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Ocular Disease 3 > Ocular Disease III: Exam 2: Lecture 8: Diabetic Retinopathy 3 > Flashcards

Ocular Disease III: Exam 2: Lecture 8: Diabetic Retinopathy 3 Flashcards

After Slide 28, we start talking about Vascular Occlusive Diseases!

1
Q

Non-Steroidal Treatments Drug Therapies (Oral Agents)

1. PKC-PKC-B inhib Arxxant (
i don’t think he’ll ask a question on this…more FYI…

A
  1. goal to normalize Retinal BF abnormalities for Pt with DR. and Decrease Risk of Mod. Vision Loss in those w/DME
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2
Q

Non-Steroidal Treatments Drug Therapies (Oral Agents)

  1. IVT Anti-VEGF Agents (Lucentis, Ranibizumab, Avastin, Bevacizumab)
    a. Advantages over ROIDS?
    b. DISADVANTAGE?
A
  1. a. Better side effect profile than Steroids

b. TEMPORARY IMPROVEMENT of DME ONLY, Recurrent injections

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3
Q

Non-Steroidal Treatments Drug Therapies (Oral Agents)

  1. New Anti VEGF Drug is AFLIBERCEPT (VEGF Trap-Eye, Eylea)

a. Approved by FDA for Tx of what?
b. Compared to Lucentis?

A
  1. CNV due to AMD! (2011)

b. It’s simply NON-INFERIOR to Ranibizumab. (has Ab based VEGF binding but uses a different BINDING SITE)

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4
Q

Non-Steroidal Treatments Drug Therapies (Oral Agents)

  1. DA VINCI Study: Phase 2 VEGF Trap-Eye in Pts w/CSME
    a. Looked at DM pts with what?
  2. OUTCOME Goal to MEASURE what?
  3. Results?
  4. What ABOUT LONG TERM CONSEQUENCES?
A
  1. a. with CSME
  2. to look at VA and CENTRAL THICKNESS at 6 MONTHS
  3. At 24 wks (6 months): The Acuity looks much significantly Better than laser, as well as reduction in Central Retinal THICKNESS!
  4. LONG TERM CONSEQUENCES of these ANTI-VEGF THERAPIES FOR DME in DM PATIENTS REMAINS UNDEFINED!

(they can combine this with Focal Laser)

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5
Q

Management

  1. Mild NPDR w/CSME
    a. FA?
    b. Ret. Con?
    c. FU Months?
    d. Focal Tx?
    e. PRP Tx?
  2. Mod NPDR w/CSME
    a. FA?
    b. Ret. Con?
    c. FU Months?
    d. Focal Tx?
    e. PRP Tx?
  3. Sev/V Sev NPDR w/CSME
    a. FA?
    b. Ret. Con?
    c. FU Months?
    d. Focal Tx?
    e. PRP Tx?
  4. Non-High-Risk PDR w/CSME
    a. FA?
    b. Ret. Con?
    c. FU Months?
    d. Focal Tx?
    e. PRP Tx?
  5. HR PDR w/CSME
    a. FA?
    b. Ret. Con?
    c. FU Months?
    d. Focal Tx?
    e. PRP Tx?
A
  1. a. Yes
    b. 0-3 wks
    c. 2-4 months
    d. Yes
    e. No
  2. a. Yes
    b. 0-3 Wks.
    c. 2-4 Months
    d. Yes
    e. NO
  3. a. Yes
    b. 0-3 wks
    c. 2-3
    d. Yes
    e. Occ After Focal
  4. a. Yes
    b. 0-2 wks
    c. 2-3
    d. Yes
    e. Occ After Focal
  5. a. Yes
    b. 24-48 hrs
    c. 1-2
    d. YES
    e. YES
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6
Q

CLINICAL PEARLS

  1. Proper DIAGNOSIS!
    a. MISDIAGNOSIS by 1 LEVEL UNDERESTIMATES RISK for DEVELOPING PDR in 1 YR by AT LEAST what %?
    b. Severe NPDR Pt has % risk

c. PDR in 1 Yr
d. Focal Laser for CSME Decreases Risk for what?
e. ETDRS:

A
  1. a. At least 50%
    b. 52% of development
    c. V. Severe NPDR Pt has 75% risk of developing PDR in 1 yr
    d. for Mod. VA Loss (doubling Visual Angle) from about 30% to 12%.
    e. PRP decreases risk of Sev. VA LOSS (BVA
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7
Q

