P-PosteriorSegment Flashcards
ddx for bull’s eye maculopathy
*PAC a punch to SBCCCthe target
-plaquenil
-AMD
-chronic macular hole
-Stargardt: advanced
-benign concentric annular macular dystrophy: AD, good VA
-cone-rod dystrophy
- hx: onset (infancy to late childhood), progression (can be stationary or progressive), FHx (AR or AD)
- sxs: decreased VA, decreased color, photophobia
- exam: ocular VS, color vision, VF
- ERG: non-recordable photopic response
-ceroid lipofusinosis = batten’s disease: neurodegenerative 2/2 accumulation of lipopoigments
- sxs: rapid vision loss, nyctalopia, loss of color vision -> ataxia, seizures, psych.
- exam: bulls eye maculopathy, optic atrophy
- testing: abnormal ERG
- No treatment.
-central alveolar choroidal dystrophy: looks like AMD and in similar age group but AD PRPH2, lesion more well defined and regular with rosettes (answer pic); bilateral, symmetric, 20/20-scotoma, decreased color vision. No treatment
55f h/o RA p/w decreased vision, nyctalopia and poor color discrimination
- description
- eval
- mgmt
Bull’s eye maculopathy:
chloroquine / hydroxychloroquine toxicity:
- hx: onset, progression, sxs (blurry, red deficit, missing central vision, flashes, metamorpsia), RFs (chloroquine (<2.3 mg/kg/day) or hydroxychloroquine (<5.0 mg/kg/day), >5yrs, liver / renal disease, pre-existing retinal disease, tamoxifen)
- exam: VA, K verticillata, Amsler grid, DFE (bull’s eye, disc pallor, peripheral pigmentation), eyelash whitening (a/w plaquenil)
-testing:
– OCT: parafoveal thinning of the outer retinal layers = UFO sign
– HVF 10-2 / 24-2 for asians: central defects
– fundus autofluorescence: ring of parafoveal hyperfluorescence (picture)
-mgmt:
–stop plaquenil and seek other forms of treatment
–counsel that once toxicity is evident, visual function may continue to progress despite stopping the medication. Rarely recovers.
68F p/w poor vision and visual distortions
description
ddx and eval
subretinal hemorrhage with greenish lesion deep to the retina
neovascular AMD
-hx: onset, progression, sxs (decreased VA, metamorpsia, central scotoma), RFs (age, female, caucasian, Fhx, smoking, HTN, hyperopia, light iris color)
- exam: drusens, CNV (green discoloration, SRF), RPE atrophy
- testing: IVFA (drusen staining and window defect), OCT (drusen, CNV, SRF)
trauma (choroidal rupture - picture)
polypoidal choroidal vasculopathy (PCV)
- a/w HTN
- testing: ICG (hairpin turns of RAP lesions or polyp patterns)
angiod streaks
-linear cracks in calcified bruch’s membrane
-mintor trauma -> SR heme
-50% a/w systemic, 50% idiopathis: PEPSI (pseudoxanthoma, Ehlers, Paget’s disease, Sickle, Idiopathic)
-ddx lacquer cracks (breaks in Bruch’s)
pathologic myopia
-axial length >32, >-8D
-hx: lacquer crack -> sudden decrease in VA, metamorphopsia, often in teenagers
-exam: long oval disc, temporal crescent, posterior staphyloma, tigroid fundus, lacquer cracks, RT/RD
multifocal choroiditis
-hx: onset (20-50yo, F>M)
-exam: multiple white lesions at level of choroid -> atrophic, uveitis
-FA: acute lesions block, older lesions = window defects
-FAF: hypo
-OCT: discontinuous outer segment
-mgmt: steroids
-complications: CNV
POHS
idiopathic
Mgmt of nAMD
monthly anti-VEGF, follow macular thickness via OCT
ANCHOR (anti-VEGF vs. PDT) + MARINA (anti-VEGF vs. sham) show that anti-VEGF x24mo is effective at improving vision. PDT / local laser photocoagulation are rarely used and only for extrafoveal CNVM
Counsel:
- progressive nature of AMD
- options for treatment
- stop smoking
- AREDS for intermediate dry AMD in fellow eye
- amsler grid monitoring
68F p/w decreased vision
-Description
-DDx
-Eval
W additional info:
- dx
- plan
- fundus photo w central red spot containing yellow precipitates, surrounding gray cuff of subretinal fluid
