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Clinical Medicine > Ophthalmic disorders - Kelley - Lecture 6 > Flashcards

Ophthalmic disorders - Kelley - Lecture 6 Flashcards

1
Q

retinal detachment

A

separation of the sensory retina from the pigment epithelium and underlying choroid

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2
Q

what does the tear in retinal detachment allow for?

A

allows fluid to accumulate b/w the 2 layers

starts to pull retina way

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3
Q

what does retinal detachment result in?

A
  • ischemia and rapid progressive photoreceptor degeneration

- If have ischemia, will start to lose vision

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4
Q

what can occur in retinal detachment?

A
  • Permanent blindness can occur if macula is detached

- True ophthalmic emergency

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5
Q

risk factors for retinal detachment?

A
  • Myopia
  • Previous ocular surgery
  • Cataract extraction
  • Use of FQ’s
  • Trauma to eye
  • Family history (Ie. Lattice degeneration)
  • Marfan disease
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6
Q

causes of retinal detachment?

A
  • Retinal tears or holes
  • Traction on the retina caused by systemic influences (Diabetic retinopathy)
  • Tumors
  • Exudative process (Infection, Malignancy)
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7
Q

retinal detachment symptoms

A
  • Increasing number of floaters
  • Flashes of light in visual fields
  • Shower of black spots in the visual fields
  • Curtain spreading over visual field
  • Cloudy or smoky vision
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8
Q

what about progression of symptoms for retinal detachment? how do they range?

A

Progression of symptoms can range from hours to days (with large tears) or one to four weeks (with small holes or tears)

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9
Q

diff dx for retinal detachment

A
  • Vitreous hemorrhage
  • Vitreous inflammation
  • Ocular lymphoma
  • Intraocular foreign body
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10
Q

what is used to dx retinal detachment?

A

BEDSIDE ULTRASOUND

can also do ophthalmoscopic exam, see “billowing sail” or “ripple on a pond” - exposed choroid

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11
Q

what is the first thing you do for retinal detachment in terms of txt?

A

CONSULT OPHTHALMOLOGY

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12
Q

txts of retinal detachment?

A
  • drainage of sub retinal fluid
  • laser photocoagulation
  • cryotherapy to sclera (cryoretinopexy)
  • pneumoretinopexy
  • scleral buckle replacement
  • vitrectomy surgery
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13
Q

what is the goal of txt for retinal detachment?

A

to close tears

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14
Q

what txts do you used for retinal tears (not full detachment)?

A
  • laser photocoagulation

- cryotherapy to sclera (cryoretinopexy)

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15
Q

how long does it take your body to form adhesions when treated for retinal detachment?

A

2 weeks

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16
Q

what are in-office txts for retinal detachments/tears?

A

laser photocoagulation, cryoretinopexy, pneumoretinopexy

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17
Q

what txt is for large retinal detachments?

A

pneumoretinopexy

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18
Q

what txt for retinal detachment is in the operating room?

A

scleral buckle replacement

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19
Q

what exam reveals retinal detachment?

A

funduscopic exam

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20
Q

is txt often successful for retinal detachment?

A

yes, if performed early

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21
Q

optic neuritis

A

Common inflammatory disease of the optic nerve

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22
Q

optic neuritis characterized by what on exam?

A
  • normal fundus exam initially
  • “The doctor sees nothing, and the patient sees nothing”
  • Normal exam, originally blind in central vision, but vision returns
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23
Q

will pt recover after single episode of optic neuritis?

A

Gradual recovery is typical after single episode

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24
Q

what is optic neuritis strongly associated with?

A

demyelinating diseases

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25
Q

what is the one demyelinating disease you will see optic neuritis in?

A

Multiple Sclerosis

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26
Q

mean age for optic neuritis?

A

32 (20-40)

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27
Q

gender for optic neuritis?

A

female mostly

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28
Q

what is the chance a patient with optic neuritis will develop MS?

A

50% chance patient will develop MS in 15 years

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29
Q

causes of optic neuritis

A

-demyelination (MS most common)

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30
Q

symptoms of optic neuritis

A
  • unilateral loss of vision that develops over a few days
  • lose central vision
  • pain exacerbated by movement
  • pain behind eye
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31
Q

diff dx for optic neuritis

A
  • infections involving the optic nerve
  • retinal detachment
  • giant cell arteritis
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32
Q

dx for optic neuritis

A
  • ophthalmic exam - see “optic atrophy” (optic disc pallor) develops over several months
  • also do brain MRI to dx MS
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33
Q

optic neuritis management

A
  • neuro-ophthalmologist

- steroids (methylprednisolone & tapering of oral prednisone)

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34
Q

does vision usually recover in optic neuritis?

