Ocular disease Pt 2 Flashcards
Asteroid hyalosis
What is it made up of?
associated with aging over 60 yo
made with calcium soaps
What are the signs and symptoms of asteroid hyalosis?
Sx: asymptomatic, no floaters
signs: numerous small, yellow-white refractile particles attached to collagen fibrils in a normal vitreous, unilateral in 75% of cases
Synchysis Scintillans
usually found AFTER a anterior chronic uveitis, vitreous heme or trauma
made up of cholesterol crystals, unilateral golden brown, refractile that are freely mobile in the vitreous cavity and often settle inferiorly?
What’s the difference between asteroid hyalosis and synchysis scintillans?
Asteroid hyalosis - calcium soaps, occurs w/ normal aging
Synchysis scintillans - cholesterol crystal, settle inferiorly, occurs w/ chronic anterior uveitis/vit heme/trauma
BOTH UNILATERAL
PVD
- more common in females
- prevalence ~50 yo (50% by age 50 and 65% by age 65)
- can occur 20 years earlier in myopes
- collagen clumps causing the liberated collagens to contract –> causing PVD. Pockets of liquefaction (syneresis) can travel through the hole in the posterior hyaloid causing separation between the vitreous and the retina
What signs can aid in detecting a RD/break after a PVD?
schafer’s sign (tobacco dust) and vitreous heme (70% increase risk of a break)
What are risk factors for PVD?
diabetes, myopia, age, surgery, inflammation, vitreous heme, trauma
What are the signs and symptoms of a PVD?
Sx: acute floaters, decreased vision, flashes of light
Sign: Weiss ring, anterior displacement of the posterior hyaloid, pigmented cells (shafer’s sign), vit heme
What else can PVD result in?
erm, macular hole, VMT, vitreous and retinal heme, retinal breaks
If you see vitreous heme, what should you ask about?
trauma, diabetes, HTN
What can cause a vitreous heme?
trauma, DR VOS
Diabetes
ROP
Vein occlusion
OIS (ocular ischemic syndrome)
Sickle cell
What are the signs and symptoms of a Vitreous heme/pre-retinal heme ?
Pre-retinal heme: asymptomatic unless the macula is involved, sudden vision loss or VF loss
Vitreous heme can cause sudden, painless vision loss and/or black spots that have corresponding flashing lights
Signs:
Preretinal heme: located between the retina and posterior vitreous, very red and keel shape
Vitreous heme: anterior to the posterior vitreous face (within the vitreous). mild vitreous heme will be characterized by blood that obscures only part of the fundus, severe heme will completely obscure the view of the fundus chronic cases will appear yellow
Whats the most common cause of a spontaneous vitreous heme?
DR (31-54% of cases)
What test should you order if you have a difficult time seeing the fundus through the vit heme
B-scan
What are the 2 types of neo? What causes each of them?
- Preretinal - DR VOS
- Choroidal - CHBALA
CRVO
- 3rd most common vascular cause of vision loss, DR is the most common
- compression of an artery on a vein leading to turbulent blood flow
- venous vessel walla damage, thrombus formation, thrombus at or near lamina cribosa
What are the risk factors for CRVO
HTN, diabetes, cardiovascular dz, open-angle glc
what’s the ocular dz that’s most commonly associated with CRVO?
Glaucoma/POAG (40-60%)
What are the causes of CRVO or BRVO in a young patient?
a young pt with clotting issues
oral contraceptive, protein S/ protein C/ antithrombin III deficiency, factor XII deficiency, antiphospholipid antibody syndrome, collagen vascular dz, and AIDS
What are the signs and symptoms of a CRVO?
sudden, unilateral, painless vision loss in an elderly pt ( 90% of pts are >50 yo)
signs:
thrombus formation leads to ischemia and release of VEGF with characteristic signs including retinal heme in all 4 quads, collaterals, dilated tortuous retinal veins, CWS, optic disc edema
** remember veins drain blood from the retina**
Collateral veins
visible over several weeks to months, often on the disc and permits blood flow between the retina and choroidal circulations
helping to accelerate drainage of excessive fluid (retinal edema) into the choroidal circulation after a CRVO
What are some vision-threatening complications that CRVO can cause?
- Macular edema, macular ischemia, intramacular hemes
- Neo (BAD!!),
- 90-day glaucoma (within first 3 months of diagnosis of CRVO)
ischemic CRVO
-60% of ischemic cases develop iris neo and 30% develop neo glaucoma
- higher risk of neo glaucoma
non-ischemic CRVO
6% of nonischemic cases develop rubeosis or angle neo
ALWAYS DO GONIO
What is the leading cause of vision loss in ischemic and non-ischemic CRVO?
macular edema
What defines ischemic CRVO?
