Posterior eye/retinal pathology

Question 1

What is the vitreous body?

Answer 1

Gel inside eye ball that maintains structure of the eyeball and keeps retina pressed onto choroid.

Made of collagen and water and in age becomes less able to maintain its shape.

Question 2

What is posterior vitreal detatchment?

Answer 2

Where the vitreous body comes away from the retina, common in older patients.

Question 3

Clinical presentation of posterior virtual detachment?

Answer 3

Completely painless and asymptomatic.

Can present with spots of vision loss/floaters and flashing lights.

Question 4

Management of posterior vitreous detachment?

Answer 4

No treatment required vision will improve as brain adjusts.

Question 5

What conditions are patients with posterior vitreous detachment predisposed to?

Answer 5

Retinal tears

Retinal detachment

Both present in a similar way

Question 6

What is retinal detachment?

Answer 6

The retina of the eye separates from the underlying choroid. This is usually due to an underlying retinal tear.

Question 7

Why is retinal detachment sight threatening?

Answer 7

The retina relies on the blood vessels from the choroid for its blood supply and detachment can therefore lead to retinal ischaemia.

Question 8

Risk factors for retinal detachment?

Answer 8

posterior virtual detachment

Diabetic retinopathy

Trauma to the eye

Retinal malignancy

Older age

Family history

Question 9

Clinical presentation of retinal deatchment?

Answer 9

Acute onset peripheral vision loss

Blurred or distorted vision

Flashes/floaters in vision

Question 10

Management of retinal detachment?

Answer 10

Slit lamp examination

Immediate referral to ophthalmology

Surgical intervention to create adhesions - e.g. Laser therapy or cryotherapy.

OR

Vitrectomy (vitreous body removed and replaced with oil or gas), scleral buckling or pneumatic retinopexy

Question 11

Clinical presentation of retinal vein occlusion?

Answer 11

Blood clot or thrombus forms in the retinal veins at the back of the eye and blocks the drainage of blood away from the retina.

Question 12

Course of the retinal vein and overall role?

Answer 12

Runs through the optic nerve and is responsible for draining blood from the retina.

Question 13

Clinical presentation of central retinal vein occlusion?

Answer 13

Sudden loss of vision.

VEGF release leading to neovascularisation

Question 14

Appearance of central retinal vein occlusion on fundoscopy?

Answer 14

Flame and blot haemorrhages
Optic disc oedema
Macula oedema
Neovascularisation

Question 15

Risk factors for central retinal vein occlusion?

Answer 15

Hypertension 
Diabetes
Smoking
Glaucoma 
Sytemic inflammatory conditions 
SLE

Question 16

Investigations for central retinal vein occlusion?

Answer 16

Fundoscopy and slit lamp examination

Full medical history 
Full blood count 
ESR (inflammatory disorders)
BP for HTN 
Serum glucose/Hba1c - diabetes?

Question 17

Management of central retinal vein occlusion?

Answer 17

Immediate referral

Laser photocoagulation
Intravitreal steroids (e.g. dexamethasone intravitreal implant)
anti-VEGF therapies e.g. Ranibizumab

Question 18

Clinical presentation of central retinal artery occlusion?

Answer 18

RAPD

Pale retina with CHERRY RED SPOT.

Question 19

Course of central retinal artery to the orbit?

Answer 19

Internal carotid artery branches into the ophthalmic artery which branches off to form the central retinal artery.

Question 20

Most common cause of central retinal artery occlusion?

Answer 20

Atherosclerosis

Question 21

What are the causes of central retinal artery occlusion?

Answer 21

Atherosclerosis

Temporal arteritis - vasculitis affecting the ophthalmic or central retinal artery reduces the blood flow.

Question 22

Risk factors for retinal artery occlusion?

Answer 22

Older age 
Family history 
Smoking
Hypertension 
Alcohol 
Diabetes
Poor diet
Inactivity
Obesity

Question 23

Typical patient of central retinal artery occlusion?

Answer 23

White female over the age of 50.

Already affected by RA/polymyalgia rheumatica/giant cell arteritis

Question 24

How are patients managed with central retinal artery occlusion?

Answer 24

Immediate referral

ESR blood test and temporal artery biopsy

If GCA - manage with high dose steroids.

If patients present acutely after vision changes - ocular massage, anterior chamber fluid aspiration and inhaling carbogen and sublingual isosorbide dinatrate can be tried.

Question 25

Long term management of central retinal artery occlusion?

Answer 25

Treat underlying risk factors

Question 26

What is retinitis pigmentosa?

Answer 26

Congenital condition - degeneration of rods and cones of retina in the back of the eye

Question 27

What are the causes of retinitis pigmentosa?

Answer 27

Isolated or associated with conditions.

Rods degenerate more than the cones - often present with night blindness.

Decrease in central and peripheral vision.

Question 28

Clinical presentation of retinitis pigmentosa?

Answer 28

Most symptoms start in childhood.

Night blindness - due to degeneration in rods

Peripheral vision lost before central vision

Question 29

Fundoscopy findings in retinitis pigmentosa?

Answer 29

Pigmentation is most concentrated around mid peripheral area of retina.

Narrowing of arterioles

Pale optic disc.

Question 30

Associated disease with retinitis pigmentosa?

Answer 30

Ushers syndrome (hearing loss + retinitis pigmentosa)

Question 31

Management of retinitis pigmentosa?

Answer 31

Referral

Vision aids

Sunglasses to protect retina against accelerated damage

Driving limitations/informing DVLA

Oral acetazolamide, anti-VEGF treatments are some specialist options that can be considered.

Regular follow up