Ophtho 4 Flashcards
What is optic neuritis?
an inflammatory demyelinating condition that results in acute vision loss in one eye
What disease is optic neuritis strongly a/w? Occurs most commonly in?
MS
-may also occur w/ viral infections (measles, mumps, influenza)
Women ages 20-40
You are concerned your patient has optic neuritis based on their story. What are some of their presenting complaints?
- acute onset (hrs to days)
- monocular vision loss
- eye pain, worse with EOM’s
- visual field defect, usually central scotoma
In optic neuritis, what is the same of the most common visual field defect?
Central scotoma
What would you see on PE of a pt with optic neuritis?
- loss of color vision
- visual acuity decreased (variable)
- relative afferent pupillary defect (APD)
- optic nerve changes may be seen
2/3 of optic neuritis are ____, showing ______ in the fundus.
In 1/3, the optic nerve is ____ w/ ______ and occasionally has ____.
retro-bulbar
no changes
swollen w/ pallor
flame-shaped peri-papillary hemorrhages
How do you confirm diagnosis of optic neuritis?
MRI of brain and orbits
Tx of optic neuritis?
refer urgently to optho/neuro
IV methylprednisolone for 3 days, then oral taper to accelerate vision recovery
Visual acuity usually returns after tx of optic neuritis, how long?
If it doesn’t return, what do you need to rule-out?
2-3 weeks
compressive lesion or tumor
What is papilledema? Usually a/w what?
swelling of the optic nerve head
usually a/w elevated intracranial pressure
What would you see on PE of a pt with papilledema?
optic disc, margins, cup, venules
- optic disk is swollen, w/ blurred margins, cup may be obscured due to swelling
- venules are dilated and tortuous
- there may be flame hemorrhages and infarctions (white, indistinct “cotton wool spots) in the nerve finger layer, and edema in the surrounding retina
Pt’s with papilledema often 1st complain of other signs/symptoms of ______ before papilledema.
Like what?
increased intracranial pressure
HA
Transient vision changes
Ddx for papilledema
- intracranial mass/lesion (tumor)
- cerebral edema (encephalopathy, TBI)
- disorders of the CSF
- obstructive hydrocephalus
- idiopathic intracranial hypertension (aka pseudotumor cerebri)
What do you do if papilledema is found?
Urgent ophthalmology referral and complete workup
What is the leading cause of adult blindness in industrialized countries?
Age-related macular degeneration
What is age-related macular degeneration?
a degenerative dz of the macula (central retina) that results primarily in loss of central vision
What are risk factors for age-related macular degeneration?
- Age (over 50 increased incidence)
- female
- smoking hx
Symptoms of a pt with age-related macular degeneration?
What would you see on PE?
- gradual or acute painless vision loss
- metamorphopsia (wavy/distorted vision)
- central scotoma
PE:
+/- decreased vision
Amsler grid distortion
Characteristics of dry AMD
- retinal drusen (lipids) appear as discrete yellow deposits
- retinal pigment epithelium atrophies decreasing central vision
- Dry AMD has better prognosis than wet
Characteristics of wet AMD
- growth of abnormal vessel into the sub retinal space
- new vessels leak
Is wet or dry AMD more likely to cause blindness?
Wet AMD accounts for 80-90% of causes of blindness due to AMD
Tx of AMD
- ophthalmology referral
- vitamins (antioxidants/zinc)
- smoking cessation
- daily Amsler grid
- photocoagulation, photodynamic therapy, intravitreal steroid/anti-angigenic injections
- low vision aids
Most common cause of retinal detachment?
a tear in the retina- vitreous fluid can then work its way under the retina, causing detachment
Most common site of retinal detachment?
superior temporal retinal area
Risk factors of retinal detachment
- age > 50 yo
- extreme myopia
- previous ocular surgery
- fam hx
- diabetes
What might a pt with retinal detachment complain of?
