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Ocular Disease 3 > Ocular Disease III: Exam 2: Lecture 10-11: Hypertensive Disorders > Flashcards

Ocular Disease III: Exam 2: Lecture 10-11: Hypertensive Disorders Flashcards

*Know differences b/w HTN and Diabetic Retinopathy

1
Q

Pressure

  1. Systolic Pressure Avg?
  2. Diastolic Pressure Avg?
  3. Pulse Pressure Avg?
A
  1. 100-140 mmHg
  2. 60-100 mmHg
  3. 40-50 mmHg
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2
Q

Blood Pressure: JNC 7 GUIDELINES. KNOW!

  1. Normal:
    a. Systolic
    b. Diastolic
  2. Prehypertension
    a. Systolic
    b. Diastolic
  3. Hypertension Stage 1
    a. Systolic
    b. Diastolic
  4. Hypertension Stage 2
    a. Systolic
    b. Diastolic
A
  1. a. or equal to 160

b. >or equal to 100

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3
Q

Implications of Hypertension

  1. KNOWN as WHAT?
  2. CDC: TOP 3 CAUSES of DEATH?
A
  1. The SILENT KILLER
  2. a. Heart Disease
    b. Cancer
    c Stroke (Cerebrovascular Diseases)
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4
Q

2 Types of Hypertension

  1. Essential (Primary) Hypertension

a. % of total?
b. % that Have BMI OVER 25 (Overweight)
c. Risk increases with what?

  1. Secondary Hypertension
    a. Caused by what?
    b. Also due to what diseases?
A
  1. 95%
    b. 85%
    c. with AGE
  2. a. an Identifiable, Underlying secondary condition, which is usually treatable or reversible
    b. Kidney Disease, Adrenal Disease, Tumors, Medication Side effects.
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5
Q

Hypertension

  1. What race has it more?
  2. 50% are OVER what AGE?
  3. WOMEN under what age are LESS LIKELY to develop HTN?
  4. What women OVER 65 YRS are the MOST REPRESENTED GROUP?
  5. Middle Aged Men & Postmenopausal Women
    a. Under age 45, who is more diagnosed?

b. B/W 45-54?
c. Over age 54?

A
  1. Blacks more than whites
  2. Over 65
  3. Under 65
  4. Black Women
  5. a. Men more likely
    b. Equal
    c. Women more likely Diagnosed
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6
Q

Renin-Angiotensin-Aldosterone System (RAAS):

  1. What does this system do?
  2. Beta Blockers
  3. Calcium Channel Blockers
  4. ACE Inhibitors
  5. ARBs (Angiotensin Receptor Blockers)
A
  1. Blood Pressure and Water Balance
  2. -olol
  3. -dipine
  4. -pril
  5. -Tan/-Tin
    * He’ll NOT ASK A QUESTION on these on the TEST!
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7
Q

Atherosclerosis

  1. HDL
    a. Type of Cholesterol?
    b. Should account for what % of Lipids?
  2. LDL
    a. Type of Cholesterol?
    b. Should be LESS than what?
A
  1. GOOD: Takes cholesterol to Liver to be metabolized
    b. 40%
  2. a. Bad: Takes it to the Tunic Intima
    b. <130 mg/dl
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8
Q

What can hypertension do to the eye? (3 things)

A
  1. Hard Exudates
  2. Flame Hemes
  3. CWS
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9
Q

Ocular Hypertensive Disease: Classification

  1. 3 types of Hypertensive in eye. What are they?
A

Hypertensive

a. Retinopathy
b. Choroidopathy
c. Optic Neuropathy

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10
Q

Arteriolosclerosis: HTN Retinopathy

  1. Key thing?
    a. What happens to A-V?
    b. Arteriolar Color Changes: What 2 things?
A
  1. NARROWING VESSELS (Arteriolar)
    a. VENOUS BANKING (A-V Crossing)
    b. Copper Wiring and Silver Wiring
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11
Q

Hypertensive Retinopathy: Arteriolar Narrowing

  1. HALLMARK of HYPERTENSIVE RETINOPATHY?
    a. Norm A/V Ratio?

b. Narrowing attributed to what happening?

  1. Long Standing Elevated BP
    a. Elastic Tissue forms what?
    b. Muscular Layer is REPLACED with WHAT?
    i. Intima Replaced what?
    c. THIS IS CALLED WHAT?
A
  1. VESSEL NARROWING (arteriolar Narrowing)
    a. 2/3

b. Localized areas of SPASM, as well as EDEMA in the WALL or Localized FIBROSIS

  1. a. Multiple Concentric Layers
    b. with Collagen
    i. by Hyaline Thickening

c. ARTERIOLOSCLEROSIS!

