudative RD, successful tx of the underlying condition leads to resolution of the detachment
Follow up: Pts treated for RD are reexamined per retinal specialist, 1 day, 1 week, 1 month, 2-3 months, 6-12 months.
Tractional retinal detachment
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms: VF loss or defect, may be asymptomatic
Description: fibrocellular bands in the vitreous from PDR
Treatment/Workup:
- scleral depression, OCT, B-scan
- Pts w/ acute RRD that threatens the fovea should be treated same day or ASAP
- Prognosis is significantly worse in detachments that involve the fovea. Surgical options include laser photocoagulation, cryotherapy, pneumatic retinopexy, vitrectomy and/or scleral buckle
- All RRDs that are mac off or tractional detachemnts that involve the macula should be repaired but not urgent (depending on the retinal specialist) but usually performed 7-10 days of the onset
- chronic mac off are treated within 1 week if possible
Follow up: Pts treated for RD are reexamined per retinal specialist, 1 day, 1 week, 1 month, 2-3 months, 6-12 months.
X-Linked (Juvenile) Retinoschisis
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms:
- VH, macular changes, asymptomatic
- Foveal schisis seen as stellate maculopathy
Description:
- family hx x-linked recessive
- separation of NFL
Treatment/Workup:
- OCT, family hx
- No tx for stellate maculopathy. CAI have shown to decr foveal thickness and improve VA in some pts
- for nonclearing VH, consider vitrectomy
- surgical repair for RD should be performed
- Superimposed amblyopia may be present in children younger than 11 years of age when one eye is severely affected, and a trial of patching should be considered
Follow up: q6 months, more frequently if treating amblyopia
Age-Related (Degenerative) Retinoschisis)
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms: asymptomatic, decreased VA
Description: Separation of OPL, usually located inferotemporal, bilateral
Treatment/Workup:
- Rule out RD (look for cells/pigmentation)
- OCT and VF (absolute scotoma)
- sx is indicated if clinically significant RD develops
- small RD walled off by a demarcation line is usually not treated
Follow up:
- q6 months
- inform pts about RD symptoms and to RTC immediately if they experience any symptoms
Retinal detachment vs retinoschisis VF defect
Retinoschisis produces an absolute VF defect
Cotton Wool Spot
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms: Asymptomatic
Description: Whitening of superficial NFL
- most common cause is DM
- usually caused by acute obstruction of precapillary retinal arteriole causing blockage of axoplasmic flow and subsequent build-up of axoplasmic debris in the NFL
Treatment/Workup:
- underlying systemic condition (DM, HTN, VO, retinal emboli, collagen vascular dz, GCA, HIV retinopathy, infections, hypercoagulable state, radiation, interferon therapy, purtscher, cancer, etc)
- check BP in office
- A1c, hemoglobin
- ESR, CRP, platelets (GCA), carotid and orbital doppler, CT, echocardiography, HIV testing, FA
Follow up:
- CWS typically fades 5-7 weeks (longer if assoc w/ DR)
- Depends on underlying etiology
- If concern for infectious process, serial dilated examinations are recommended
CRAO
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms: Unilateral, painless, acute vision loss (CF to LP 94% of eyes) occurring over seconds, may have hx of amaurosis fugax
Description: Whitening of the retina, cherry red spot at the center of the macula, Marked RAPD, Narrow retinal arterioles, boxcarring or segmentation of the the blood column in the arterioles
- retinal arteriolar emboli or cilioretinal artery sparing of the foveola is evident
- VA is light perception or worse, strongly suspect ophthalmic artery occlusion
- caused by emboli, thrombosis, GCA, collagen vascular dz, hypercoagulable state, trauma, etc
Treatment/Workup:
- ESR, CRP, and platelets to rule out GCA if the pt is 55 yo or older
- check BP
- fasting blood sugar and hemoglobin A1c, CBC, w/ differential prothrombin time, PT/PTT
- in pt younger than 50 consider lipid profile: ANA, RPR,/VDRL, FTABS, serum protein electrophoresis, hemoglobin electrophoresis and further evaluation for hypercoagulable state
- Carotid duplex
- Cardiac eval with electrocardiography (ECG, echocardiography, possibly Holter monitoring
- Consider IVFA, OCT, ERG to confirm diagnosis
Follow up:
- If embolus is seen, refer to internist or neurologist immediately for stroke management, complete workup as above and treatment of any underlying disorders. Follow as directed by internist/neurologist
- Repeat eye examination 1-4 weeks: check for neo (if present, refer for PRP and/or adminster anti-VEGF)
BRAO
Signs/Symptoms:
Treatment/Workup:
Follow up:
Signs/Symptoms: Unilateral, painless, abrupt change in vision, hx of amaurosis fugax
- superficial whitening/opacification along the distribution of a branch retinal artery
- narrowed branch artery, boxcarring, segmentation of blood column, or emboli
- cholesterol emboli appears bright, reflective crystal, usually at vessel bifurcation
Treatment/Workup:
- ERG is NOT helpful
- treat underlying medical problem
Follow up:
- Pt needs immediate eval to treat any underlying disorders (esp GCA)
- Reevaluate q3-6 months initially to monitor progression
- ocular neo after BRAO is RARE
CRVO (Ischemic and non-ischemic )
Signs/Symptoms:
Description:
Treatment/Workup:
Follow up:
Signs/Symptoms: Painless vision loss, usually unilateral
Description:
- Etiology: Atherosclerosis, HTN, optic disc edema, glc, optic disc drusen, hypercoagulable state, vasculitis, drugs (BC,
- Diffuse retinal heme in all 4 quads
- dilated, tortuous retinal vens
- CWS, disc edema, heme, mac edema, optociliary collateral vessels on the disc (lateral finding), neo
Treatment/Workup:
- Discontinue BC
- reduce IOP if increased in either eye
- tx underlying medical disorder
- If NVI or NVA present, perform PRP promptly
- Aspirin 81-325 mg po daily often recommended (may incr risk of heme)
- gonio to rule out neo, IVFA, OCT
Follow up:
- q1 month initially w/ gradual taper based on vision, presence of ME and response to tx
- Dilate and gonio at each visit (early NVI/NVA should prompt immediate PRP and/or anti-VEGF therapy and monthly follow-up until stabilized or regressed
- Pt should be informed that there is an 8-10% risk of CRVO in the fellow eye
