Ophthalmic disorders - Kelley - Lecture 6 Flashcards
retinal detachment
separation of the sensory retina from the pigment epithelium and underlying choroid
what does the tear in retinal detachment allow for?
allows fluid to accumulate b/w the 2 layers
starts to pull retina way
what does retinal detachment result in?
- ischemia and rapid progressive photoreceptor degeneration
- If have ischemia, will start to lose vision
what can occur in retinal detachment?
- Permanent blindness can occur if macula is detached
- True ophthalmic emergency
risk factors for retinal detachment?
- Myopia
- Previous ocular surgery
- Cataract extraction
- Use of FQ’s
- Trauma to eye
- Family history (Ie. Lattice degeneration)
- Marfan disease
causes of retinal detachment?
- Retinal tears or holes
- Traction on the retina caused by systemic influences (Diabetic retinopathy)
- Tumors
- Exudative process (Infection, Malignancy)
retinal detachment symptoms
- 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
what about progression of symptoms for retinal detachment? how do they range?
Progression of symptoms can range from hours to days (with large tears) or one to four weeks (with small holes or tears)
diff dx for retinal detachment
- Vitreous hemorrhage
- Vitreous inflammation
- Ocular lymphoma
- Intraocular foreign body
what is used to dx retinal detachment?
BEDSIDE ULTRASOUND
can also do ophthalmoscopic exam, see “billowing sail” or “ripple on a pond” - exposed choroid
what is the first thing you do for retinal detachment in terms of txt?
CONSULT OPHTHALMOLOGY
txts of retinal detachment?
- drainage of sub retinal fluid
- laser photocoagulation
- cryotherapy to sclera (cryoretinopexy)
- pneumoretinopexy
- scleral buckle replacement
- vitrectomy surgery
what is the goal of txt for retinal detachment?
to close tears
what txts do you used for retinal tears (not full detachment)?
- laser photocoagulation
- cryotherapy to sclera (cryoretinopexy)
how long does it take your body to form adhesions when treated for retinal detachment?
2 weeks
what are in-office txts for retinal detachments/tears?
laser photocoagulation, cryoretinopexy, pneumoretinopexy
what txt is for large retinal detachments?
pneumoretinopexy
what txt for retinal detachment is in the operating room?
scleral buckle replacement
what exam reveals retinal detachment?
funduscopic exam
is txt often successful for retinal detachment?
yes, if performed early
optic neuritis
Common inflammatory disease of the optic nerve
optic neuritis characterized by what on exam?
- normal fundus exam initially
- “The doctor sees nothing, and the patient sees nothing”
- Normal exam, originally blind in central vision, but vision returns
will pt recover after single episode of optic neuritis?
Gradual recovery is typical after single episode
what is optic neuritis strongly associated with?
demyelinating diseases
what is the one demyelinating disease you will see optic neuritis in?
Multiple Sclerosis
mean age for optic neuritis?
32 (20-40)
gender for optic neuritis?
female mostly
what is the chance a patient with optic neuritis will develop MS?
50% chance patient will develop MS in 15 years
causes of optic neuritis
-demyelination (MS most common)
symptoms of optic neuritis
- unilateral loss of vision that develops over a few days
- lose central vision
- pain exacerbated by movement
- pain behind eye
diff dx for optic neuritis
- infections involving the optic nerve
- retinal detachment
- giant cell arteritis
dx for optic neuritis
- ophthalmic exam - see “optic atrophy” (optic disc pallor) develops over several months
- also do brain MRI to dx MS
optic neuritis management
- neuro-ophthalmologist
- steroids (methylprednisolone & tapering of oral prednisone)
does vision usually recover in optic neuritis?
Gradual recovery in vision without treatment typically
what do steroids to for txt for optic neuritis?
- Steroids accelerate recovery but do not change end point
- Can help people short term, but does not stop them from losing their vision
txt of demyelinating plaques in optic neuritis
Interferon Beta-1a can retard the development of more lesions
- fights infections
- used to treat MS
- injectable
what type of vision loss for optic neuritis? binocular or monocular?
monocular
papilledema found when?
physical exam finding during funduscopic exam
-pts w/increased ICP
what do you lose in papilledema?
loss of definition of the optic disc
-edema of the head of the optic nerve
where does papilledema initially occur?
Initially occurs superiorly and inferiorly, then nasally and temporally
what else can you see on papilledema?
- Central vessels are pushed forward
- Veins are markedly dilated
is vision altered initially?
NO
causes of papilledema
-increased ICP along optic nerve
is HTN retinopathy related to increased ICP?
NO, reason why it is not a true cause of papilledema, even though often described as such
causes of ICP?
- Intracranial mass lesions
- Cerebral edema
- Hydrocephalus
- Obstruction of venous outflow
- Idiopathic intracranial HTN (Pseudotumor cerebri)
what is hydrocephalus?
- Excess fluid in brain
- Increased CSF production or decreased CSF absorption
symptoms of increased ICP?