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12
Q

HTN Retinopathy: AV-Nicking…

  1. GRADE 1:
  2. Grade 2
  3. Grade 3
  4. Grade 4
A
  1. Subtle Narrowing (it’s just a subtle narrowing)
  2. An OBVIOUS Broadening of the Arteriolar Light Reflex, and Deflection of Veins at ARTERIOVENOUS CROSSING (SALUS SIGN!!!)
  3. COPPER-WIRING of ARTERIOLES!
    * WONT ASK the SIGNS on test.(Banking of Veins DISTAL to Arteriovenous Crossing: BONNET SIGN)
    a. Gunn Sign: Tapering of Veins on BOTH SIDES of Crossing and right Angled Deflection of Veins
  4. SILVER WIRING: Arterioles Associated with Grade 3 Changes
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13
Q

Common Findings in HTN Retinopathy?

7

A
  1. Multiple CWS
  2. ATTENUATED ARTERIOLES
  3. FLAME SHAPED HEMES
  4. A/V crossing/nicking/nipping
  5. Macular Edema (RARE)
  6. MACULAR START/RING of EXUDATES! (SPECIFIC FOR HTN Retinopathy SPECIFICALLY)
  7. Disc Edema Papilledema
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14
Q

Hypertensive Retinopathy: Classifying it…

  1. Is it urgent or Emergent?
  2. Is Tractional RD an Emergency?
  3. What about CRAO?
A
  1. It’s EMERGENT!!
  2. No
  3. NO. It’s an URGENT. meaning, get them to the cardiologist for a workup in a few days or so.
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15
Q

Hypertensive Retinopathy Classification

  1. Grade 1
    a. Classification
    b. Symptoms
  2. Grade 2
    a. Classification
    b. Symptoms
  3. Grade 3
    a. Classification
    b. Symptoms
  4. Grade 4
    a. Classification
    b. Symptoms
    c. WHAT 2 THINGS MAKE it a GRADE 4?
A
  1. a. Mild, Generalised RETINAL Arteriolar Narrowing or Sclerosis
    b. NO SYMPTOMS
  2. a. FOCAL narrowing, A/V Crossings. Mod-marked Sclerosis of Retinal Arterioles. Exaggerated Arterial Light REflex.
    b. Asymptomatic
  3. a. Retinal Hemes, Exudates, CWS. Sclerosis and Spastic Lesions of Retinal Arterioles
    b. Symptomatic
  4. a. SEVERE Grade III, and Papilloedema.
    b. REDUCED SURVIVAL

c. PAPILLEDEMA and MACULAR STAR (ring of Hard Exudates)
* Then he said Papilledema is the KEY thing…but usually you won’t have it w/o a Macular Star.

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16
Q

HTN Retinopathy Classification (The one he likes)

  1. No Retinopathy
    a. Description
    b. Systemic Associations
  2. Mild Retinopathy
    a. Description
    b. Systemic Associations
  3. Moderate Retinopathy
    a. Description
    b. Systemic Associations
  4. Malignant Retinopathy
    a. Description
    b. Systemic Associations
A
  1. a. No detectable Retinal Signs
    b. None
  2. a. 1 or more of the following: Generalised Arteriolar Narrowing; Focal Arteriolar Narrowing; A/V nicking; Arteriolar Wall Opacity (SILVER WIRING)
    b. Modest Association w/risk of clinical stroke, subclinical stroke, coronary heart disease, and mortality
  3. 1 or more of the following: Hemes (dot/blot, flame), Microaneurysm, CWS, Hard Exudates
    b. Strong Association w/risk of clinical Stroke, Subclinical Stroke, Cognitive Decline, and Cardiovascular Mortality
  4. a. Moderate Retinopathy Plus Optic Disc Swelling
    b. Strong Association with mortality
17
Q

Hypertensive Retinopathy Complications

7 we talked about

  1. What is an EMERGENCY?
A
  1. Central or Branch Artery Occlusion
  2. Central or Branch Vein Occlusion
  3. Microaneurysms
  4. Epiretinal Membrane
  5. Retinal Neo-Vascularization
  6. Vitreous Hemorrhage
  7. Cystoid Macular Edema
  8. Papilledema! (20/30 vision or whatever…)
18
Q