Clinical Pearls

  1. Control levels of what in Diabetics?
    a. % that’s Adequate?
    b. Norm?
    c. % of NPDR over 10 years?
    d. Increased risk of progression in PDR over 10 years?
  2. For A1c 5-8%
    a. Decrease A1c by what 10% DECREASES RISK of DR PROGRESSION by what %? (Meta-Analysis of what study)?
  3. Decrease BP by how much?
    a. this decreases progression of DR by what %? (Study)
  4. When VH Obscures Retina or RD Exists: What MAY BE INEFFECTIVE?
    a. What should be done at this POINT and according to what STUDY?
A
  1. HbA1c
    a. 5-7%
    b. 4-6%
    c. 44%
    d. 145%
  2. a. 43% (of DCCT, and UKPDS)
  3. 10/5 mmHg
    a. 34% (UKPDS)
  4. PRP
    a. Vitrectomy and RD Repair (DRVS)
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8
Q

Venous Occlusive Disease

  1. How prevalent is this retinopathy?
  2. STRONGLY ASSOCIATED with what?
  3. Very prominent what 2 things?
  4. Most COMMONLY seen in Pts over what?
  5. can you laser Exudates?
A
  1. 2nd Most Prevalent Retinopathy (Behind DM retinopathy)
  2. with SYSTEMIC DISEASE
  3. morbidity and mortality
  4. > 45 yrs.
  5. NO! even if you have CSME, they will NOT LASER it, cuz (slide 9) there’s nothing to laser. So they will probably do an INJECTION of Avastin or something like that (they are moving AWAY from Steroids these days) or Lucentis or Eylea
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9
Q

Anatomy

  1. Central Retinal Vein
    a. Single trunk in Nerve, but may Bifurcate w/in what?
    b. Constricts w/in LAMINA CRIBROSA in order to enter what?
    c. Drains the Retina thru what?
  2. CRA
    a. Feeds what part of the Retina
    b. Branch of what artery?
    c. Parallels what?
A
  1. w/in the substance of the nerve to a DUAL TRUNK

b. to enter the Globe
c. Thru 4 Tributaries

  1. a. Inner 2/3rds of the Retina
    b. of Ophthalmic Artery
    c. the Venous Arcades
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10
Q

Venous Occlusive Disease

  1. What 4 did we talk about?
A
  1. CRVO
  2. HRVO (Hemi-Retinal)
  3. BRVO (Branch Retinal)
  4. Papillophlebitis
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11
Q

CRVO: Background

  1. Age of people this is seen in?
  2. Incidence b/w men and Women?
  3. Prevalence?
  4. USUALLY Uni/Bi?
  5. 3 Risk Factors for CRVO?
A
  1. ELDERY (50-70 yrs)
  2. Same
  3. 0.1%-0.4%
  4. UNILATERAL (BUT: Estimated up to 7% of persons may develop CRVO in the other eye w/in 5 YEARS!)
  5. a. HYPERTENSION (47-57%)
    b. Diabetes
    c. POAG
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12
Q

CRVO: Pathogenesis

  1. Physical Blockage
    a. Lumina of CRA and CRV are narrower where?

b. Vessels are bound by what?
c. Lamina Limits Expansion and Displacement of what?

  1. Hemodynamic Factors
    a. Results in what?
A
  1. a. at the LAMINA CRIBROSA
    b. by a Common Sheath
    c. of ON and Vessels!
  2. a. Results in an Obstruction to BLOOD FLOW!
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13
Q

CRVO

  1. THROMBOTIC/ATHEROSCLEROTIC PHENOMENON
  2. What is the NIDUS for Occlusion?
    a. Why?
  3. WHAT External Factors MAY Cause FURTHER COMPRESSION and Contribute to OCCLUSION? (2)
A
  1. Some property of the blood and CRV act in Concert to Cause Occlusion.
  2. The LAMINAR CONSTRICTION SITE!
    a. Due to Intraluminal Pressure of the Vein decreases, leading it to being susceptible to Collapse. Compression by an Arteriolosclerotic CRA further Affects Flow and Thrombus Formation
  3. Increased IOP in POAG and Papilledema (causing increased pressure in the optic nerve sheath)
    * Other factors that can cause Occlusion: Many: orbital tumor, abscesses, Cavernous Sinus Thrombosis, Retrobulbar Intranerve sheath Injection
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14
Q

CRVO: Symptoms

  1. What happens to Vision?
  2. What other two things?
  3. Asymptomatic. IT’s RARE. What 2 Occlusive diseases ARE MORE LIKELY to be ASYMPTOMATIC?
  4. What is the KEY SYMPTOM (HALLMARK)?!
A
  1. Blurred (unilateral)
  2. Scotoma, and Photopsia (rare cases)
  3. in BRVO or HRVO
  4. SUDDEN (Keyword) PAINLESS LOSS OF VISION!!!!
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15
Q