- macular hole
- macular pucker
- CME intraretinal cyst - hx:
–onset, progression
–sxs (vision, distortions, flashes)
–RFs (trauma, surgery, sun-gazing, h/o CME, ERM) - Exam:
–ocular VS
–macula exam: Watzke-Allen (broken slit beam = hole, distorted = pucker)
–RT/RD - Test: OCT, FA (autofluorescence; if concurrent tractional ERM, then maybe leaking)
- FTMH with no subretinal fluid or tractional ERM
- Stage macular hole:
1: impending hole: observe (50% resolves spontaneously)
2: <400um, no PVD
3: >400um, no PVD or operculum
4: hole with cuff and complete PVD**
2-4:
–vitrectomy +/- ILM peel (face down positioning required for >400um but not under)
–ocriplasmin 40-60% successful but concerns about pan-retinal ERG abnormalities thus less often used now - prognosis good if operated <6mo and <400um; poor if >1yo and large
- counsel regarding low risk of RD and surgical risk (may enlarge hole)
20yo p/w painless and gradual loss of vision over years
description
ddx
RPE pigmentary changes, macular yellow pisciform lesion
Stargardt - common hereditary macular dystrophy
- hx: onset (<20yo), progression (to middle age, lesions come and go, final VA 20/200), FHx (mostly AR)
- sxs: decreased VA, nyctalopia, color vision impairment
- exam: b/l pisciform flecks @ level of RPE, beaten-metal appearance of fundus, bull’s eye maculopathy, foveal atrophy
- testing: FA silent choroid, flecks are hyperfluorescent on FAF (both due to accumulation of lipofusion in RPE)
- genetic testing: ABCA4 (AR)
Batten Disease (neuronal ceroid lipofuscinosis)
cone / cone-rod dystrophy
Rod dystrophy = Fundus albipunctatus (picture), part of CSNB (which has entities w normal fundus and those w abnormal fundus)
- hx: onset (congenital), progression (stationary), sxs (nyctalopia; normal VA, color vision and field), RFs (FHx AR)
- exam: midperipheral deep yellow spots spare macula (similar appearance to Alport syndrome: AD, kidney failure, deafness, anterior lenticonus and anterior polar cataract)
- ERG: abnormal scotopic normalizes after dark adaptation, almost normal photopic
Retinitis punctate albescens
- night blindness, abnormal vision and field
-depressed ERG does not recover after dark adaptation
Dark choroid on FA
Management of Stargardt
-no treatment -> vision services
-avoid vitamins, quit smoking, UV protection
-genetic counseling
15yo, sequential involvement of both eyes
-likely dx
-eval
-ddx
-prognosis
Best disease = vitelliform dystrophy - 2nd most common inherited macular dystrophy
hx: onset (1st decade), progression (progressive, from none to 20/100, no correlation to lesion appearance), sxs (hyperopia, decreased VA -> strab), RFs (AD)
exam: small round macular dot -> egg yolk -> scrambled egg (picture) -> atrophic scar -> CNV in 20%
testing:
-FA: blockage by egg yolk lesions -> window defect
-FAF: hyper in early -> hypo in atrophic
-OCT: look for CNV
-normal ERG (retinal response to light) *surprisingly good VA; abnormal EOG (arden <1.5) *egg is abnormal [abnormal ERG + normal EOG = stargardt]
DDx
-CACD
-adult-onset foveomacular vitelliform dystrophy
-CSCR
-AMD
-toxoplamosis
-macular hole
good prognosis unless CNV
16M p/w blurry vision
ddx and what to look for
mgmt
Seafan neovascularization
Sickle Cell
- medical hx
- exam: black sunburst (RPE hypertrophy), salmon patch (intraretinal heme), iridescent spots (intraretinal spots after resorption of salmon patch), angioid streaks (breaks in thickened bruch’s), conj comma-shaped capillaries in inferior fornix
- testing: sickledex (qualitative screening, needs followup w electrophoresis), hemoglobin electrophoresis
-mgmt:
– IOP control for any secondary glaucoma
– PRP to ischemic area anterior to sea fan -> surgery for NCVH