Hypertensive Choroidopathy: Background

  1. Choroid is sensitive to what Circulating Vasoconstrictors? (3)
    a. These factors (along w/neural stimulation) can start what?
    b. The result of this is what?
A
  1. Angiotensin II, Adrenaline, Vasopressin!
    a. VASOCONSTRICTION of the CHOROID and Choriocapillaris
    b. Ischemia…can compromise the RPE and outer Blood-retinal Barrier
19
Q

Retinal Detachments

  1. Tractional Retinal Detachment
  2. Serous RD
  3. he mentioned some other RD…maybe it’s the Vitreal RD.
A
  1. Associated w/DIABETES

2. Associated with HYPERTENSIVE CHOROIDOPATHY (due to SEROUS FLUID)

20
Q

Hypertensive Choroidopathy: Clinical Features

  1. Spots?
  2. Streaks?
  3. RD type?
  4. Chronic Depigmentation of what?
  5. Sclerosis of what?
A
  1. Elschnig Spots
  2. Seigrist’s Streaks
  3. Serous RD
  4. Chronic RPE Depigmentation
  5. Choroidal Vascular Sclerosis
21
Q

Hypertensive Choroidopathy: Clinical Features

Elschnig Spots

  1. What is it?
  2. What is it of the RPE?
  3. How do you know it’s a CHOROIDAL LOCATION?
  4. THEY’RE BIOMARKERS for what?
A
  1. Degenerative RPE (depigmentation with a SPOT IN THE MIDDLE)
  2. Ischemic Infarcts of the RPE (Coincide to HYPOPERFUSION of the Underlying Choroid)
  3. Retinal Vessels OVERLY the SPOT (basically…they’re Window Defects with a COOL NAME)
  4. For something to COME.
22
Q

Hypertensive Choroidopathy: Clinical Features

Seigrist’s Streaks

  1. What is it?
  2. Ischemic Infarcts of the RPE Coincide to what?
  3. Where are they Located?
  4. MAY INDICATED WHAT?
A
  1. LINEAR RPE Changes
  2. to HYPOPERFUSION of the Underlying Choroid
  3. Equator
  4. MORE ADVANCED SCLEROSIS!
23
Q

Hypertensive Neuropathy

  1. How bad is it?
  2. What grade is it?
A
  1. It’s probably the DEADLIEST one of the ALL (even more deadly than the Artery branch occlusion)
  2. Grade 4…(actually…they would just call it MALIGNANT HYPERTENSION!)
24
Q

Optic Disc Neuropathy

  1. What 3 things do you SEE on the OPTIC DISC?
  2. Sign of Malignant Hypertension?
A
  1. Pallor
  2. Edema
  3. Ischemia
  4. Cause of Optic Disc Swelling remains Controversial…
25
Q

Malignant Hypertension

  1. Urgent/Emergent condition?
  2. Develop Disc Edema from Hypertension BP of what?
    a. What’s more important in this case? The Systolic or Diastolic reading?
A
  1. EMERGENT. CALL 911
  2. of 250/150 mmHg
    a. Your DIASTOLIC is the MOST IMPORTANT READING!
    * Can die any day/hour/minute
    * GO TO ER IMMEDIATELY!
26
Q

Clinical Pearl: Difference B/w HTN Retinopathy and DR

  1. HTN Retinopathy is what kind of eye condition?
  2. DR is what kind of eye condition?
A
  1. DRY EYE Condition (Multiple CWS, RARE HEMEs, Edema, and Exudates)
  2. WET EYE CONDITION (Rare CWS, EXTENSIVE HEMES, Edema and Exudates)
27
Q

Ocular Ischemic Syndrome (OIS): he said he will ASK MULTIPLE QUESTIONS ON IT (cuz it’s the MOST MISSED CONDITION, AND it’s COMMON!)

  1. So what is OIS?
    a. What causes it?

b. Why is Dx of this VITAL?

A
  1. HYPOPERFUSION of the ANTERIOR and POSTERIOR SEGMENTS of the EYE
    a. CAROTID OBSTRUCTIVE DISEASE
    b. Because of the INCREASED MORTALITY and MORBIDITY RATE.
28
Q