CRVO: SIGNS

  1. WHAT WILL YOU SEE in the FUNDUS?
  2. Veins?
  3. MAIN CAUSE FOR VISION REDUCTION?
  4. What White stuff do you see?
  5. What will you SEE LATER oN?
A
  1. BLOOD AND THUNDER!! All 4 Quadrants!
  2. DILATED, TORTUOUS VEINS!
  3. MACULA EDEMA!
  4. COTTON WOOL SPOTS (cuz it’s an INFARCT. Rarely see exudates in CRVO)
  5. COLLATERAL VESSELS (as body tries to correct itself) and Post and Ant Segment NEO
    * Collaterals form b/w CRV and Vortex Vein thru Unopened Telangiectatic Vessels (they’re already there…but open at this point)
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16
Q

Collateral Vessels

  1. Why is it good to see these?
    a. They still HAVE WHAT in THEM (will BE ON TEST?!)
  2. When will you see them?
  3. Present in what % of CRVOS?
  4. CRVO with IRIS/ANGLE NV is how MANY TIMES LESS LIKELY to have Collaterals?
A
  1. BECAUSE its NOT NEO! (You WANT TO SEE THEM. It’s the body’s response to fix the problem in a GOOD WAY)
    a. THEY DO NOT LEAK because they still have ENDO LUMEN with TIGHT JUNCTION!
  2. 3-14 MONTHS AFTER OCCCLUSION (you WILL NOT SEE THEM INITIALLY…if you think what you see is that, then it isn’t Collaterals)
  3. 58% of CRVO’s WITHOUT IRIS/ANGLE NV
  4. 25x’s LESS LIKELY!
17
Q

CRVO: Classification

  1. Perfused (Non-Ischemic)
    a. Refers to what?
    b. % of all CVOs?
  2. Non-Perfused (ISCHEMIC)
    a. Refers to what?
    b. % of CRVO?
    c. To be CALLED Non-Perfused (ISCHEMIC): YOU NEED TO HAVE HOW MANY DISC DIAMETERS?
A
  1. a. Min. to Moderate. Capillary Non-Perfusion (LESS than 50%)
    b. 70-80% of ALL CVO’s
  2. a. More than 50% Non-Perfusion
    b. 19-30%
    c. MORE THAN 10 DD of NONPERFUSION to be considered NON-PERFUSED!
18
Q

CRVO: Perfusion vs. Non-Perfusion

  1. What is the MAJOR COMPLICATION of CRVO?
    a. THIS IS CORRELATED WITH THE DEGREE OF WHAT?
  2. Alternate Classification
    a. PERFUSED
    b. NON PERFUSED
    i. Problem with this method?
  3. How do you check Non-perfusion?
A
  1. NEOVASCULARIZATION
    a. with the DEGREE OF CAPILLARY NON-PERFUSION
  2. a. 10 DD of NONPERFUSION
    i. May not be able to classify due to too many Hemorrhages and you can’t adequately visualize it.
  3. with an FA, but WAIT until BLOOD has CLEARED UP!
19
Q

CRVO: Natural History of it

  1. Visual Acuity
    a. If 20/40 or Better?
    b. 20/50 to 20/200?
    c. 20/200 or worse?
  2. % of CRVOs that are ISCHEMIC?
    a. APD?
  3. If you have an APD is that good or bad?
  4. % of all CRVOs that DEVELOP NVI/NVA? (What study?)
    a. % risk of Vascular occlusion (any kind) in the other eye?
A
  1. a. Good likelihood of keeping good VA
    b. Varies
    c. 80% stay at that LEVEL or WORSE!
  2. 20-33%
    a. + APD, poorer VA, non-perfusion on FA, +CWS
  3. It’s NOT GOOD!
  4. 16% (according to CVOS study)
    a. 1%/year risk
20
Q

CRVO: Non-Ischemic

  1. % of ALL CASES
  2. ACUITY >20/200: Risk for NEO?
  3. Low or Deep Hemorrhage?
    a. Type?
  4. Prognosis?
  5. SHOULD BE TREATED as what?
  6. % of “INTERMEDIATE” CRVO that convert to Ischemic CRVO over 4 Months?
  7. Over 3 Years, % of perfused eyes that progressed to Ischemic CRVO?
  8. Dynamic Phenomenon: What is this?
  9. VA: usually what?
  10. How common are CWS in this?
A
  1. 70-80%
  2. Low risk
  3. Deep
    a. Dot/Blot
  4. Good. Most have Final VA of 20/40 or BETTER!
  5. the TIP of the SYSTEMIC ICEBURG
  6. 83%
  7. 34%
  8. Pt Recovers Vision very well. SPONTANEOUSLY!
  9. Normal to Finger count, but MOST have 20/50 or better.
  10. They’re RARE!
21
Q