10DD or more of nonperfusion on FA
- 90% of cases are 20/200 or worse
- poor prognosis, final VA CF
16% of nonischemic cases become ischemic
BRVO
most common retinal vascular occlusive dz, pts have similar health hx as pts with CRVO
- caused by thrombus after compression of an artery on a vein (AV crossing)
- 60% occur at an AV crossing within the sup/temporal quad
What are the risk factors for BRVO?
HTN, cardiovascular dz, increased body mass index at 20 years, open angle glc
Where does most AV crossing occur in a BRVO?
S/T quad
What if the BRVO does not occur at an AV crossing? What should you suspect?
evaluate for vasculitis
What are the signs and symptoms for a BRVO?
sx: sudden, unilateral, painless VF loss , blurred or no sx
signs:
usually occur at the occluded area, dilated tortuous, retinal veins, CWS, collateral vessels, and intraretinal heme
What are vision-threatening complications for BRVO?
- macular disease - ishcemia, edema, heme
- Neo complications - pre-retinal/vitreous heme
CRAO
- amaurosis fugax (transient vision loss)
- common in elderly pts
- 10% risk of CRAO in the fellow eye
- commonly arise from the heart and/or carotid artery emboli
“Big APD , 70 yo M”
What are the risk factors for CRAO?
HTN, DM, carotid occlusive dz, cardiac valve dz
What should you consider if you see a CRAO in a younger pt?
drug use and BC
Which one is more dangerous?
calcific emboli or carotid emboli?
calcific emboli is more dangerous, large, from calcified heart valves and often located in the CRA. near the optic nerve
carotid emboli = smaller cholesterol plaques (hollenhorst plaques) = MOST COMMON CAUSE
What tests would you recommend for a pt with a retinal emboli?
evaluate for carotid artery and cardiac dz with carotid doppler and EKG/Echo
What are causes for CRAO?
retinal emboli is the most common cause
other culprits include GCA, acute elevation in IOP, collagen vascular dz, IV drug use, oral contraceptives, sickle cell and syphilis
What are the signs and symptoms for CRAO?
Sx: transient vision loss
acute profound vision losss (often 20/400 or worse), unless cilioretinal artery is present to spare the macula, VA is LP or worse, strongly consider opthalmic artery occlusion
Signs: superficial whitening of the inner retinal layers (color is restored after perfusion but does not regain function), narrowed arterial vasculature, cherry red spots inthe foveola, APD, hollenhorst plaque (40% of cases)
What does the cilioretinal artery branch from?
SPCAs of the choroidal, allows the macula to remain functional in a CRAO (present in 15-30%)
T or F Neovascular glaucoma is rare in CRAO
T, because the retina dies too fast
What’s the most common cause of BRAO?
retinal emboli
other causes are calciium, fibrin, and platelet
What are the signs and sx of BRAO?
Sx: asymptomatic, VFdefect or sudden unilateral painless vision loss if the area of occlusion is close to or involving the macula
Signs: superficial whitening of the affected vessels (90% are temporal vessels) due to infarction and edema, hollenhorst plaques or other emboli found in the area of occlusion 62% of cases, edema/retinal whitening resolves within weeks but tissue remains nonfunctional and pts will have permanent VF defect
What’s the difference between CRAO and BRAO?
BRAO only affects area of the occluded vessel vs CRAO is all 4 quad
Indications for a diabetic retinal examination
initial examination should be done within 3-5 years after diagnosis
- pts w/ no DR, repeat exam every year
- pts w/ mild to mod retinopathy, repeat every 6-12 months
- pts with severe NPDR or PDR, repeat examinations every 2-4 months
Myelinated nerve fiber
congenital, benign, white patches in the superficial retina with feathery edges that represent abnormal myelination of GC axons anterior to the lamina cribosa
- can obscure retinal vessels and located near the optic nerve usually
what’s the leading cause of blindness in the US?
DR
What’s the most important risk factor for the development of DR?
duration
DR
- occurs b/c loss of pericytes and damage to the retinal capillary BM causing breakdown of the BRB
- DR can be broken down into NPDR and PDR
What’s the diagnosis for a severe NPDR?
when a pt meets one of the three criteria 4-2-1 rule
HVI
- retinal heme in all 4 quads
- 2 quads of venous beading
- 1 quad of irma
What’s the diagnosis for very severe NPDR?
2 or more criteria is met within the 4-2-1 rule
HVI
- retinal heme in all 4 quads
- 2 quads of venous beading
- 1 quad of irma
PDR
- dx based on the presence of neo in a pt w/ DR
High risk characteristics:
-NVD: neo of the disc greater than 1/4 disc diameter within 1DD of ON
-NVD or NVE w/ associated vitreous or preretinal heme
What are the signs and sx of PDR?
sx: asymptomatic, may experience blurred vision, metamorphopsia
signs: numerous signs of DR, most important threats to vision include macular dz and neo
What are the threats to vision from a macular dz?
