Ocular Disorders: Posterior

Question 1

Most common cause of reversible blindness worldwide

Answer 1

Cataracts

Question 2

Cataracts

Answer 2

Opacification of the intraocular lens resulting in vision changes

Question 3

Most common cause of cataracts

Answer 3

age-related changes in crystalline lens

Question 4

Other causes of cataracts

Answer 4

• diabetes mellitus
• galactosemia
• hypocalcemia
• Radiation
• Trauma

Question 5

What is attenuation?

Answer 5

(↓ force/effect) of light

Question 6

Cataracts pathophysiology

Answer 6

• Loss of optical clarity
• Morphological changes
• Building up a diffusion barrier to
  nucleus coloration/clouding of lens
• Biochemistry
• ↓ glutathione (antioxidant) levels
• Formation of advanced glycolated
  end products
• Loss of alpha-crystallin chaperone

Question 7

Cataracts clinical presentation

Answer 7

• Often detected during routine eye
  exam in asymptomatic patients
• May report gradual painless loss
  of vision at distance
• Typically bilateral, but can be
  asymmetrical

Question 8

Diagnosis of cataracts

Answer 8

• Most diagnosed during rouXne ophthalmoscopic exam in asymptomaXc paXents
• Suspect in older paXents with progressive ↓ vision or other S/S
• Diagnosis confirmed by comprehensive eye exam (Ophthalmology)

Question 9

Cataracts management

Answer 9

• Management of symptomatic cataract is primarily surgical
• Nonsurgical management
• Prescribe eyeglasses (if appropriate)
• Counsel patients about cataract-related visual symptoms
• Provide reassurance about cause of visual impairment

Question 10

Age-related Macular Degeneration (AMD)

Answer 10

Progressive chronic retinal disease of aging eye(s), characterized by:
- Drusen (focal yellowish deposits of acellular, polymorphous debris)
- Geographic atrophy of retinal pigment epithelium
- Neovascularization leading to visual impairmen

Question 11

Age-related Macular Degenera4on (AMD) Pathogenesis

Answer 11

• Cause unknown
• Drusen forms below retinal pigment
  epithelium & Bruch’s membrane
• Geographic atrophy begins to
  manifest as retinal pigment
  epithelium changes

Question 12

AMD Clinical presentation

Answer 12

Incidental finding <——-> Sudden central visual distortion
* May report ↓ vision, flashes of light (photopsia), or difficulties with light
adaptation

Question 13

AMD diagnosis

Answer 13

• Comprehensive exam, including visual acuity & Amsler grid
• Dilated fundoscopic exam with stereoscopic biomicroscopic exam of the macula
• presence of few medium (63-124 micrometers) Drusen (early AMD)
• retinal hyperpigmentation or hypopigmentation
• retinal atrophy
• Optical coherence tomography

Question 14

___ is #1 severe, irreversible vision impairment in developed countries

Answer 14

AMD

Question 15

AMD Management

Answer 15

• Smoking cessation (if applicable)
• Early AMD → obervation
• Intermidiate/Advanced AMD → antioxidant vitamin (carotenoids, vitamins C & E) & mineral supplements (selenium & zinc)

Question 16

1st Line treatment for AMD

Answer 16

Neovascular AMD → Intravitreal injection of antivascular endotheial growth factor antibodies

Question 17

Complications & Referral Considerations for AMD

Answer 17

• Blindness
• ↑ risk for depression, hip fracture, & nursing home placement
• Charles Bonnet syndrome
• ↑ mortality in patients aged 49-75 years

Question 18

Glaucoma: Two types

Answer 18

Acute angle closure: Primary glaucoma in which contact of the iris with the peripheral cornea excludes aqueous humor from the
trabecular drainage meshwork.
Chronic open angle: Primary glaucoma in which the aqueous humor has free access to the trabecular meshwork.

Question 19

Glaucoma – Angle Closure clinical presentation

Answer 19

• Asymptomatic early
• Symptomatic: >90% of attacks are unilateral
• Severe ocular pain
• Sudden vision loss
• Blurred vision
• Halos around lights
• Headache
• Eye redness
• Nausea & vomiting (if IOP high)

Question 20

Glaucoma – Angle Closure physical exam

Answer 20

• Structural assessment of optic cup
• Visual field loss in severe cases
• More diffuse with angle-closure glaucoma
• Slit-lamp biomicroscopy
  *** Tonometry

Question 21

Diagnostic Criteria for Glaucoma – Angle Closure

Answer 21

≥ 2 symptoms
1. ocular or periocular pain
2. nausea &/or vomiting
3. Hx of intermittent blurring of
vision w/ haloes

Question 22

Glaucoma – Open Angle clinical presentation

Answer 22

• Asymptomatic early
• Symptomatic
• Ocular burning/smarting/stinging/soreness
• ocular tiredness
• blurry/dim vision
• Eye foreign body sensation
• visual difficulty in daylight &/or darkness
• halos around lights
• Ask about use of steroids

Question 23

Left untreated open angle
glaucoma will lead to
_____

Answer 23

permanent blindness

Question 24

Glaucoma results in ____ as the central cup becomes enlarged

Answer 24

“cupping”