- HA (worse lying down and upon awakening in morning)
- N/V
- binocular horizontal diplopia
- pulsatile machinery-like sound in ear
- brief transient visual blurring
stages of papilledema
early, fully developed, chronic
early stage of papilledema signs
- Loss of spontaneous venous pulsations
- Optic cup is retained early on
fully developed stage of papilledema signs
- Optic disc elevated & margins obscured
- Cup is obliterated
- Blood vessels buried
- Engorged veins
- Flame hemorrhages
- Cotton wool spots (white spots)
what do cotton wool spots result from/
nerve fiber infarction
chronic stage of papilledema signs
- Cup remains obliterated
- Hemorrhagic and exudative components resolve
- Nerve appears flat with irregular margins
- Disc pallor
dx testing for papilledema
- MRI (ideal), CT (if MRI delayed)
- lumbar puncture
- visual field testing
papilledema management
- reduce ICP and continuously monitor
- osmotic therapy & diuresis
- hypertonic saline
- steroids
- hyperventilation
- barbiturates
- removal of CSF
- decompressive craniectomy
what does hypertonic saline do for txt of papilledema?
reduces ICP early, but long-term clinical outcomes are unclear
what do steroids do for txt of papilledema?
- reduce swelling for intracranial tumors and CNS infections
- worse outcomes with head injury
what does hyperventilation do for txt of papilledema?
Mechanic ventilation rapidly reduces ICP through vasoconstriction
what do barbiturates do for txt of papilledema?
Reduces brain metabolism and cerebral blood flow thus lowering ICP
clinical features of idiopathic intracranial HTN
- N/V, HA, blurred vision
- CN VI paresis/horz diplopia
- BILATERAL papilledema
- spontaneous venous pulsations are absent
- visual field defect
most cases for idiopathic intracranial HTN?
90% obese women of childbearing age
15-44 y.o
management of idiopathic intracranial HTN?
- 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)
what is retinal artery occlusion caused by?
embolism or thrombus
what is retinal vein occlusions caused by?
-HTN, DM, sickle cell anemia, conditions that slow venous blood flow
what does reduction in blood flow result in for retinal vein occlusion?
- 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
retinal artery occlusion
- acute, painless loss of monocular vision
- consider CVA (stroke)
what types of occlusions can occur in retinal artery occlusion?
- central retinal artery occlusion (CRAO)
- branch retinal artery occlusion (BRAO)
epidemiology of retinal artery occlusion?
- Mean age 60-65 years old
- Men>women
- Patients have cardiovascular risk factors (HTN, smoking, DM, high cholesterol)
what is the most common cause of retinal artery occlusion?
CAROTID ARTERY ATHEROSCLEROSIS
what else can cause retinal artery occlusion?
- cardiogenic embolism (afib)
- giant cell arteritis
- sickle cell disease
- hypercoagulable states
CENTRAL retinal artery occlusion symptoms
- sudden, painless, profound loss of vision in ONE eye
- may be preceded by transient monocular blindness (amaurosis fugax)
- rarely, flashing lights in visual field
what is central retinal artery occlusion preceded by?
transient monocular blindness (amaurosis fugax)
BRANCH retinal artery occlusion
monocular vision loss - ay be restricted to just part of the visual field
associated symptoms of retinal artery occlusion?
- HA (from giant cell arteritis or carotid dissection)
- numbness, weakness, or slurred speech (carotid disease)
retinal artery occlusion PE
- visual acuity reduced (partial visual field in BRAO to nearly complete vision loss)
- afferent pupillary defect (Marcus Gunn pupil)
- funduscopic exam
what will you see on funduscopic exam of retinal artery occlusion?
- ischemic retinal whitening
- CHERRY RED SPOT in macula
what is a sign that a patient with retinal artery occlusion has complete vision loss?
can’t tell how many fingers clinician is holding up
management of retinal artery occlusion
- check sedimentation rate & C-reactive protein
- consult ophthalmology immediately
why check sedimentation rate & C-reactive protein in retinal artery occlusion?
- To rule out giant cell arteritis
- Immediate administration of steroids can preserve vision in these patients
what occurs within a few hours of retinal artery occlusion?
Irreversible retinal damage
what will ophthalmologist do for retinal artery occlusion?
- Anterior chamber paracentesis and IV acetazolamide reduce IOP
- Inhaled oxygen-CO2 mixture induces retinal vasodilation
what is not recommended as management for retinal artery occlusion?
The data on immediate revascularization with thrombolytic therapy is mixed and therefore not necessarily recommended
how does retinal vein occlusion occur?
thrombus formation or compression of the vein by retinal arterioles at the arteriovenous crossing point
retinal vein occlusion classification?
branch retinal vein occluion
central retinal vein occlusion
hemiretinal vein occlusion
branch retinal vein occlusion
Distal vein is occluded leading to hemorrhage along the distribution of the small vessel
central retinal vein occlusion
Occurs due to thrombus within the central retinal vein leading to involvement of entire retina
hemiretinal vein occlusion
Occurs when blockage is in a vein that drains the superior or inferior hemiretina
associated conditions of retinal vein occlusion
- DM
- HTN
- Leukemia
- Sickle cell disease
- Multiple myeloma
retinal vein occlusion clinical presentation
- sudden, painless loss of vision
- funduscopic exam features vary from a few scattered retinal hemorrhages and cotton wool spots to a market hemorrhagic appearance
management of acute retinal vein occlusion
- No treatment in the acute stage is established to alter visual outcomes
- Consult ophthalmology immediately
what will ophthalmologist do for acute retinal vein occlusion?
- 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