- Macular ischemia - may look normal or thickened, HYPOfl on FA
- Macular edema - can occur at any stage of DR CSME
** FA can differentiate between macular ischemia vs edema**
What’s the criteria for dx DR CSME
- retinal thickening within 500um (1/3 DD) of the foveal center
- Hard exudates within 500um of the foveal center with adjacent retinal thickening
- Retinal thickening of 1DD within the foveal center
Threats to vision from neo include the following
- Preretinal/vitreous heme
- Neovascular glc
- Tractional retinal detachment
HTN retinopathy
- BP must typically be at least 140/110 for the latter stages of HR to occur
- autoregulation is altered at extremely high or chronically elevated systolic pressures and retinopathy results
What are the signs and symptoms of HR
sx: asymptomatic, unless there is presence of ME (macular star), papilledema, serous retinal detachment or vein occlusion
signs: bilateral but asymmetric
What are the signs and symptoms of OIS?
Sx: gradual vision loss, dull periorbital pain or headache, amaurosis fugax
signs: unilateral, dot/blot heme of the mid-peripheral fundus, dilated, narrowed retinal arteries and possible neo of the disc and/or ant seg (67% of pts with OIS have NVI/NVA at the time of diagnosis)
What if a pt had HR retinal findings AND a carotid artery obstruction what would the condition be called?
venous stasis retinopathy
What if pt had presence of both posterior and anterior segment signs of HR what would the condition be called?
OIS, common in male 50-70yo
What is OIS commonly associated with?
HTN, DM, cardiac dz; the latter is most common cause of 40% of a 5 yr mortality rate
Amaurosis fugax
TIA characterized by monocular vision loss that typically lasts seconds to minutes; vision returns to normal after an ischemic event
most common cause is a carotid artery embolus
TIA
characterized by temporary neurologic deficit due to transient loss of blood flow to the brain. Perfusion is always restored in less than 24 hours, resulting in complete resolution of the pts sx without any permanent damage
stroke
characterized by a permanent neurologic deficit due to prolonged loss of blood flow that results in irreversible damage to the brain
Hyperviscosity retinopathy
- increase resistance to blood flow 2’ to elevated levels of plasma proteins, RBC, and/or WBC, resulting in impaired circulation of blood flow causing damage to walls of the vessels, leaking of fluid, and retinal ischemia
What is the most common cause of hyperviscosity retinopathy? What else is it associated with?
hyperglobulinemia - a condition found in waldenstrom’s macroglobulinemia, multiple myeloma, serum positive RA, SLE, HIV infection
What are the signs of hyperviscosity?
Retinal venous dilation, retinal heme, CWS and exudates, CRV may also occur and is bilateral in 10% of pts
HIV retinopathy
signs/sx?
most common ocular manifestation of HIV/AIDS
Signs: CWS and retinal heme, similar to DR and early CMV retintitis
Sx: asymptomatic, non-infectious
Interferon Retinopathy
- Pts on interferon therapy can develop retinal findings similar to DR, CWS, and retinal heme in the posterior pole
- retinopathy occurs 3-5 months after interferon is started and tends to resolve w/o tx after interferon has been discontinued
- Pts on interferon therapy without retinopathy should be followed every 4-6 months; if retinopathy is present, f/us should occur more frequently
Talc retinopathy
- Presents bilaterally in IV drug users who use talc as a filler
- talc gets caught in the retinal capillaries and will appear as multiple, yellow, refractile deposits that tend to be clustered near the macula
- talc may cause capillary occlusion and retinal ischemia
Vascular sheathing/periphlebitis
- inflammatory condition by exudates around the vessels (seen as white cuffing of the vessels
- retinal edema, ischemia, and heme
- vessel walls will stain on FA
- most common in syphilis, sarcoidosis (candle wax dripping), pars planitis, and sickle cell dz
- testing should be done and case hx
Describe stage 1-4 for HR
Stage 1: arterial attenuation
Stage 2: Stage 1 + AV nicking and exaggeration of arterial light reflex
Stage 3: Stage 2 + color. CWS, hard exudates (likely star config) within the OPL radiating away from the fovea, retinal edema
Stage 4: Stage 3 + papilledema (malignant HTN), send to ER IMMEDIATELY, HIGH RISK OF STROKE. BP at this stage is usually 220/120
HTN is associated with which 2’ conditions that can lead to vision loss?
NAION, retinal macroaneurysm, vascular occlusion, ocular motor nerve palsies, Worsening of diabetes
Elschnig spots vs Elschnig pearls
spots = choroidal infarcts that occurs with HR
pearl = post cataract sx, usually tx w/ Nd:Yag
Which drug is associated with an NAION?
