Posterior Chamber Disorders Flashcards
Retinal Detachment
Primary event is a retinal tear
Fluid vitreous passes though the tear and lodges behind the sensory retina
Combined traction and pull of gravity results in progressive detachment.
Retinal Detachment Predisposing factors
Age – 50-75 Myosis Cataract extraction Trauma Family history Advanced diabetes
Retinal Detachment Signs and Symptoms
Blurred vision in one eye, progressively worse
Floaters (photopsias)
Move about vision
Sometimes described as “ a large horsefly”
Flashing lights
Last less the a second
Cause by the tugging on the retinal surface by the separating vitreous
NO PAIN, NO REDNESS
Retinal Detachment Treatment
Cryotherapy (freezing)
Scleral buckle
Intravitral gas
Vitrectomy
Central Retinal Artery Occulsion (CRAO)
Emboli enter and occlude the retinal artery
Central Retinal Artery Occulsion (CRAO) Predisposing factors
Age – mean is 60-80, can happen earlier Carotid artery disease Atrial fibrillation Hypertension Diabetes Temporal Arteritis
Central Retinal Artery Occulsion (CRAO) Signs and Symptoms
Sudden profound monocular visual loss (seconds, minutes)
Can be preceded by amarousis fugax
Painless
visual acuity can detect hand movements but can’t count fingers
Central Retinal Artery Occulsion Fundascope exams reveals
Pallor of the optic disc
Ischemic retinal whitening
Cherry red spot on macula or fovea
Arteriole narrowing
“boxcar” segmentation of the retinal veins
Marked afferent pupillary defect = When a light is shone in the abnormal eye of a patient with an APD, the pupil of the affected eye paradoxically dilates rather than constricts.
Central Retinal Artery Occulsion (CRAO) Treatment
Very poor prognosis for vision (particularly if not resolved within 90 minutes)
REFER immediately
Ocular massage
Anterior chamber paracentesis
Revasularization techniques
Thrombolysis
Central Retinal Vein Occlusion Etiology
Systemic etiologies: Increasing age HTN Coagulation disorders Diabetes
Ocular etiologies: Raised intraocular pressure (> 25 mmHg) vein inflammation (vasculitis)
Central Retinal Vein Occlusion Signs and Symptoms
Visual impairment is commonly first noticed upon waking
Usually a sudden monocular loss of vision
PAINLESS
Diagnosis can be made with ophthalmoscopic exam
Refer ALL to ophthalmologist
Central Retinal Vein Occlusion Fundoscopic exam
(WHAT differs CRAO and CRVO) Minimal APD venous tortuosity / dilatation Retinal hemorrhages variable cotton-wool spots mild to moderate disc edema macular edema
Amaurosis Fugax
Monocular loss of vision lasting a few minutes with complete recovery
Usually caused by retinal emboli from ipsilateral carotid disease
Visual loss is usually described as “a curtain passing VERTICALLY across the field of vision leading to complete loss of vision and then a similar curtain effect as the vision returns”
MUST have evaluation of carotids by doppler ultrasound or CT/MRI angiography
ALL MUST also have EKG to ensure A. Fib is not cause of emboli
In ALL CASES, place them on low dose ASA
Amaurosis Fugax Labs
CBC
Fasting blood sugar
ESR and CRP (C reactive protein)
Lipid profile
Optic neuritis Etiology
Multiple sclerosis (MS) optic neuritis is often the initial manifestation of MS 30% risk at 5 years Check MRI - consider IV steroids Idiopathic Viral infections, TB, sarcoidosis
Optic neuritis Signs and Symptoms
Unilateral decreased vision over 1-3 days
Occasional pain with eye movement
Age 18-45 female
Optic neuritis Fundoscope exam
Optic nerve usually has a normal appearance acutely
Can have swollen disc, but less common
Relative afferent pupillary defect (RAPD)
Decreased color vision
May get worse with exercise or temperature increase (Uhtoff’s sign)
Optic neuritis treatment
Complete ophthalmic exam pupils!! color vision decreased light brightness sensitivity with penlight visual field test
Complete neurologic exam / MRI & possible IV steroids
Do NOT use oral steroids - MALPRACTICE!!!
Check BP
ESR / CRP/ TA bx if suspect Giant Cell Arteritis (if >55 y/o)
Papilledema Etiology
Intracranial tumors Hydrocephalus Pseudotumor (fat fertile females) Subdural hematoma (trauma) Brain abscess / Meningitis
Papilledema signs and symptoms
Slow vision loss from increased ICP / optic nerve swelling
Can have acute attacks of vision loss when lying flat
Giant cell arteritis (GCA)-Temporal Arteritis signs and symptoms
Patients >55 years old Sudden, non-progressive visual loss Headache, eye pain Scalp tenderness Jaw claudication Fever Weight loss Polymyalgia rheumatica association (Muscle and joint aches)
Giant cell arteritis (GCA)Temporal Arteritis Labs
ESR (sed rate)
CRP (C-reactive protein)
ESR>47 and CRP>2.45 is 97% specific
Go by SYMPTOMS; ESR & CRP can be NORMAL in 20% of patients
Giant cell arteritis (GCA)Temporal Arteritis Exe fundoscopic exam
+ RAPD
Pale, swollen optic disc
Giant cell arteritis (GCA)Temporal Arteritis Treatment
Treat with steroids even before biopsy is done
DON’T WAIT FOR BIOPSY IF SUSPICIOUS
Treatment is to preserve visual loss in other eye
risk to the fellow eye of significant visual loss without TX
a. 30% in 24 hours
b. 30% in 1 week
c. 30% in 1 month
if no / mild visual symptoms:
60-90mg Prednisone po qd
if severe symptoms or visual loss:
1gm Solumedrol IV q 6 hrs x 3-5 days, then SLOW taper off oral steroids over 2 weeks