– hyperbaric o2 if symptom onset within 24 hrs
– f/u 6-12mo if no retinopathy, 3-4mo if yes retinopathy
– prognosis is variable
Sarcoid
- exam: uveitis, iris nodules
- testing: ACE, lysozyme, CT chest
- mgmt: steroid -> immunosuppressive agents
Eales (idiopathic peripheral obliterative vasculopathy)
- a/w TB
- lethal complication of cerebral vasculitis (same as APMPPE)
- steroids for active inflammation; PRP to non-perfused areas
Embolic retinopathy (e.g. talc from IVDU)
Stage sickle cell disease
1: peripheral arteriolar occlusion
2. peripheral AV anastomoses
3. NV
4. VH
5. RD
55M p/w painless decrease in VA to 20/400 and RAPD
description
ddx and what to look for
4 quadrant flame shaped hemorrhages + swollen optic disc
CRVO
- hx: onset, progression, sxs (painless loss of vision, TVOs), RFs (cardiovascular disease, hypercoagulable [OCP, hyperhomocysteinemia, cancer, pancreatitis], glaucoma / thyroid)
- exam: ocular VS (+RAPD), hertel, gonioscopy, macular edema, NVD/NVI/NVA/NVE, disc edema, BP
- testing: IVFA or ERG (to assess if ischemic or non-ischemic, non-ischemic typically has better vision and no RAPD; ERG normal in non-ischemic, reduced photopic b-wave in ischemic), OCT (to assess macular edema), A1c, CBC, lipid
- If age<50yo, assess rare causes (hypercoagulable PT/PTT, protein S/C, factor V, homocysteine; collagen vascular diseases RF, ANA, anti-dsDNA; syphillis)
DR
radiation retinopathy
HTN retinopathy
Management of CRVO
- for NV: PRP (this only occurs in ischemic disease)
- for macular edema: anti-VEGF or steroids
- for systemic disease: CV and hypercoagulation workup and referral if needed
- for followup: q monthly x 6mo
- for counselling: 100day glaucoma, 10% chance of contralateral eye developing CRVO/BRVO
- guarded prognosis
65M p/w painless loss of vision
- description
- ddx and what to look for
- mgmt
- retinal whitening with cherry red spot
- CRAO
–hx: onset, progression, sxs (painless loss of vision, TVOs), RFs (cardiovascular disease, GCA [temple pain, jaw claudication], sickle cell, hypercoagulable [OCP, cancer, pancreatitis, hyperhomocysteinemia, collagen vascular diseases like lupus] , IVDU/fillers/steroids)
–exam: look for emboli (hollenhorst cholesterol refractile, calcium white, platelet-fibrin dull white long), BP
–test: IVFA, ESR/CRP, A1c (consider EKG, echo, holter, carotid ultrasound), PT/PTT, electrophoresis
-Mgmt
–if <90min, try ocular massage, lower IOP, hyperventilate -> ED for stroke workup
–if GCA : stat steroids
–medicine for underlying disease, ASA 81
–Monitor monthly x3mo for OIS and NV (5% develop) -> PRP or anti-VEGF if found - Tay-Sachs
–intellectual disability, seizures
–internal medicine for metabolic disease
-Nieman-Pick’s
–ataxia, muscle disturbances
–internal medicine for metabolic disease
- Commotio Retinae
–trauma
65M p/w painless decreased vision
description
ddx and eval and mgmt
- retinal hemorrhages and cotton wool spots in inferior arcade distal to an AV crossing
- BRVO
–hx: onset, progression, sxs (painless decreased VA), RFs (cardiovascular disease, hypercoagulable [OCP, hyperhomocysteinemia, cancer, pancreatitis], glaucoma / thyroid)
–exam: ocular VS, hertel, gonioscopy, macular edema, NVD/NVI/NVA/NVE, BP
–testing: IVFA (to assess if ischemic or non-ischemic), OCT (to assess macular edema), A1c, PT/PTT, lipid, homocysteine
–mgmt:
-if macular edema: anti-VEGF or steroid if VA < 20/30
-Monitor monthly x6mo for NV -> PRP or anti-VEGF if found
-refer to medicine for underlying disease
-Counsel 10% risk of contralateral involvement - HTN retinopathy (picture)
–sxs: eye pain, headache, reduced vision
–exam: arteriole attenuation / copper wiring w AV nicking, retinal heme, hard exudates, CWS, macular edema, disc edema
–mgmt: reduce BP - radiation retinopathy
