P-PosteriorSegment Flashcards

1
Q

ddx for bull’s eye maculopathy

A

*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

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2
Q

55f h/o RA p/w decreased vision, nyctalopia and poor color discrimination

  • description
  • eval
  • mgmt
A

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.

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3
Q

68F p/w poor vision and visual distortions

description

ddx and eval

A

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

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4
Q

Mgmt of nAMD

A

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

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5
Q

68F p/w decreased vision

-Description
-DDx
-Eval

W additional info:
- dx
- plan

A
  • 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)
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6
Q

20yo p/w painless and gradual loss of vision over years

description

ddx

A

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

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7
Q

Dark choroid on FA
Management of Stargardt

A

-no treatment -> vision services
-avoid vitamins, quit smoking, UV protection
-genetic counseling

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8
Q

15yo, sequential involvement of both eyes

-likely dx
-eval
-ddx
-prognosis

A

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

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9
Q

16M p/w blurry vision

ddx and what to look for
mgmt

A

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)

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10
Q

Stage sickle cell disease

A

1: peripheral arteriolar occlusion
2. peripheral AV anastomoses
3. NV
4. VH
5. RD

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11
Q

55M p/w painless decrease in VA to 20/400 and RAPD

description

ddx and what to look for

A

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

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12
Q

Management of CRVO

A
  • 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
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13
Q

65M p/w painless loss of vision

  • description
  • ddx and what to look for
  • mgmt
A
  • 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
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14
Q

65M p/w painless decreased vision

description
ddx and eval and mgmt

A
  • 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
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15
Q

45yo p/w painless decreased vision and elevated IOP

description

ddx

A
  • 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
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16
Q

mgmt of active toxoplasmosis

A

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

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17
Q

unconscious patient

-description

  • ddx and eval
A

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

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18
Q

management of Purtscher’s
counsel

A

-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

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19
Q

45yo p/w painless decreased vision and floaters

description

eval
ddx

A

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

20
Q

mgmt of CMV retinitis

A

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

21
Q

50yo p/w worsening vision

description

ddx and eval

A

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

22
Q

Management of choroidal melanoma

A

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)

23
Q

p/w painless flashes

description

ddx

eval

management

A

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

24
Q

52F PMH breast ca.

description

ddx

A

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

25
Q

management of tamoxifen crystalline retinopathy

A

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

26
Q

65M w worsening vision 6mo after CEIOL.

-description
-ddx and eval

A

-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

27
Q

Mgmt of RP CME

A

very responsive to CAI: topical CAI + NSAIDs -> PO CAI -> IV triamcinolone

28
Q

Mgmt of Irvine-Gass

A
  • 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

29
Q

ddx for microaneurysm + dot/blot heme + hard exudates

tests and what to look for

A

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

30
Q

mgmt of DR according to ETDRS/DRS
1. what is CSME
2. when to PRP
3. indications for vitrectomy

A

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.

31
Q

mgmt of post-op endophthalmitis

A

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

32
Q

description

ddx and eval

A

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

33
Q

mgmt of fungal endophthalmitis

A
  • 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

34
Q

middle aged man, VA 20/30
-description
-ddx
-eval

A

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

35
Q

middle aged man, VA 20/30
-dx
-mgmt

A

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

36
Q

28F w painful vision loss over 3 days
- description
- ddx
- eval

A

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

37
Q

mgmt of ARN

A

-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)

38
Q

fundus photo orientation

A
39
Q

BRVO vs. CRVO
1. DM association
2. features
3. definition of ischemic type

A
  1. DM a/w CRVO only
  2. both can have CME and NV but only CRVO a/w 100d glaucoma
  3. 5dd vs. 10dd of nonperfusion on FA
40
Q

dx?

A

Terson’s

intracranial hemorrhage -> elevated intracranial pressure -> blocked venous return from eye -> VH

acute neck stiffness

41
Q

OCT layers

A
42
Q

AIDS patient p/w painless vision loss

dx, features and treatment

A

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

43
Q

ddx for peripheral neovascularization

A

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

44
Q

h/o cancer s/p treatment 6mo-3yrs ago
dx (and what is it?)
threshold dose
exam
mgmt

A

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

45
Q

h/o pre-eclampsia
dx?
sxs?
exam?
mgmt?

A

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

46
Q

ddx for nyctalopia

A

vit A / zinc def
RP / CSNB / choroideremia / gyrate atrophy / stargardt / Goldman Favre (AR, nummular pigments, optically empty, macular retinoschiss)
plaquenil tox