Question 25

Glaucoma – Angle Closure Management

Answer 25

Laser trabeculoplasty is the ini7al therapy in selected patients or alternative for patients who can/will not use medications reliably

Question 26

Glaucoma – Open Angle Management

Answer 26

* Long-term medications (↓ IOP) delay visual progression in pts with primary open-angle glaucoma or ocular hypertension * Topical medications * Beta-blockers * Prostaglandin analogs * Parasympathomimetic agents * Alpha-adrenergic agonists * Systemic carbonic anhydrase inhibitors

Question 27

#1 cause of preventable blindness in US adults 20-74 yo

Answer 27

Diabetic Retinopathy

Question 28

Diabetic Retinopathy Clinical persentation

Answer 28

* Often Asymptomatic! * Blurred or double vision * ↓ field of vision * Seeing dark spots * Pressure or pain in eyes * ↓ vision in dim light * Sudden blindness (rarre)

Question 29

Advanced Hypertensive Retinopathy findings on exam

Answer 29

* Flame hemorrhages * Arteriovenous nicking [a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing] * Cotton-wool spots

Question 30

Diagnosis of Diabetic Retinopathy

Answer 30

* Funduscopic Exam Findings (direct ophthalmoscopy) * Ideally done during routine, annual, asymptomatic screening

Question 31

_____ are generally the 1st clinical sign in the early-stages of Diabetic Retinopathy

Answer 31

Microaneurysms

Question 32

Central Retinal Artery Occlusion

Answer 32

blockage of the arterial supply to the retina leading to retinal ischemia or infarction & transient or permanent vision loss.

Question 33

Central Retinal Artery Occlusion most common cause

Answer 33

Embolism

Question 34

Central Retinal Artery Occlusion common clinical presentation

Answer 34

* Sudden painless, monocular vision loss or degradation “a veil/curtain/shade suddenly coming down over my eye”

Question 35

Retinal opacity, or whitening, with cherry red spot is earliest sign for ____

Answer 35

Central Retinal Artery Occlusion

Question 36

Central Retinal Artery Occlusion Management

Answer 36

* The prognosis for visual recovery is related directly to the promptness in treatment; thus... * Rapid transport to the ED is essential!

Question 37

____ constitute the second most common retinal vascular disorder.

Answer 37

CRVO & Branch Retinal Vein Occlusion (BRVO)

Question 38

Central Retinal Vein Occlusion

Answer 38

Backup of the blood in the re?nal venous system & increased resistance to venous blood flow 2° thromboembolism

Question 39

Leading cause of visual loss in both ischemic & nonischemic CRVO

Answer 39

* Ischemic damage to the retina may stimulate ↑ production of vascular endothelial growth factor (VEGF) in the vitreous cavity → neovascularization of the posterior & anterior segment * VEGF causes capillary leakage → macular edema

Question 40

Central Retinal Vein Occlusion Diagnosis

Answer 40

Visual acuity: Variable → one of the important indicators of prognosis * Retinal hemorrhages may present in all 4 quadrants. * can be superficial, dot & blot, &/or deep. * may be seen in the peripheral fundus only. * mild to severe, covering the whole fundus * “Blood & Thunder” appearance

Question 41

Re&nal Detachment

Answer 41

Separation of neurosensory retina from underlying retinal pigment epithelium

Question 42

Re&nal Detachment most common cause

Answer 42

Rhegmatogenous detachment → entry of liquid vitreous into subretinal space through a retinal break

Question 43

Retinal Detachment - Exudative detachment

Answer 43

subretinal fluid accumulates & causes detachment without any corresponding break in the retina * Tumor growth or inflammation

Question 44

Retinal Detachment - Traditional attachment

Answer 44

centripetal mechanical forces on retina, usually mediated by fibrotic tissue & scarring from previous disease * Diabetic retinopathy * sickle cell disease * penetrating trauma

Question 45

Retinal Detachment exam findings

Answer 45

* Marcus-Gunn pupil * Intraocular pressure measurement in both eyes * Relative hypotony of >4-5 mm Hg less tobacco dust (Shafer sign) than the fellow eye is common] * Described as a dim “shadow” or “curtain"

Question 46

Retinal Detachment is a ______

Answer 46

Surgical Emergency

Question 47

Optic Neuritis

Answer 47

occurs when inflamma?on damages the optic nerve

Question 48

Periocular pain can occur in >90% of patients who have ____

Answer 48

Optic Neuritis

Question 49

Optic Neuritis Clinical Presentation

Answer 49

* May present with visual deteriora?on during exercise or elevated temperature * Uhthoff phenomena

Question 50

Anterior Ischemic Optic Neuropathy

Answer 50

Sudden loss of vision due to a decreased or interrupted blood flow to the eye's op?c nerve

Question 51

Most common cause of acute op?c neuropathy in older age groups

Answer 51

Anterior Ischemic Op*c Neuropathy

Question 52

Amaurosis Fugax

Answer 52

Amaurosis “dark” & Fugax “flee?ng” – Transient loss of vision