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Kanski > Retina > Flashcards

Retina Flashcards

1
Q

Ophthalmic complications of diabetes-rare

A

Rare:

  • papillopathy
  • pupillary light-near dissociation
  • Wolfram syndrome (progressive optic atrophy and multiple neurological and systemic abnormalities)
  • acute-onset cataract
  • rhino-orbital mucormycosis
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2
Q

DRP risk factors

A
  • duration of DM (#1🏆): 10 years %50, 30 years %90
  • poor control of DM: raised HbA1c~increased risk of PDR
  • nephropathy
  • pregnancy
  • HT (also CVD, previous stroke)
  • hyperlipidemia, smoking, cataract surgery, obesity, anemia
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3
Q

Classification of DRP

A
  • background DRP(BDR): microaneurysms (the earliest sign🏆), dot-blot haemorrhages, exudates
  • diabetic maculopathy: oedema and ischemia
  • preproliferative DRP(PPDR): cotton wool spots, venous changes, IRMA, deep retinal haemorrhages
  • PDR: NVD, NVE
  • advances diabetic eye disease: tractional RD, significant persistant vitreus haemorrhage, neovascular glaucoma
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4
Q

Ophthalmic complications of diabetes-common

A

Common:

  • retinopathy
  • iridopathy (minor transillumination defects)
  • unstable refraction
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5
Q

Ophthalmic complications of diabetes-uncommon

A

Uncommon:

  • recurrent styes
  • xanthelasmata
  • accelerated senil cataract
  • neovascular glaucoma
  • ocular motor nerve palsies
  • reduced corneal sensitivity
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5
Q

ETDRS Classification of DRP

 -NPDR
A

NO DR - 1⃣2⃣ months
Very mild NPDR: microaneurysms only - 1⃣2⃣ months
MILD NPDR: microaneurysms, retinal haemorrhages, exudates, cotton wool spots - 6⃣-1⃣2⃣ months
MODERATE NPDR: 1-3/4 retinal haemorrhages or mild IRMA, 1/4 venous beading, cotton wool spots commonly present - 6⃣ months
SEVERE NPDR: 4⃣/4 severe haemorrhages, >=2⃣/4 venous beading, >=1⃣/4 moderate IRMA - 4⃣ months
VERY SEVERE NPDR: 2 or more of the criteria for severe - 2⃣-3⃣ months

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6
Q

ETDRS Classification of DRP

 -PDR
A

MILD-MODERATE PDR: NVD or NVE - treatment
HIGH RISK PDR: NVD>1⃣/3⃣ disc area, NVD+vitreus haemorrhage, NVE>1⃣/2⃣ disc area+vitreous haemorrhage - treatment immediately
ADVANCED DIABETIC EYE DISEASE

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7
Q

Layers of retina

A
  1. Inner limiting membrane
  2. Nerve fiber layer➡️haemmorrhage, cotton wool
  3. Ganglion cell layer
  4. Inner plexiform layer
  5. Inner nuclear layer➡️m.a
    ➡️CMO
  6. Outer plexiform layer➡️exudates
  7. Outer nuclear layer
  8. External limiting membrane
  9. Layer of rods and cones
  10. RPE
    ➡️drusen
    Bruch
    Choroiocapillaris
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8
Q

Signs of DRP-Layers

A

Microaneurysms-inner nuclear layer (inner capillary plexus)
Flame haemorrhages-retinal nerve fibre layer (precapillary arterioles)
Dot-blot intraretinal haemorrhages-middle retinal layers (venous end of the capillaries)
Deep dark haemorrhages-middle retinal layers (represent haemorrhagic retinal infarcts)
Exudates-outer plexiform layer
DMO-btw the outer plexiform and inner nuclear layers
Cotton wool spots-retinal nerve fiber layer (result from ischaemic disruption of nerve axons)

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9
Q

ETDRS Clinically significant DMO

A
  • retinal thickening within 500 〽️m of the centre of the macula
  • exudates within 500 〽️m of the centre of the macula
  • retinal thickening 1 disc area(1500〽️m) or larger, any part of which is within 1 disc diameter to the centre of the maculay
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10
Q

Indications for PPV in advanced diabetic eye disease

A
  • severe persistant vitreous haemorrhage (#1🏆)
  • progressive tractional RD
  • combined tractional+rhegmatogenous RD
  • premacular retrohyaloid haemorrhage
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11
Q

RVO risk factors

A
  • age (#1🏆)
  • HT
  • hyperlipidemia
  • DM
  • glaucoma
  • oral contraceptive pill
  • smoking
  • uncommon: dehydration, myeloproliferative disorders, trombophilia, inflammatory disease associated with occlusive periphlebitis(Behçet, sarcoidosis, Wegener), orbital disaese, chronic renal failure
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12
Q

Systemic assessment after RVO

A
  • BP
  • ESR
  • FBC
  • random blood glucose
  • random total cholesterol and HDL
  • plasma protein electrophoresis
  • urea, electrolytes, creatinine
  • thyroid function testing (high prevelance of thyroid disease in RVO patients)
  • ECG