–sxs: slowly progressive microangiopathy 6mo-3yrs after radiation, threshold dose 300rads / 45Gy
–exam: microaneurysms, telangiectasia, nonperfusion, hard exudates, cotton wool spots, macular edema, disc edema-> neovascularization, vitreous hemorrhage
–mgmt: PRP for NV / focal laser for macular edema / anti-VEGF for CME; follow monthly -> extend
–prognosis: worse for thicker tumors close to the fovea, >50% of brachy patients have low vision (20/200 or worse) - goal is to preserve globe, not conserve vision - DR
45yo p/w painless decreased vision and elevated IOP
description
ddx
- temporal macular scar + IT retinitis + vitritis
- toxoplasmosis
–hx:
-sxs: painless decreased VA. Acquired [flu-like, rash, meningoencephalitis]. Congenital [MR, seizures, intracranial calcifications, microcephaly, hydrocephaly, hepatosplenomegaly, v/d]
-RFs (raw meat, cats, immunocompromise)
–exam: other chorioretinal scars, AC cell / vitritis, elevated IOP in active toxo
–testing: toxoplasma IgM (2-6 wks after initial infection) and IgG
- toxocariasis (answer pic)
–leukocoria, in 3 presentations depending on age [kids endophthalmitis, teenagers localized granuloma, adults peripheral granuloma],** vitritis, dragging of macula -> XT, TRD**
–testing: ELISA for toxocara ab; AC tap for eosinophils
–mgmt: steroid for uveitis; vitrectomy; RD repair
- ARN 2/2 viral retinitis
- TB / syphillis
mgmt of active toxoplasmosis
for IOP: gtts except prostaglandin
if inflammation is mild in immunocompetent patient and lesion is non-vision threatening: no tx
If immunocompromised (babies, pregnant, HIV) + lesions near macular or optic disc, treat w one of the following for 6+ wks:
-pyrimethamine + sulfadiazine + folinic acid + weekly CBC while on pyrimethamine -> PF 48hrs after
-bactrim DS BID (cheaper and easier)
-atovaquone (also acts against tachyzoites and dormant bradyzoites but is expensive)
-if allergic to S: clinda or azithro
workup for TB/syphilis/HIV if planning systemic steroids
prognosis:
- good in immunocompetent patients
- poor in immunocompromised
unconscious patient
-description
- ddx and eval
Large CWS + retinal heme, normal disc (though Purtcher’s can have optic disc edema),
Purtscher’s (occlusive microvasculopathy)
-hx: indirect (non-ocular) trauma, esp head trauma, long bone fracture for compressive injury to trunk
-exam: retinal whitening, heme, CWS, papillitis -> may have RAPD
-IVFA: blocked choroidal fluorescence (either due to retinal whitening or blood), leakage
Purtscher-like
-hx: pancreatitis, cancer, renal failure, collagen vascular disease (lupus, dermatomyositis), retrobulbar anesthesia, embolism (fat, air, amniotic fluid), TTP, HELLP
-tests: amylase/lipase, PT/PTT
HTN retinopathy
CRVO
management of Purtscher’s
counsel
-no ocular treatment, manage underlying cause
-f/u 2-4 wks when retinal lesions typically resolve but may take up to 3mo to resolve
-50% return to baseline VA
45yo p/w painless decreased vision and floaters
description
eval
ddx
superior arcade retinitis + retinal heme in a brushfire pattern
hx: onset, progression (progressive hemorrhagic necrotizing retinitis involving all layers), sxs (often asymptomatic), RFs (HIV - very high risk of CMV if CD4 <50)
exam:
-3 variants: 1. pizza pie posterior pole necrosis + heme, 2. brushfire = peripheral granular atrophy (picture) 3. frosted branch angiitis
- retinal hole / detachment
test:
-AC fluid or diagnostic vitrectomy for PCR (CMV, HSV, VZV, toxo)
-RPR/FTA, pneumocystis carinii; consider neuroimaging for intracranial involvement
CMV retinitis
ARN
pneumocystis: multifocal choroiditis
toxoplasmosis
TB
syphillis
mgmt of CMV retinitis
