posterior segment

Question 1

What is the differential diagnosis for microaneurysms and dot/blot hemorrhages?

Answer 1

Diabetic retinopathy
Retinal vein occlusion
Hypertensive retinopathy
Radiation retinopathy

Question 2

What is definition of high risk PDR?

Answer 2

1. NVD >1/3 of the disc area
2. Any NVD with preretinal or vitreous heme
3. NVE with >1/2 DA with preretinal/vit heme
4. Any NVI/NVA

Question 3

What is history/physical exam/eval for microaneurysms and dot blot hemes?

Answer 3

Ask about history of: DM, htn, radiation. Check blood pressure and glucose.
Full eye exam checking vision and IOP
Fundus exam looking for diabetic hemorrhages, vessel engorgement, macular edema, and neovascularization.
FA and OCT.

Question 4

What is ddx for fundus photo showing small white flecks in foveal avascular zone which appear to be crystalline

Answer 4

Crystalline retinopathy

Metabolic/endogenous:

• Cystinosis
• Hyperoxaluria
• Bietti crystalline dystrophy

Exogneous:
Drugs:
- Tamoxifen
- Nitrofurantoin
- halothane anesthetic
- Oxalate crystals from methoxyflurane
- Talc inhalation (methamphetamine abuse)

Ocular:

• Refractile/calcific drusen
• Hard exudates
• Macular telangiectasia

Question 5

Ddx for CME

Answer 5

post cataract extraction CME (Irvine-Gass)
DEPRIVENS
D =Diabetes
E = Epinephrine
P = Pars planitis/uveitis
R = RP (retinitis pigmentosa)
I = Irvine-Gass
V = Vein occlusion
E = E2 prostaglandins
N = Nicotinic acid
S = Surgery

Question 6

Ddx for young person with painless decreased vision with elevated eye pressure. Fundus photo shows temporal macular pigmented scar, retinitis, and overlying vitritis

Answer 6

Toxoplasmosis
Acute retinal necrosis (ARN)
Toxocariasis
Tuberculosis
Syphilis
Sarcoid

Question 7

What is work up for toxoplasmosis?

Answer 7

Ask about history of eating raw meats, exposure to cats, on any immunosuppressive therapy, history of organ transplant, poorly controlled DM?
AC tap sending PCR for HSV, VZV, CMV, toxoplasmosis, toxocara.
Serum blood test for toxo IgG and IgM, HIV test, quant gold/PPD, FTA-Abs/VDRL, CXR.

Question 8

What is treatment for toxoplasmosis?

Answer 8

*Triple therapy: pyrimethamine, sulfadiazine, folinic acid
(needs weekly CBC when on pyrimethamine)

*Bactrim DS twice daily

*Clindamycin

Question 9

Ddx for fundus photo with multiple large cotton wool spots and areas of retinal hemorrhage surrounding a normal disc.

Answer 9

Purtscher’s retinopathy
Purthscher-like retinopathy
Hypertensive retinopathy
CRVO
CRAO (much less likely)
HIV retinopathy
Collagen vascular disease (lupus, scleroderma, dermatomyositis)

Question 10

Ddx for 45 year old HIV patient with decreased vision floaters no pain. Fundus photo shows inferior arcade retinitis, hemorrage, retinal whitening

Answer 10

CMV retinitis
Acute retinal necrosis (ARN)
HIV retinitis
Toxoplasmosis
Pneumocystiscarinii

Question 11

What is treatment for CMV retinitis?

Answer 11

IV ganciclovir
Oral valganciclovir
HAART to improve CD4 count
For those who progress despite therapy or have macular threatening lesions, can use intravitreal antivirals

Question 12

Ddx for 50 year old noting worsening vision. Fundus photo shows large elevated pigmented lesion

Answer 12

Choroidal melanoma
Choroidal nevus
Metastasis
Melanocytoma
Choroidal detachment
Peripheral exudative hemorrhagic chorioretinopathy (PEHCR)

Question 13

For choroidal melanoma - what would you expect to see on ultrasound (A scan and B scan)

Answer 13

Ultrasound to assess lesion height and evaluate for extrascleral extension

A scan- low to medium internal reflectivity
B scan - acoustically hollow (reflective anterior border but darker internal appearance)

Question 14

What work up do you send when concerned for choroidal melanoma?

Answer 14

Assess for metastases (especially to Liver and Lungs): order LFTs and CBC, order CT chest abdomen pelvis.
Refer to oncologist for further evaluation and consultation for metastasis.

Question 15

What is treatment for choroidal melanoma based on the COMS?

Answer 15

1. observation for small choroidal melanomas
2. plaque brachytherapy rathern than enuc for medium sized choroidal melanomas with FNAB at time of plaque placement
3. enuc without preceding radiation for large melanomas

Question 16

What is ddx for this lesion? How would you describe it?

Answer 16

Reddish-orange vascular mass and presence of feeding dilated and tortuous retinal artery and draining engorged retinal vein with hard exudates

Retinal capillary hemangioima
Retinal cavernous hemangioma
Vasoproliferative tumor
Racemose hemangioma

Question 17

What systemic disease is associated with a retinal capillary hemangioma?

What are important questions to ask if concerned?

Answer 17

Von Hippel Lindau

Work up of potential systemic tumors (cerebellum and spinal cord hemangiomas, renal cell carcinoma, pheochromocytoma) and genetics consult due to autosomal dominant inheritance

Question 19

What is this lesion and a differential diagnosis to consider for this lesion?

Answer 19

Dermolipoma

DDx:

Isolated Dermolipoma (choristoma)

Dermolipoma associated with Goldenhar syndrome

Prolapsed orbital fat

Other: infectious or inflammatory dacryoadenitis, lymphoma