➡️in patients under 50, in bilateral RVO, in patients with previous thromboses/family history: chest x-ray, CRP, plasma homocysteine, trombophilia screen, autoantibodies, serum ACE, treponemal serology, carotid duplex imaging

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13
Q

The mostly affected quadrant in BRVO🏆

A

Superotemporal

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14
Q

Fundus in BRVO

A

Dilatation and tortuosity of the ‘affected venous segment’, flame-shaped and dot/blot haemorrhages, cotton wool spots, retinal oedema
⬇️
Resolve within 6⃣-1⃣2⃣ months
⬇️
Venous sheathing and sclerosis, variable persistent/recurrant haemorrhage, collateral vessels, chronic macular oedema, retinal neovascularization

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15
Q

Treatment in BRVO

A
  • observation if VA is 6/9 or better
  • IV injection without waiting if macular oedema is present
    • anti-VEGF: raise VA more than PC
    • dexamethasone: repeated after 4⃣-6⃣ months
  • urgent sector PRP if NVI is present
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16
Q

Review in BRVO

A

-3⃣ months➡FA(to exclude substantial macular ischemia prior to grid laser) and PC
❗️ablation of collaterals(good prognosis😊) should be avoided
-3⃣-6⃣ monthly intervals for up to 2⃣ years -to detect nv
-typically appear within 6-12 months

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17
Q

Impending(partial) CRVO

A
  • younger patients
  • minor/transient blurring-worse on waking⭐️
  • fundus: mild retinal venous dilatation and tortuosity, few dot/blot haemorrhages
  • treatment: correcting any predisposing systemic conditions, avoiding dehydration, lowering IOP to improve perfusion
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18
Q

Non-ischaemic CRVO (‘Venous stasis retinopathy’)

A
  • more common than ischaemic
  • ~1⃣/3⃣ will progress to ischaemic (within months)
  • VA is impaired to a variable degree
  • RAPD is absent/mild
  • patchy(perivenular) ischaemic retinal whitening
  • disc collaterals (‘optociliary shunts)😊➡️decreased risk of nv
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19
Q

Ischaemic CRVO

A
  • VA is CF or worse, visual prognosis is generally extremely poor
  • RAPD is present⭐️
  • NVI develops in ~%50⚠(in ~3⃣ months=’💯 day nv glaucoma’)
    • much more than in BRVO (%2-3)
    • ⚠️pupillary margin examination & routine gonioscopy should be performed, prior to pupillary dilatation
  • OD swelling and hyperemia is present
  • retinal nv occurs in ~%5
    • much less than with BRVO (%8)
  • disc collaterals😊➡decreased risk of nv
20
Q

Hemiretinal VO

A
  • less common
  • may be ischaemic/non-ischaemic
  • occlusion of the superior or inferior branch of CRV
  • hemispheric/hemicentral
  • sudden onset altitudinal visual field defect, VA reduction is variable
  • NVI (CRVO>hemispheric>BRVO)
21
Q

Treatment in CRVO

A
  • observation if VA is 6/9 or better
  • IV injection without waiting if macular oedema is present
    • anti-VEGF: monthly for 1⃣2⃣3⃣4⃣5⃣6⃣ months, then less intensive
    • dexamethasone: repeated after 4⃣-6⃣ months
    • triamcinolone
  • PC is typically NOT beneficial for visual outcome (except in some younger patients)
  • urgent sector PRP if NVI is present
23
Q

Review in CRVO

A
  • review in ischemic:
    • monthly intervals for 1⃣2⃣3⃣4⃣5⃣6⃣ months -to detect nv
    • monitor up to 2⃣ years
  • review in non-ischemic:
    • initial follow-up after 3⃣ months
    • subsequent review up to the clinical picture and any treatment
    • monitor up to 2⃣ years
24
Q

Branches of the ophtalmic artery

A
  • it is the first branch of the internal carotid artery (easy route!)
  • its branches:
    1. Central retinal artery (first branch)
    2. Ciliary arteries
25
Q

Systemic assessment after RAO/amaurosis fugax

A

⚠️urgent specialist vascular evaluation within 2⃣4⃣🕙 (the risk of stroke is relatively high in the first few days)
-smoking
-symptoms of GCA(%1-2): headache, jaw claudication, scalp tenderness, limb girdle pain, weight loss, polimyalgia rheumatica, age>55-60
⭐P(-)➡️usually indicates either GCA or ophthalmic artery occlusion
-pulse (AF!)
-BP
-cardiac and carotid auscultation
-ECG
-ESR and CRP
-FBC, glucose, lipids, urea, electrolytes
-carotid duplex scanning

26
Q

Review in RAO

A
  • BRAO: in 3⃣ months
  • CRAO: after 1⃣ month and min twice at monthly intervals
    • to detect nv (NVI develops in %20 and earlier than CRVO: in ~1⃣ month)
27
Q