OIS

  1. What Happens at the Internal Carotid Artery?
  2. What happens at Common Carotid Artery.
  3. So what is it?
    a. *MOST Important thing: YOU NEED to HAVE STENOSIS of what % in order for it to be this?
  4. Who does it affect more?
  5. Age range that it occurs?
    a. MOST COMMON in WHAT DECADE?
  6. BILATERAL in what % of CASES?
  7. 70-70 RULE
    a. What is it?
    b. W/90% Stenosis, you only drop down to what % Perfusion in the CRA?
  8. Chronic Sx’s?
    a. Is IT PAINFUL?
A
  1. Atheromatous Ulceration
  2. STENOSIS at BIFURCATION of Common Carotid Artery
  3. It’s STENOSIS of the COMMON CAROTID ARTERY
    a. MORE than 90% (NO BLOOD FLOW IN THE EYE!!)
  4. Males 2:! to females
  5. 50s to 80s
    a. in the 60s
  6. 20% (Which is pretty dang common)
  7. 70% BF to Brain thru ICA and you don’t start to get in trouble until you HAVE AT LEAST 70% OCCLUSION!
    b. to 50% perfusion in CRA
  8. Decreased Vision in Bright Light; Choroidal Insufficiency causing Photoreceptor metabolism Compromise, PAIN, Progressive Vision Loss
    a. YES…cuz it’s in the ANTERIOR PORTION of the EYE as well as POSTERIOR!
29
Q

OIS: Systemic Correlations

  1. Other Less Common Causes
    a. GCA
    b. What others are less common causes?
  2. NUMBER 1 CAUSE OF MORTALITY?
    a. 5 Yr Mortality for Malignant Choroidal Melanoma?
    b. 5 Yr. Mortality for OIS?
A
  1. RARELY Causes OIS cuz VESSELS are TOO SMALL
    b. Dissecting Aneurysm, Syphilitic Arteritis, Takayasu’s Disease
  2. CARDIAC DEATH
    a. 35%
    b. 40% (MORE DEADLIER THAN CANCER!!!!!!)
30
Q

OIS: Clinical Findings

  1. Dot/Blot Hemes: Mild/Severe and where located?
  2. What about the VESSELS?
  3. Can you get Macular Edema and CWS?
  4. This is one of the ONLY conditions that has SPONTANEOUS WHAT?
    a. When does this happen?
A
  1. MILD, MID-PERIPHERAL Dot/Blot HEMES!!! (BE SCARED of THEM…NOTHING in the MACULA…this is probably what it is!!)
  2. DILATED, but NOT TORTUOUS VESSELS!
    * CRVO has Dilated, Tortuous Vessels
  3. It’s possible.
  4. SPONTANEOUS ARTERIAL PULSATION!
    a. IOP exceeds Pressure w/in CRA (happens if IOP is VERY HIGH or if Arterial Pressure is VERY LOW)
31
Q

OIS: Anterior Segment

  1. What do you see on the Cornea?
  2. What about Aqueous?
  3. Iris atrophy, so what happens w/the Pupil?
  4. What about NEO?
A
  1. Diffuse Episcleral Injection and Corneal Edema
  2. Aqueous Flare with FEW CELLS (LOOKS MILD! (Ischemic Pseudo-iritis)) but it is BAD!
  3. Mid-Dilated Pupil and Poorly Reacting Pupil
  4. YES! Rebeosis Iridis is COMMON and usually leads to NVG.
    * Cataract in vey advanced cases.
32
Q

OIS: Anterior Segment

  1. Cornea
    a. Changes from increased IOP due to what?
    b. What 2 things are seen?
  2. Cataract
    a. Uni/Bi; Sym/Asym?
    b. Due to what?
  3. 20% of Cases have AC RxN
    a. Always Keep this condition in the back of your mind when you treat what?
    b. Uveitis is UNCOMMON in what PATIENT?
    c. AC RxN typically what?
  4. UNI/Ipsilateral Red Eye
    a. Why does this happen?
  5. Rubeosis Irides
    a. Seen in what % of CASES of OIS?
    b. May progress to what?
    c. Eyes are OFTEN what due to Ischemia and Poor Perfusion to CB w/Resultant Aqueous what?
    d. Secondary ANGLE Closer w/o what?
A
  1. a. due to NVG
    b. KPs, and Striae
  2. Unilateral or Asymmetric
    b. Prolonged Ischemia
  3. Uveitis
    b. in ELDERLY PATIENTS (so pt who is older comes in w/uveitis like symptoms…THINK THIS as a POSSIBILITY!)
    c. Mild and usually Asymptomatic
  4. a. Blood gets shunted from the ICA to the ECA system, and there’s 2ndary Congestion of Conjunctival and Episcleral Vessels
  5. a. 66%! (KNOW)
    b. to NVG (50%)
    c. they’re often HYPOTONOUS; and resultant Aqueous HYPOSECRETION

d. w/o Pupil Block & PAS w/Fibrovascular Tissue

33
Q

OIS FA

  1. *KNOW THIS FACT: EARLY PHASE SHOWS WHAT?
  2. Late Phase: Shows what?
A
  1. DELAYED CHOROIDAL FILLING and PROLONGED ATERIOVENOUS TRANSIT TIME
  2. Disc and Perivascular Hyperfluorescence, AND LEAKAGE at the POSTERIOR POLE!!
34
Q

OIS: Vascular Conditions

  1. Rubeosis

a. develops into NVG w/EXTREMELY ELEVATED what?
b. This can cause OCCLUSION of what?