tx CMV: IV cidofovir (fx anterior uveitis can be treated w steroids to allow continuing use + renal damage) or PO ganciclovir (fx myelosuppression). If progressive despite systemic treatment or macula threatening: intravitreal injection (cidofovir, foscarnet - fx anemia, renal, seizures)
tx retinal hole / detachment: laser barricade (controversial), if large requiring vitrectomy, use SO
decrease risk: medicine management of HIV w HAART
f/u:
- active lesions daily -> weekly; look at size and activity @ border of lesions
- q3mo if CD4<100
counselling:
- risk of RD and worsening vision
- guarded prognosis
- 20% will experience involvement in fellow eye despite treatment
50yo p/w worsening vision
description
ddx and eval
elevated pigmented lesion in ST macula
choroidal melanoma
- hx: onset (first note of lesion), progression, sxs(decreased VA and VF, flashes), RFs (sunlight, smoking, caucasian race, ocular melanocytosis, uveal nevi)
- exam:
–assess melanoma vs nevus via To (thickness >2mm) Find (SRF) Small (sxs) Ocular (orange pigmentation - accumulation of lipofuscin in RPE) Melanoma (margin within 3mm of optic disc) Using Helpful (ultrasound hollow) New Hints (no halo); sentinel vessel; drusen is more likely to be benign
–secondary glaucoma
- testing: Ascan (low internal reflectivity, mushroom shape 2/2 invasion through bruch’s membrane - picture)
choroidal met
- hx: cancer
- exam: orange and multifocal
melanocytoma
- exam: darkly pigmented and near optic nerve
choroidal detachment
- hx: recent surgery or trauma
choroidal hamartoma
Management of choroidal melanoma
Workup for mets: uveal melanomas go to liver/lung, so LFT, CBC, chest and abd CT. Refer to onc.
collaborative ocular melanoma study:
-large (>16mm basal OR >10mm apical OR within 2mm to optic nerve and >8mm apical): enucleation (no pre-enuc radiation needed)
-medium (<=16mm basal and 2.5-10mm apical): brachytherapy (as good as enucleation; enucleated patients have 10% risk of mets anyway)
-small (<=16mm basal and 1-3mm apical): observation (mortality = 1% at 5yrs)
counsel:
- treatment options
- risk of mets: 10yr risk of met-related death is up to 50%
- FNA can aid prognostication but not necessary for dx or tx
- spindle A config better prognosis than spindle B (epithelioid)
p/w painless flashes
description
ddx
eval
management
horseshoe tear with minimal detachment
RRD from vitreoretinal traction
RRD from trauma
hx: onset, progression, sxs (VA, flashes, curtains), RFs (FHx, high myopia, trauma, lattice, ED/Marfan’s)
exam:
- scleral depression, ?lattice degeneration.
- If trauma: heme? commotio? open globe? IOFB? uveitis?
laser retinopexy or cryotherapy (tear <2’, superior 8’)
Counselling:
- causes of RD
- return precautions, also for the fellow eye
- increased life time risk of retinal problems
52F PMH breast ca.
description
ddx
small white flecks that appear to be crystalline
crystalline retinopathy
-exogenous (m!Chtt, asx or decreased VA / color disturbance): tamoxifen (breast cancer, foveal location), canthaxanthine (tanning), halothane (anesthetic), methoxyflurane (anesthetic), talc (IVDU, may lead to peripheral nonperfusion and NV)
-endogenous: bietti (picture, K crystals, diffuse, triad similar to RP of vision loss, progressive nyctalopia and VF loss in third decade of life), hyperoxaluria, cystinosis (K and conj crystals in first year of life -> photophobia and blepharospasm)
- hard exudates
-hx: diabetes, HTN
-exam: subretinal fluid, microaneurysms, NV
-testing: OCT, IVFA, glucose testing
calcified drusens
- exam: drusens in fellow eye
management of tamoxifen crystalline retinopathy
if symptomatic: stop meds but confer w oncology
if asymptomatic: ok to continue tamoxifen
f/u 2-3mo
counselling:
- progressive worsening of vision while on tamoxifen but recovers when off; though the crystals stay
65M w worsening vision 6mo after CEIOL.