- acute onset of monocular, decrease vision and may describe a “curtain coming down” over their eye
- cloudy or smoky vision, “floaters”, “flashes of light”
- no pain or redness
What would you expect to see on PE of a pt with a retinal detachment?
- afferent pupillary defect
- fundoscopic exam may reveal a billowing or tent-like elevation of the rugose retina
- the elevated retinal often appears out-of-focus and gray
- may also notice virtuous hemorrhage
Tx of retinal detachment
- immediate referral to ophthalmology
- during transport pt should remain supine and with head turned to ipsilateral side to help the retina fall back into place w/ the aid of gravity
- closing tears using cryosurgery or laser surgery
Meaning of Amaurosis Fugax? What is it usually caused by?
fleeting blindness
caused by retinal emboli from ipsilateral carotid disease
how is the visual loss in Amaurosis Fugax usually described?
a curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes, and a similar curtain effect as the episode passes
What diagnostic testing can you do in a pt with Amaurosis Fugax?
noninvasive evaluation of the carotids can be done using ultrasound and MRA
emboli fro cardiac sources may also be responsible, so EKG and echo may be indicated
Describe what happen in central retinal artery occlusion
occlusion of retinal arteries by emboli results in decrease blood flow and hypoxia to retina
Pt symptoms central retinal artery occlusion
sudden painless, total monocular vision loss
no pain or redness
PE findings in central retinal artery occlusion
including 1 very important one
Pale retina w/ “cherry red spot”!
often no light perception
afferent pupillary defect
Treatment and preventing further emboli in central retinal artery occlusion
emergent referral to ophthalmology
tx not effective unless started within a few hrs of onset
prevention= evaluate:
- carotid plaques
- cardiac emboli
- r/o temoral arteritis is pt > 55
Symptoms of central retinal VEIN occlusion
often noticed 1st thing upon waking
- acute painless unilateral vision loss
- no pain or redness
Sings of central retinal VEIN occlusion
including 1 distinct one!
“Blood and Thunder” fundus!
variable vision
+/- APD
multiple hemorrhages
venous dilation and tortuosity
Tx of central retinal VEIN occlusion
Urgent referral to ophthalmology
aspirin
obs
Which has a worse prognosis, central retinal vein occlusion or central retinal artery occlusion?
Artery!
1 cause of blindness in the Western world in pts < 50 yo
Diabetic retinopathy
How common is retinopathy in diabetic pts?
present in about 40%
Acute increases in serum glucose can cause what?
blurred vision due to acute increases in serum glucose, causing lens swelling and a refractive shift
Characteristics of non-proliferative diabetic retinopathy
microaneurysms (earliest sign)
dot-blot hemorrhages
cotton-wool spots
Characteristics of proliferative diabetic retinopathy
All features of non-proliferative diabetic retinopathy +:
neovascularization
vitreous hemorrhage
traction RD
Diabetic retinopathy: macular edema
when can it occur? Fundoscopic findings?
can occur at any stage
retinal thickening
microaneurysms
hard exudates
What is the earliest sign of non-proliferative diabetic retinopathy?
microaneurysms
Tx of diabetic retinopathy
blood sugar control
-glucose < 120
HbA1C < 7
reduce comorbidity
Ophthalmology referral
What is hypertensive retinopathy? Sx?
retinal vascular changes due to systemic HTN
Asymptomatic!
Explain the Keith-Wegener-Baker Classification
Group 1:
- Arteriolar narrowing (copper wiring)
- arteriolar sclerosis (silver wiring)
Group 2: (group 1, plus)
-A:V crossing changes (A:V nicking)
Group 3: (group 2, plus)
- cotton-wool spots
- retinal hemorrhages
- retinal edema/exudates (macular star)
Group 4: (group 3, plus)
-disk edema (papilledema)
Tx of hypertensive retinopathy
Systemic BP control Ophthalmology referral (if severe HTN, associated vision loss)