Viagara
Retinal artery Macroaneurysm (RAM)
signs/sx
- more common in elderly W, 7th decade
- asymptomatic but can have gradual vision loss from ME or sudden vision loss from vit heme
- unilateral focal area of dilation in the retinal artery (100-250um in diameter) with multi-level hemorrhage (subretinal, intraretinal, preretinal and/or vit heme) from a ruptured aneurysm with surrounding circinate exudates, often located at AV crossing
OIS/venous stasis retinopathy
- more common in men, ages 50-80
- occclusion of the ICA and/or ophthalmic artery (less common), usually 2’ to atherosclerosis; may occur as a result of GCA
Idiopathic Juxtafoveolar Retinal Telangiectasia (IJXT)
abnormal perifoveal capillaries present within the juxtafoveal region (1-199um from the center of the fovea)
Divided into 3 categories
1. Unilateral congenital form - 40 yo M, 20-25-20/40 VA
2. Unilateral idiopathic form - middle aged men; 20/25 or better VA
3. Bilateral acquired form - M&F 5th-6th decade, poor visual prognosis
What are the signs and sx of IJXT
sx: decreased vision
sign: right angle venules and dilated tortuous vessels, hemes, varying degrees of exudate (moderate to none at all) within or nearby the fovea, macular edema, and or CNVM
Coat’s dz
- Male less than 20 yo
- 2/3 of cases present prior to 10yo
- progression is more rapid under 4yo, stimulating retinblastoma
- idiopathic peripheral vascular dz, if left untreated will gradually progress to total exudative detachment
What are the signs/symptoms of coats dz
sx: decreased vision, strabismus, leukocoria
signs: Unilateral, telangiectatic dilated vessels that display a characteristic “light bulb” appearance
- progression can lead to marked hard exudates (classic for coat’s)
- intraretinal heme, exudative retinal detachment, NVG ( results in red, painful, blind eye)
A chronic extensive serous detachment in Coat’s dz results in?
Retinal ischemia –> which leads to devel. of ant seg neo
- similar to DR VOS conditions
- NVA and NVI result in NVG
Retinopathy of prematurity (Retrolental fibroplasia)
- occurs in premature infants (less than 32 weeks)
- low birth weight infants (<1500) who have recieved oxygen therapy
- Immature blood vessels vasoconstrict and stop developing in response to high concentration, leading to proliferative retinopathy.
What are the threats to vision with ROP
pretinal vitreous heme and tractional retinal detachment
What are the signs for ROP?
leukocoria, strabismus, vitreoretinal traction, preretinal/vitreous heme, and TRD
Leukocoria
white pupillary reflex that results from fibrovascular scarring 2’ to TRD and in cases of ROP
What’s the LAST area to achieve mature vascular developement during 9th month of gestation?
anterior temporal retina
this area is most susceptible to neo and subsequent TRD in pre-term infants with ROP
What’s the area that’s most susceptible to neo and TRD in pre-term infants with ROP?
anterior temporal retina
What’s the most common intraocular malignancy in children?
Retinoblastoma
What’s the 2nd most common intraocular malignancy tumor of all age groups?
choroidal melanoma
Retinoblastoma
- most common intraocular malignancy in chidlren
- 95% of cases dx by the age of 5
- no gender or race predilection
- tumor derived from cells in developing retina (retinoblast) as a result of mutations to the retinoblastoma (Rb) tumor supressor gene
Bilateral = heretable retinoblastoma (40%)
Unilateral = non-heritiable (60%)
What are the signs and sx of retinoblastoma
- leukocoria, strabismus, intraocular inflammation, decreased vision (depending on tumor size and location)
Differentials for leukocoria
- Coats dz, Rb, toxocariasis, ROP
Congenital Hypertrophy of the retinal pigmented epithelium (CHRPE)
signs:
- congenital w/ no race or sex predilection
Signs;
- benign, pigmented (brown to black), non-progressive lesions with sharp borders and central hypopigmented lacunae
- unilateral and solitary, measuring 1-6mm in diameter (aka bear tracks)
- Atypical CHRPE; bilateral, multifocal (4 or more), tear shaped, with a hypopigmented border on one end
What is an atypical CHRPE associated with?
Gardner’s syndrome
Choroidal nevus
- most common in whites
- benign focal accumulation of melanocytes within the choroid
- thought to be present at. birth and are typically non-progressive
- ANY growth should cause concern for malignant melanoma, 10% of suspicious nevi progress to malignant melanoma
What are the most significant risk factors for transformation into choroidal melanoma?
“To find small ocular melanomas, use helpful hints”
T = thickness (elevation >2mm)
F = fluid (subretinal)
S = symptoms (blurred vision, floaters)
O = orange pigment (lipofuscin on the surface of the lesion)
M = margins (irregular borders)
UH = ultrasonographic hollowness (acoustically hollow with low internal reflectivity)
H = halo absence
nevus should be sus if it has a large diameter >4DD or 6mm and close proximity to the ON and often contains overlying drusen