A

Gradual recovery in vision without treatment typically

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35
Q

what do steroids to for txt for optic neuritis?

A
  • Steroids accelerate recovery but do not change end point

- Can help people short term, but does not stop them from losing their vision

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36
Q

txt of demyelinating plaques in optic neuritis

A

Interferon Beta-1a can retard the development of more lesions

  • fights infections
  • used to treat MS
  • injectable
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37
Q

what type of vision loss for optic neuritis? binocular or monocular?

A

monocular

38
Q

papilledema found when?

A

physical exam finding during funduscopic exam

-pts w/increased ICP

39
Q

what do you lose in papilledema?

A

loss of definition of the optic disc

-edema of the head of the optic nerve

40
Q

where does papilledema initially occur?

A

Initially occurs superiorly and inferiorly, then nasally and temporally

41
Q

what else can you see on papilledema?

A
  • Central vessels are pushed forward

- Veins are markedly dilated

42
Q

is vision altered initially?

A

NO

43
Q

causes of papilledema

A

-increased ICP along optic nerve

44
Q

is HTN retinopathy related to increased ICP?

A

NO, reason why it is not a true cause of papilledema, even though often described as such

45
Q

causes of ICP?

A
  • Intracranial mass lesions
  • Cerebral edema
  • Hydrocephalus
  • Obstruction of venous outflow
  • Idiopathic intracranial HTN (Pseudotumor cerebri)
46
Q

what is hydrocephalus?

A
  • Excess fluid in brain

- Increased CSF production or decreased CSF absorption

47
Q

symptoms of increased ICP?

A
  • HA (worse lying down and upon awakening in morning)
  • N/V
  • binocular horizontal diplopia
  • pulsatile machinery-like sound in ear
  • brief transient visual blurring
48
Q

stages of papilledema

A

early, fully developed, chronic

49
Q

early stage of papilledema signs

A
  • Loss of spontaneous venous pulsations

- Optic cup is retained early on

50
Q

fully developed stage of papilledema signs

A
  • Optic disc elevated & margins obscured
  • Cup is obliterated
  • Blood vessels buried
  • Engorged veins
  • Flame hemorrhages
  • Cotton wool spots (white spots)
51
Q

what do cotton wool spots result from/

A

nerve fiber infarction

52
Q

chronic stage of papilledema signs

A
  • Cup remains obliterated
  • Hemorrhagic and exudative components resolve
  • Nerve appears flat with irregular margins
  • Disc pallor
53
Q

dx testing for papilledema

A
  • MRI (ideal), CT (if MRI delayed)
  • lumbar puncture
  • visual field testing
54
Q

papilledema management

A
  • reduce ICP and continuously monitor
  • osmotic therapy & diuresis
  • hypertonic saline
  • steroids
  • hyperventilation
  • barbiturates
  • removal of CSF
  • decompressive craniectomy
55
Q

what does hypertonic saline do for txt of papilledema?

A

reduces ICP early, but long-term clinical outcomes are unclear

56
Q

what do steroids do for txt of papilledema?

A
  • reduce swelling for intracranial tumors and CNS infections

- worse outcomes with head injury

57
Q

what does hyperventilation do for txt of papilledema?

A

Mechanic ventilation rapidly reduces ICP through vasoconstriction

58
Q

what do barbiturates do for txt of papilledema?

A

Reduces brain metabolism and cerebral blood flow thus lowering ICP

59
Q

clinical features of idiopathic intracranial HTN

A
  • N/V, HA, blurred vision
  • CN VI paresis/horz diplopia
  • BILATERAL papilledema
  • spontaneous venous pulsations are absent
  • visual field defect
60
Q

most cases for idiopathic intracranial HTN?

A

90% obese women of childbearing age

15-44 y.o

61
Q

management of idiopathic intracranial HTN?

A
  • self-limited
  • observe/brief hospitalization
  • weight loss
  • serial lumbar punctures
  • acetazolamide
  • high dose steroids if rapid vision loss
  • surgery for severe, refractory cases (shunt from spinal cord to abdomen)
62
Q

what is retinal artery occlusion caused by?

A

embolism or thrombus

63
Q

what is retinal vein occlusions caused by?

A

-HTN, DM, sickle cell anemia, conditions that slow venous blood flow

64
Q

what does reduction in blood flow result in for retinal vein occlusion?