CRVO: Perfusion vs. Non-perfusion

  1. VAs?
  2. Pupils?
  3. What exams are done?
  4. What is seen on ERG?
A
  1. 20/200 or worse
  2. APD
  3. Dilated Fundus, VF, FA
  4. a/b wave Reduction
22
Q

Non-Perfused (Ischemic) CRVO

  1. Presentation more severe compared to Perfused CRVO?
  2. AVG age?
  3. Symptoms?
A
  1. MORE SEVERE
  2. 68
  3. Pt usually aware of SUDDEN, PAINLESS, DECREASE in VISION
23
Q

Non-Perfused (Ischemic) CRVO: Clinical Features

  1. VA RANGE?
  2. BIG THING YOU SEE?
  3. What is seen in the PUPIL?
  4. Prognosis?
  5. Why would NVI Happen?
A
  1. Range from 20/400 to HM
  2. MULTIPLE CWS’s
  3. POSITIVE APD!
  4. POOR! *Very HIGH RISK of NEO of the IRIS and ANGLE and Low/Mod risk of DISC or RETINAL NEO!!!!!
  5. CRVO stimulates VEGF: FINDS POSTERIOR IRIS and forms NEO into the ANGLE! (When you have CRVO, YOU ARE LOOKING AT THE IRIS for NEO!!
    * Because of the look of the Fundus, you probably DONT HAVE TO DO AN FA!
24
Q

NEO:

  1. Ischemic CRVO: NEO
    a. NVG % ? KNOWN AS WHAT?
  2. Tx of NEO Complications thru what?
  3. PREVIOUS THINKING?
  4. RETINAL NEO in CRVO is common/RARE?
  5. WHAT ABOUT ANTERIOR (NVI, NVG)
A
  1. a. 47% (90 DAY GLAUCOMA: usually occurs w/in 90 days Post Occlusion)
  • If pt has NVI but has CRVO: what is the TX? (PRP!!)
  • WHEN DO YOU DO IT? WHEN YOU SEE NEO! AND ONLY THEN!
  1. thru PRP to destroy Ischemic RETINA and REDUCE O2 NEED.
  2. Prophylactic laser.
    * MUST ALWAYS WAIT UNTIL COMPLICATIONS DEVELOP
  3. RARE
  4. COMMON (Iris 58% and NVG 47%)
    * Non-Ischemic CRVO: NEO IS RARE!
25
Q

Iris/Angle NEO of CRVO

  1. What is the MOST COMMON SERIOUS COMPLICATION of CRVO?
    a. Proportionate to level of what?
  2. & of Ischemic CRVO?
    a. % that Progresses to NVG?!
  3. Initial NEO Location?
  4. Onset?
    a. Critical Period?
A
  1. IRIS/ANGLE NEO!!
    a. of ISCHEMIA (>10 DD)
  2. 60-70%
    a. 45% AT LEAST
  3. IRIS in 88-94%, then Angle (6-12%)
  4. 2 weeks-2.5 years
    a. 3 Month-1 Year
26
Q

CRVO: NEO (Ischemic)

  1. ALWAYS DO WHAT TEST ON ALL PATIENTS WITH CRVO TO RULE OUT NVI?
  2. If PATIENT HAS NVI, what % will DEVELOP NEO GLAUCOMA?
A
  1. GONIOSCOPY!!

2. 2/3-3/4 will develop Neo Glaucoma!

27
Q

Ischemic Vs. Non-Ischemic CRVO

Characteristics: Ischemic

  1. Clinical Impressions
  2. FA
  3. Pupil Defects
  4. VA
A
  1. a. Retinal Details obscured by Flame-shaped hemes
    b. CWS
    c. Orange, Turbid, Edematous and Sick looking Retina
  2. 10+ DD of Retinal Non-Perfusion on FA
    • APD
  4. <20/200 (Finger count at 2 Ft)
28
Q

Ischemic Vs. Non-Ischemic CRVO

Characteristics: Non-Ischemic

  1. Clinical Impressions
  2. FA
  3. Pupil Defects
  4. VA
A
  1. a. Dot/Blot Hemes
    b. Still looks like Blood and thunder w/Flame-shaped hemes
  2. 0-9 DD of Retinal Non-Perfusion
    • APD
  4. > 20/200
29
Q

