Ophthalmology - Progressive Visual Disturbances Flashcards
What are some causes of progressive visual loss?
- cataracts
- retinitis pigmentosa
- age-related macular degeneration (ARMD)
- diabetic retinopathy
- primary open-angle glaucoma
- ametropia
- hypertensive retinopathy
Symptoms of chronic hypertensive retinopathy.
Hypertensive retinopathy due to chronic hypertension is usually asymptomatic and can only be diagnosed through clinical examination.
Symptoms of accelerated hypertensive retinopathy.
Acute rises in blood pressure causes symptoms:
- blurring of vision
- visual field defects
- headache
- facial plethora
- nausea and vomiting
- painless loss of vision due to vessel occlusion
Fundoscopic features of hypertensive retinopathy.
What grading system is used to classify hypertensive retinopathy?
Keith-Wagener-Barker classification
What grade of hypertensive retinopathy does malignant hypertension present with?
Grade 4 on Keith-Wagener-Barker classification:
- AV nicking
- flame haemorrhages
- cotton-wool spots
- hard exudates
- papilloedema
Imaging of hypertensive retinopathy.
Optical coherence tomography (OCT)
Management of hypertensive retinopathy.
Reduction of blood pressure.
Blood pressure targets for patients aged:
a) <80 years
b) ≥80 years
a) <135/85mmHg
b) <145/85mmHg
Management of accelerated hypertension.
Referral for same-day specialist assessment.
IV anti-hypertensives (e.g. labetalol, nicardipine) to reduce blood pressure over 24-48 hours*.
*reducing blood pressure too quickly may result in organ hypoperfusion.
Complications of hypertensive retinopathy.
- retinal vessel occlusion
- neovascularisation
- vitreous haemorrhage
- retinal detachment
- progression of diabetic retinopathy
- irreversible visual loss
Differential diagnosis to hypertensive retinopathy.
Diabetic retinopathy.
Ophthalmic complications of diabetes.
- diabetic retinopathy
- cataracts
- cranial nerve palsy
- retinal vessel occlusion
What is the most common cause of blindness in the UK?
- diabetic retinopathy
Risk factors for diabetic retinopathy.
- length of exposure to hyperglycaemia
- duration since diabetes diagnosis
- hypertension
- ethnicity
- renal disease
- pregnancy
Symptoms of diabetic retinopathy.
Usually asymptomatic, however:
- floaters
- blurred vision and distortion
- decreased visual acuity
- loss of vision
- blindness
Investigating diabetic retinopathy.
Bedside investigations:
- urinalysis (?glucosuria, proteinuria)
- visual acuity
- fundoscopy
Laboratory investigations:
- random plasma glucose
- HbA1c
- U&Es (end organ damage)
- LFTs (end organ damage)
Imaging:
- OCT
What are the fundoscopic classes of diabetic retinopathy?
- non-proliferative
- proliferative
- diabetic macular oedema
Fundoscopic findings of non-proliferative diabetic retinopathy:
a) background retinopathy
b) pre-proliferative retinopathy
a) microaneurysms; dot and blot haemorrhages
b) hard exudates; cotton wool spots; venous veading; IRMAs
Fundoscopic findings of proliferative diabetic retinopathy.
- neovascularisation
- vitreous haemorrhage
- retinal detachment
Symptoms of diabetic macular oedema (DMO).
As the macula is responsible for central vision, symptoms relate to this:
- blurred vision when reading
- difficulty recognising faces
What is the most common cause of visual loss in diabetic retinopathy?
Diabetic macular oedema (DMO).
Medical management of diabetic retinopathy.
- glycaemic control
- blood pressure control
- diet, exercise and smoking cessation
HbA1c target for diabetics.
48-58mmol/mol
Primary intervention in management of proliferative diabetic retinopathy.
Photocoagulation - laser destruction of photoreceptors, decreasing retinal oxygen demand and delaying the progression of diabetic retinopathy.
What is
a) focal photocoagulation
b) pan-retinal photocoagulation
a) specific point of leakage is identified and targeted with a laser
b) periphery of the retina is targeted, aiming for a global reduction in oxygen demand
Complications of focal photocoagulation.
- decreased quality of central vision
- paracentral blind spot
- worsening DMO
Complications of pan-retinal photocoagulation.
- restricted peripheral vision
- reduced quality of night vision
- ocular pain
- worsening DMO
What is the role of intravitreal anti-VEGF injections.
Minimises neovascularisation and thus are used in proliferative diabetic retinopathy.
Complications of intravetreal anti-VEGF injections.
- cataract formation
- increased intraocular pressure
Contraindications of intravetreal anti-VEGF injections.
Stroke or MI in the last 3 months.
Screening for diabetic retinopathy.
In the UK, the NHS provides an annual eye screening programme for any individual aged >12 with diabetes.
Aims to promptly identify and manage any changes associated with diabetic retinopathy.
Complications of diabetic retinopathy.
- neovascular glaucoma
- retinal detachment
- vitreous haemorrhage
- loss of vision
What is neovascular glaucoma?
Neovascularisation within the iris and its trabecular meshwork results in narrowing and closure of the drainage angle.
This results in an increased intraocular pressure.
Prognosis of untreated proliferative DR.
a) 2 years
b) 10 years
a) 50% lose vision in 2 years
b) 90% lose most vision in 10 years
What is the most common type of glaucoma?
Primary open-angle glaucoma (POAG).