Cilioretinal artery occlusion

A
  • present in %15-50
    1. Isolated: rare, in young patients with an associated systemic vasculitis
    2. Combined with CRVO: not uncommon, occlusion is transient, prognosis is better than isolated
    3. Combined with AION: typically in patients with GCA, very poor prognosis
28
Q

Ocular ischaemic syndrome

A
  • chronic ocular hypoperfusion secondary to >%90 ipsilateral atherosclerotic carotid stenosis
  • older patients, male, %80 unilateral
  • 5 year mortality: %40
  • gradual loss of vision over weeks/months, periocular pain, bright light amaurosis fugax
  • rubeosis iridis in >%90 ⚠️
  • in diabetic patients, rethinopathy may be more severe ipsilateral to carotid stenosis
29
Q

Coats disease 👘

A
  • idiopathic intraretinal telangiectasia
  • onset in early childhood, 75% male🚹
  • 95% one eye
  • somatic mutation in the NDP gene in some patients
  • differential diagnosis: retinoblastoma (leukocoria)
  • fusiform focal aneurysmal arteriolar dilatations (often initially in the inferior and temporal quadrants)
  • intra and subretinal exudation, exudative RD
  • complications: RI, glaucoma, uveitis, cataract, phthisis bulbi
  • treatment: FK
30
Q

Easles disease 🐦

A
  • idiopathic occlusive peripheral periphlebitis
  • young males🚹
  • typically bilateral, though often asymetrical
  • 3 overlapping stages:
    1. Inflammatory
    2. Occlusive
    3. Retinal neovascular
  • tubercular protein hypersensitivity(?)
  • floaters or sudden visual reduction due to VIH, systemic neurological features, mild anterior uveitis
  • sheathing, superficial retinal haemorrhages, cotton wool spots, branch RVO, microaneurysms, tortuosity, vascular shunts, nv, recurrent VIH
  • complications: tractional RD, ERM, nv glaucoma, cataract
  • FFA: vasculitis
  • differential diagnosis: other causes of vasculitis (sarcoidosis, tbc), peripheral retinal nv (haemoglobinopathies)
  • treatment: steroids, anti-tbc treatment(?), scatter FK
31
Q

Severe NPDR

A

4️⃣haemorrhages
2️⃣venous beading
1️⃣IRMA

32
Q

RI in vascular disease

A

CRVO:%50 (💯day glaucoma)
BRVO:%2-3
CRAO:%20 (4-5 weeks)
OIS:%90

33
Q

Retinal nv in vascular disease

A

BRVO:%8
CRVO:%5
CRAO:%2

34
Q

ROP screening

A

<30 weeks
<1500 g

Postnatal 4-7 weeks
Subsequent review at 1-3 week intervals(until retinal vascularization reaches zone3)

34
Q

ICG indications

A 
PCV
AMD
Chronic CSR
Posterior uveitis
Choroidal tm
Breaks in Bruch: lacquer cracks, angioid streaks
If FA is contraindicated
35
Q

PED - FFA and ICG

A

FFA hyper

ICG hypo

36
Q

AMD risk factors

A 
Age(#1🏆)
Race
Heredity
Smoking
HT
Dietary factors
Aspirin
Cataract surgery
Blue iris color
High sunlight exposure
Female gender
37
Q

RAP

A

Bilateral
Symmetrical
ICG: hot spot, hairpin loop=a perfusing retinal arteriole and draining venule

38
Q

PCV

A 
Bilateral 
Asymmetrical
BVN=Branching vascular network
Women
Asian/African
ICG: polyps
39
Q

ERM and cells

A

Idiopathic: glial cells
Secondary: pigment cells

40
Q

Lamellar MH

A

Intact photoreceptor layer

41
Q

Angioid streaks

A

TEPPSİ

Thalassaemias
Ehler Danlos
Pseudoxanthoma elasticum(#1🏆)
Paget
Sickle cell disease
42
Q

RP triad

A

1️⃣Bone-spicule retinal pigmentation
2️⃣Arteriolar attenuation
3️⃣Waxy disc pallor

43
Q

The most common macular dystrophy

A

Stargardt=fundus flavimaculatus

44
Q

Stargardt disease

A 
The most common macular dystrophy
Gradual impairment of central vision out of proportion to examination findings
Flecks
FA: dark choroid
FAF: hyper flecks, hypo macula
45
Q

Best vitelliform macular dystrophy

A

The second common macular dystrophy
AD
Previtelliform➡️vitelliform➡️pseudohypopyon➡️vitelliruptive➡️atrophic

46
Q

The most common inherited cause of RD in children

A

Stickler syndrome

47
Q

Stickler syndrome

A

The most common inherited cause of RD in children
AD
1️⃣high myopia
2️⃣vitreoretinal degeneration
3️⃣associated extremely high rate of RD, and cataract

48
Q

FEVR=familial exudative vitreoretinopathy

A

Failure of vascularization of the temporal retinal periphery

AD

Kanski (7 decks)

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