Vision Loss due to CRVO

  1. Macular Edema
  2. RPE Atrophy
  3. Macular Ischemia
  4. Retinal Hemorrhage?
  5. NEO Glc?
  6. Vitreous Hemorrhage?
  7. Tractional RD?
A
  1. MAIN CAUSE of VISION REDUCTION in CRVO
  2. happens 2ndary to Chronic Macular Edema –> PERMANENT VISION REDUCTION
  3. Severe, Irreversible Vision Loss. Often the cause when the vision loss is MUCH MORE DRAMATIC than the CLINICAL PICTURE!
  4. Common
  5. Common
  6. Rare
  7. Rare
30
Q

CRVO tip of SYSTEMIC ICEBURG

Systemic Considerations

  1. What things?
A
  1. HTN (more detailed evals reserved for special cases like Bilateral Cases)
  2. DM

Many other things..Syphillis, AIDS, Collagen Vascular Disease

31
Q

CRVO Treatment and Management

  1. First thing to do?
  2. In Office Management
  3. ProphyLACTIC LASER?
  4. Use of Beta Blockers?
  5. REFERRAL TO RETINOLOGIST FOR WHAT?
A
  1. Treatment of Underlying Systemic Condition (rarely REVERSES VEIN OCCLUSION but may prevent it in the other eye)
  2. a. FA (not in early course)
    b. Pupil testing
    c. Retinal Photography
    d. Gonio to R/o Angle NEO
    e. Measure IOP
    f. F/U q 1 month for 4 Months, then periodically until complete Resolution (or Blindness)
  3. NOT INDICATED
  4. Not WELL THOUGHT OF Tx (reduce pressure elevations and re-establish BF)
  5. PRP IF there’s NVD, NVE, NVI, NVG or MACULAR EDEMA
32
Q

Central Retinal Vein Occlusion Study (CVOS): Questions they ASKED.

  1. Looked at NATURAL HISTORY of what?
  2. Is PHOTOCOAGULATION BENEFICIAL for what?
  3. Is PRP effective in Preventing what in Pts w/Non-Perfused CVO
A
  1. of CRVO
  2. Macular Edema (VA 20/50 or worse)
  3. INV/ANV in Pts w/Non-Perfused CVO
33
Q

Central Retinal Vein Occlusion Study (CVOS): Progression

  1. % PERFUSED that Progressed to Non-Perfused?
    a. % w/in 1 Month of Onset
  2. Risk Factors
    a. DD of Retinal Non-Perfusion
    b. VA of what or worse?
  3. Indeterminate Eyes
    a. % Progressed to non-perfused
    b. % in 6 Months?
A
  1. 16%
    a. 24%
  2. a. 5-9 DD
    b. 20/200 or worse
  3. a. 83%
    b. 92%
34
Q

CVOS study: Did Macular Grid Laser Tx help improve the vision in eyes w/CRVO and VA 20/50 or worse DUE TO MACULAR EDEMA

  1. Did Macular Laser have a SIGNIFICANT EFFECT ON VA?
  2. What is the STANDARD of CARE if you have CRVO AND MACULAR EDEMA?
A
  1. NO! so MACULAR GRID LASER is NOT INDICATED!!

2. YOU DO NOTHING!!!!!!

35
Q

CVOS Study Group: N Study

  1. Is PROPHYLACTIC PRP EFFECTIVE in reducing NVI and NVA in cases w/10 DD Areas or more of capillary non-perfusion?
    a. Results: Both groups (no Tx early on and Early Prophylactic PRP) DEVELOPED WHAT?
  2. So what is Early Prophylactic Tx Indicated here?
A
  1. NEO!!
  2. NO! EYES w/o early Prophylactic Tx Responded BETTER TO PRP!
    * More likely to regress in untreated eyes than those treated prophylactically.
36
Q

CVOS Conclusions

  1. Is there ANY ADVANTAGE to EARLY PROPHYLACTIC Tx w/PRP of ISCHEMIC CRVO?
  2. PRP ONLY AFTER WHAT IS SEEN?
  3. DID MACULAR LASER have a significant effect on VA?
  4. Monthly EVAL for what?
  5. WHAT 2 exams are done on EVERY VISIT ARE MANDATORY?!
  6. Increased risk of INV/ANV with what?
  7. Most significant risk factor for predicting INV/ANV?
  8. Eyes w/20/40 or better: F/U when?
  9. Eyes 20/200 or WORSE?
A
  1. NO
  2. after NEO is SEEN
  3. NO. So it’s NOT INDICATED!
  4. for INV/ANV
  5. SLE with GONIOSCOPY!
  6. with decreased Vision
  7. Amt of Non-perfused retina
  8. every 1-2 months for 6 months
  9. FU monthly for 6-8 months

Ocular Disease 3 (11 decks)

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