-description
-ddx and eval
-IVFA with petaloid hyperfluorescence in the macula
macular edema due to
- cataract surgery (Irvine-Gass): complicated surgery, vitreous loss and missed strands, lens pieces in angle
- diabetes
- uveitis: look for vitreous snow balls inferiorly in the pars plana on scleral depression, prostaglandin analogue usage
- vein occlusion
- tractional ERM
- RP: bony spicules + waxy pallor of disc + arteriolar attenuation (sx triad of decreased VA, progressive nyctalopia and Vf loss)
*IVFA leakage is more sensitive than OCT
Mgmt of RP CME
very responsive to CAI: topical CAI + NSAIDs -> PO CAI -> IV triamcinolone
Mgmt of Irvine-Gass
- topical NSAID + pred - > periocular or intraocular steroids but counsel regarding risk of glaucoma
- lysis of any vitreous stands if to wound causing retinal traction
Natural history is resolution with improvement in vision through topical meds
ddx for microaneurysm + dot/blot heme + hard exudates
tests and what to look for
diabetic retinopathy
hypertensive retinopathy
radiation retinopathy
retinal vein occlusion
OCT to look for and monitor macular edema
IVFA to look for 1. NV and leakage 2. capillary non-perfusion
mgmt of DR according to ETDRS/DRS
1. what is CSME
2. when to PRP
3. indications for vitrectomy
ETDRS: focal laser to leaking microaneurysm for CSME:
1. Macular Edema or hard exudates within 500um of fovea
2. 1DA of ME within 1DD of fovea
f/u 4 mo
If center-involving macular edema: anti-VEGF
DRS: PRP for PDR w high risk features, defined as
1. NVD > 1/3 DA
2. any NVD + VH
3. NVE > 1/2DA + VH
f/u 1-3 mo
Indications for vitrectomy
1. non-clearing VH / ghost cell glaucoma
2. TRD / can refractory ME
3. progressive fibrovascular proliferations despite complete PRP
Counsel regarding good blood pressure, blood sugar (want A1c <8 to significantly reduce risk of retinopathy), lipid control to decrease mortality. Ensure good medicine followup.
mgmt of post-op endophthalmitis
According to endophthalmitis vitrectomy study (EVS):
-HM or better: tap and inject (vanco + ceftazidime)
-LP or worse: vitrectomy
-send AC/vitreous fluid for culture to direct future therapy
-topical abx + steroids + cycloplegics
-follow daily
-guarded prognosis: 50% chance of returning to 20/40 or better vision over the next year
description
ddx and eval
fundus photograph with multiple elevated retinal opacities
-fungal endogenous (hematogenous spread) endophthalmitis
-Bacterial endophthalmitis
-neoplastic mets
-purtscher / purtscher-like retinopathy
-pneumocystis (image)
h/o: immunocompromise, IVDU, trauma, surgery
look for:
- e/o endophthalmitis: conj injection, lid edema, K ulcer/edema, AC cell/hypopyon, iris abscess, vitritis
- e/o purtscher: pancreatitis, amniotic embolus, retinal flame shaped heme, CWS, papillitis
- skin lesions (osler nodes or janeway lesions are part of infectious endocarditis)
-fundus photos
-OCT: diffuse thick choroid, subretinal exudate, normal neurosensory retina (whereas viral retinitis has disrupted neurosensory retina)
-medical workup: cultures of blood, urine, IV lines, catheters, cardiac echo
mgmt of fungal endophthalmitis
- tap and inject voriconazole
- send AC/vitreous fluid for culture to direct future therapy
- admit patient for IV anti-fungal and ID consult
- follow daily
-can worsen even with optimal medical control
-ideally identify route of infection to prevent future occurence
middle aged man, VA 20/30
-description
-ddx
-eval
blunted foveal reflex, decreased RPE pigment, ring of subretinal fluid
Central serous chorioretinopathy
Pigmented epithelial detachment
RD (rhegmatogenous, exudative, tractional) / retinoschisis
optic nerve pit
AMD