A
  • Reduction in blood flow results in neovascularization with fibrovascular invasion in the space between retinal and vitreous humor
  • New vessels are fragile and prone to hemorrhage
65
Q

retinal artery occlusion

A
  • acute, painless loss of monocular vision

- consider CVA (stroke)

66
Q

what types of occlusions can occur in retinal artery occlusion?

A
  • central retinal artery occlusion (CRAO)

- branch retinal artery occlusion (BRAO)

67
Q

epidemiology of retinal artery occlusion?

A
  • Mean age 60-65 years old
  • Men>women
  • Patients have cardiovascular risk factors (HTN, smoking, DM, high cholesterol)
68
Q

what is the most common cause of retinal artery occlusion?

A

CAROTID ARTERY ATHEROSCLEROSIS

69
Q

what else can cause retinal artery occlusion?

A
  • cardiogenic embolism (afib)
  • giant cell arteritis
  • sickle cell disease
  • hypercoagulable states
70
Q

CENTRAL retinal artery occlusion symptoms

A
  • sudden, painless, profound loss of vision in ONE eye
  • may be preceded by transient monocular blindness (amaurosis fugax)
  • rarely, flashing lights in visual field
71
Q

what is central retinal artery occlusion preceded by?

A

transient monocular blindness (amaurosis fugax)

72
Q

BRANCH retinal artery occlusion

A

monocular vision loss - ay be restricted to just part of the visual field

73
Q

associated symptoms of retinal artery occlusion?

A
  • HA (from giant cell arteritis or carotid dissection)

- numbness, weakness, or slurred speech (carotid disease)

74
Q

retinal artery occlusion PE

A
  • visual acuity reduced (partial visual field in BRAO to nearly complete vision loss)
  • afferent pupillary defect (Marcus Gunn pupil)
  • funduscopic exam
75
Q

what will you see on funduscopic exam of retinal artery occlusion?

A
  • ischemic retinal whitening

- CHERRY RED SPOT in macula

76
Q

what is a sign that a patient with retinal artery occlusion has complete vision loss?

A

can’t tell how many fingers clinician is holding up

77
Q

management of retinal artery occlusion

A
  • check sedimentation rate & C-reactive protein

- consult ophthalmology immediately

78
Q

why check sedimentation rate & C-reactive protein in retinal artery occlusion?

A
  • To rule out giant cell arteritis

- Immediate administration of steroids can preserve vision in these patients

79
Q

what occurs within a few hours of retinal artery occlusion?

A

Irreversible retinal damage

80
Q

what will ophthalmologist do for retinal artery occlusion?

A
  • Anterior chamber paracentesis and IV acetazolamide reduce IOP
  • Inhaled oxygen-CO2 mixture induces retinal vasodilation
81
Q

what is not recommended as management for retinal artery occlusion?

A

The data on immediate revascularization with thrombolytic therapy is mixed and therefore not necessarily recommended

82
Q

how does retinal vein occlusion occur?

A

thrombus formation or compression of the vein by retinal arterioles at the arteriovenous crossing point

83
Q

retinal vein occlusion classification?

A

branch retinal vein occluion

central retinal vein occlusion

hemiretinal vein occlusion

84
Q

branch retinal vein occlusion

A

Distal vein is occluded leading to hemorrhage along the distribution of the small vessel

85
Q

central retinal vein occlusion

A

Occurs due to thrombus within the central retinal vein leading to involvement of entire retina

86
Q

hemiretinal vein occlusion

A

Occurs when blockage is in a vein that drains the superior or inferior hemiretina

87
Q

associated conditions of retinal vein occlusion

A
  • DM
  • HTN
  • Leukemia
  • Sickle cell disease
  • Multiple myeloma
88
Q

retinal vein occlusion clinical presentation

A
  • sudden, painless loss of vision
  • funduscopic exam features vary from a few scattered retinal hemorrhages and cotton wool spots to a market hemorrhagic appearance
89
Q

management of acute retinal vein occlusion

A
  • No treatment in the acute stage is established to alter visual outcomes
  • Consult ophthalmology immediately
90
Q

what will ophthalmologist do for acute retinal vein occlusion?

A
  • Intravitreal injections of VEGF inhibitors or triamcinolone
  • Retinal laser photocoagulation
  • Various surgical techniques
  • Vitrectomy with direct injection of TPA
  • Incision of the sclera at the edge of the optic disc

Clinical Medicine (11 decks)

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