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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
Systemic assessment after RAO/amaurosis fugax
⚠️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
Review in RAO
- 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
Cilioretinal artery occlusion
- 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
Ocular ischaemic syndrome
- 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
Coats disease 👘
- 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
Easles disease 🐦
- 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
Severe NPDR
4️⃣haemorrhages 2️⃣venous beading 1️⃣IRMA
32
RI in vascular disease
CRVO:%50 (💯day glaucoma) BRVO:%2-3 CRAO:%20 (4-5 weeks) OIS:%90
33
Retinal nv in vascular disease
BRVO:%8 CRVO:%5 CRAO:%2
34
ROP screening
<30 weeks <1500 g Postnatal 4-7 weeks Subsequent review at 1-3 week intervals(until retinal vascularization reaches zone3)
34
ICG indications
``` PCV AMD Chronic CSR Posterior uveitis Choroidal tm Breaks in Bruch: lacquer cracks, angioid streaks If FA is contraindicated ```
35
PED - FFA and ICG
FFA hyper | ICG hypo
36
AMD risk factors
``` Age(#1🏆) Race Heredity Smoking HT Dietary factors Aspirin Cataract surgery Blue iris color High sunlight exposure Female gender ```
37
RAP
Bilateral Symmetrical ICG: hot spot, hairpin loop=a perfusing retinal arteriole and draining venule
38
PCV
``` Bilateral Asymmetrical BVN=Branching vascular network Women Asian/African ICG: polyps ```
39
ERM and cells
Idiopathic: glial cells Secondary: pigment cells
40
Lamellar MH
Intact photoreceptor layer
41
Angioid streaks
TEPPSİ ``` Thalassaemias Ehler Danlos Pseudoxanthoma elasticum(#1🏆) Paget Sickle cell disease ```
42
RP triad
1️⃣Bone-spicule retinal pigmentation 2️⃣Arteriolar attenuation 3️⃣Waxy disc pallor
43
The most common macular dystrophy
Stargardt=fundus flavimaculatus
44
Stargardt disease
``` 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
Best vitelliform macular dystrophy
The second common macular dystrophy AD Previtelliform➡️vitelliform➡️pseudohypopyon➡️vitelliruptive➡️atrophic
46
The most common inherited cause of RD in children
Stickler syndrome
47
Stickler syndrome
The most common inherited cause of RD in children AD 1️⃣high myopia 2️⃣vitreoretinal degeneration 3️⃣associated extremely high rate of RD, and cataract
48
FEVR=familial exudative vitreoretinopathy
Failure of vascularization of the temporal retinal periphery | AD

Kanski (7 decks)

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