  1. If Rubeosis develops BEFORE CRAO happens, the CAUSE is WHAT?
  2. If it happens AFTER CRAO, then it’s a NATURAL what?
  3. Only 50% of Pts w/Rubeosis will eventually develop NVG: Why?
A
  1. a. IOP
    b. of CRA due to Pressure forces
  2. OIS
  3. Natural Sequelae of CRAO
  4. due to CB Ischemia, poor perfusion, and Secretory Hypotony
35
Q

OIS Management

  1. Need to R/O what?
    a. What tests?
  2. Carotid
    a. Big test?
    b. MRA
  3. Anterior Segment
    a. Treat with what?
    b. NVG treated how?
    c. Would you Do a PRP? Why/why not?
  4. If you have Ant Seg. Neo, where there’s no Neo in the back of the eye but a couple of Dot/Blot Hemes, which is the most likely condition the patient has?
A
  1. HTN, DM, Aortic Arch diseases, Takayashus Pulseless Disease, Syphilitic Aortits, Cardiac Disease
    a. Serology, Cardiology, EKG, ECG
  2. a. Doppler (see extent of Stenosis) (this is better test)
    b. Overestimates degree of Arterial Stenosis
    * Also do Angiography
  3. a. Topical Steroids and Mydriatics
    b. Medically and Surgically
    c. YES (Treat Proliferation). Will cause REGRESSION of Ant. Seg. Vessels in 36% of cases
    * MORE CLOSED THE ANGLE is, the LESS LIKELY PRP will be successful.
  4. **OIS!!!
36
Q

Systemic Management of OIS *KNOW THIS INFO!

  1. 70% with NO symptoms OR >50% with SYMPTOMS?
A
  1. Monitor and Repeat imaging in 6 MONTHS
    a. Consider Antiplatelet therapy and modifying risk factors (smoking, DM, Cholesterol)
  2. SURGICAL Management is Recommended!
    a. Carotid Endartectomy, Carotid Angioplasty-Stenting
37
Q

OIS: Carotid Endartectomy (CEA)

  1. What do they do?
  2. Why is this done w/a Pt with 50-70% or 70-99% stenosis?
  3. What is the SOC for OIS?
A
  1. Incision into CAROTID Artery to remove plaque and Clots clogging the vessel
  2. Cuz there is shown beneficial Risk reductions of stroke.
  3. CEA: Carotid Endartectomy (but only if the stenosis is 50-100% blockage)
38
Q
  1. OIS
    a. Symmetry
    b. Exudates
    c. Hemes
    d. Veins
  2. DR
    a. Symmetry
    b. Exudates
    c. Hemes
    d. Veins
  3. CRVO
    a. Symmetry
    b. Exudates
    c. Hemes
    d. Veins
  4. HTN
    a. Symmetry
    b. Exudates
    c. Hemes
    d. Veins
A
  1. a. 80% unilateral; ASSYMETRIC
    b. RARE
    c. Patchy and Mid-Peripheral
    d. Dilated, NOT TORTUOUS
  2. a. Bilateral; Can be assymetric
    b. COMMON
    c. Posterior Pole: MAINLY DOT BLOT
    d. VENOUS BEADING
  3. a. Unilateral
    b. Rare: Mostly CWS
    c. Posterior Pole: More Confluent. MOSTLY Flame Hemes
    d. Dilated and VERY TORTUOUS
  4. a. Bilateral: Can be Assymetrical
    b. Rare: Mostly CWS
    c. Posterior Pole: Mostly Flame HEME
    d. A/V Narrowing
39
Q

Take Home Points

  1. Does Retinal Artery Occlusion end with vision loss?
  2. All retinal Artery Occlusions require consultation with whom?
  3. What may lie ahead for the patient?
A
  1. NO! Address SYSTEMIC HEALTH!
  2. with an Internist or Cardiologist for Systemic Assessment REGARDLESS of degree of occlusion
  3. Potential Heart Complications and/or Brain Ischemia may lie ahead.

Ocular Disease 3 (11 decks)

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