-hx: onset, progression, sxs (blurry vision, poor color vision, induced hyperopia, scotoma, metamorphopsia), RFs (middle aged man, steroids, stress, HTN, psych meds)
-exam: absent foveal reflex -> after resolution, yellow subretinal deposits and RPE changes
-testing:
–OCT: SRF + PED
–FA: leakage in expansile dot > smoke stack, guttering > diffuse pattern
middle aged man, VA 20/30
-dx
-mgmt
CSCR
-avoid corticosteroids / stress, control HTN
-observe as usually self resolves in 3-4 months
-if sharp vision needed for work or if does not resolve after 6mo: spironolactone, focal laser leakage if outside fovea, photodynamic therapy if very close to fovea
-f/u q2mo
-counsel: VA recovery can take up to 1 yr; a small subset can have permanent vision changes (metamorphopsia, scotoma, color vision abnormalities); 40-50% recur within 1 yr
28F w painful vision loss over 3 days
- description
- ddx
- eval
hazy view likely due to vitritis, retinal whitening, attenuated vasculature, hyperemic nerve
- acute retinal necrosis: HSV/VZV, rarely CMV
- endophthalmitis: bacteria/fungal so check CBC w diff
- posterior uveitis: RPR/FTA, PPD, CXR, lyme
- toxoplasmosis: toxo titer
- (not PORN cuz usually painless)
-hx: onset (acute), progression, sxs (pain, photophobia, floaters, decreased VA and VF), RFs (immunocompromise [HIV, cancer], HSV/VZV, surgery, trauma, catheters, drug use
- exam: pan-inflammation (episcleral injection, KP, iritis, vitritis), retinitis, arteritis, pale disc edema -> within 2mo, necrotic retina sloughs, coarse salt and pepper pigmentation
- testing: HIV, AC sampling / diagnostic vitrectomy for HSV, VZV, CMV
mgmt of ARN
-IV acyclovir x 1 wk -> PO acyclovir 800 5x/day for 3mo w possible extension
-intravitreal foscarnet and ganciclovir (to cover CMV)
-PO steroid to start 48hrs after IV acyclovir
-PRP to cordon off areas of necrosis to minimize RD (peak onset in 2-3 mo)
-guarded prognosis (up to 90% RD) and follow closely (watch fellow eye)
fundus photo orientation
BRVO vs. CRVO
1. DM association
2. features
3. definition of ischemic type
- DM a/w CRVO only
- both can have CME and NV but only CRVO a/w 100d glaucoma
- 5dd vs. 10dd of nonperfusion on FA
dx?
Terson’s
intracranial hemorrhage -> elevated intracranial pressure -> blocked venous return from eye -> VH
acute neck stiffness
OCT layers
AIDS patient p/w painless vision loss
dx, features and treatment
progressive outer retinal necrosis: variant of ARN in AIDS patients
-rapid progression
-painless
-minimal inflammation and vasculitis
-cracked mud appearance (picture) after resolution
mgmt: same as ARN but poorer response
counsel: 2/3 become NLP within 4 wks, 90% RD
ddx for peripheral neovascularization
vascular problems: Sickle Cell, DM, RVO, OIS, radiation
(rare) uveitis: sarcoid, lupus
occlusive: talc, hypercoagulable/hyperviscosity
pediatric: IP in girls / Coat’s in boys, ROP, FEVR, Norrie
h/o cancer s/p treatment 6mo-3yrs ago
dx (and what is it?)
threshold dose
exam
mgmt
radiation retinopathy (slowly progressive microangiopathy)
–threshold dose 300rads / 45 greys
–exam: microaneurysms, telangiectasia, nonperfusion, hard exudates, cotton wool spots, macular edema, disc edema-> neovascularization, vitreous hemorrhage
–mgmt: PRP for NV, focal laser for macular edema
h/o pre-eclampsia
dx?
sxs?
exam?
mgmt?
hypertensive retinopathy
–sxs: eye pain, headache, reduced vision
–exam: arteriole attenuation / copper wiring w AV nicking, retinal heme, hard exudates, CWS, macular edema, disc edema
–mgmt: reduce BP
ddx for nyctalopia
vit A / zinc def
RP / CSNB / choroideremia / gyrate atrophy / stargardt / Goldman Favre (AR, nummular pigments, optically empty, macular retinoschiss)
plaquenil tox
