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Foundations II > Retina and Optic Nerve > Flashcards

Retina and Optic Nerve Flashcards

1
Q

What is optic neuritis and what does it result in?

A

inflammatory demyelinating condition that results in acute vision loss in one eye

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2
Q

Optic neuritis is associated with what conditions?

A

strongly associated with demyelinating disease like MS (presenting factor in about 20 percent of MS patients!)

also may occur with viral infections like measles, mumps, and influenza

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3
Q

Most cases of optic neuritis occur in what sex and age group?

A

women, 20-40 years

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4
Q

How does optic neuritis present?

A

acute onset (hours to days)
monocular vision loss
eye pain, worse with EOMs
visual field defects – there is usually a central scotoma

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5
Q

What would a PE of a person with optic neuritis reveal?

A

loss of color vision, decreased visual acuity, optic nerve changes may be seen on exam, relative afferent pupillary defect (APD)

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6
Q

What is APD and what is it found with?

A

afferent pupillary defect, seen in optic neuritis

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7
Q

Flame shaped peri-papillary hemorrhages would indicate what?

A

optic neuritis

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8
Q

Can optic neuritis affect the fundus?

A

Most causes of optic neuritis (2/3) are retrobulbar (behind the eye)and don’t affect the fundus, but 1/3 show an optic nerve swollen with pallor, along with flame-shaped peri-papillary hemorrhages

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9
Q

What do we do when a patient with optic neuritis comes into our office?

A

Refer to ophthalmology or neurology urgently!

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10
Q

How is a diagnosis of optic neuritis confirmed?

A

MRI of brain and orbits with gadolinium contrast (also assesses risk for MS)

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11
Q

How is optic neuritis treated?

A

IV methylprednisolone for three days, then oral taper to accelerate vision recovery

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12
Q

In optic neuritis, visual acuity usually returns within…

A

2-3 weeks

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13
Q

What would we suspect if visual acuity doesn’t return in a patient with optic neuritis?

A

compressive lesion or tumor!

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14
Q

What is one complication of optic neuritis?

A

optic atrophy (if sufficient nerve fibers have been destroyed)

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15
Q

What is papilledema and what is it usually associated with?

A

swelling of optic nerve head, usually associated with elevated intracranial pressure

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16
Q

PE of a patient with papilledema

A

swollen optic disk with blurred margins, cup may be obscured due to swelling, may be flame hemorrhages and cotton wool spots (infarctions) in the nerve fiber layer and edema in surrounding retina

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17
Q

T/F. The papilledema is noted before other signs and symptoms of increased intracranial pressure.

A

False! Patients often show other signs and symptoms before the papilledema.

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18
Q

What are two symptoms of a papilledema?

A

transient vision change and headache (but sometimes vision can be normal if acute)

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19
Q

What condition would we suspect if there is a bluish tint to the conjunctiva?

A

osteogenesis imperfecta

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20
Q

What would be on the differential diagnosis for a papilledema (five things)?

A

intracranial mass tumor, cerebral edema (TBI, encephalopathy), disorders of CSF, obstructive hydrocephalus, idiopathic intracranial hypertension (a.k.a. pseudotumor cerebri)

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21
Q

What do we do if we do find a papilledema?

A

urgent referral to ophthalmology and complete work up

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22
Q

What is the leading cause of blindness in adults in industrialized countries? In the world?

A

in industrialized countries = age related macular degeneration (AMD)
world = cataracts

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23
Q

Age related macular degeneration is a ___ disease of the ___.

A

degenerative disease of the macula (central retina)

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24
Q

Age related macular degeneration results in…

A

loss of central vision

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25
Q

Incidence of age related macular degeneration increases with…

A

age (each decade over 50)

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26
Q

3 risk factors for age related macular degeneration

A

age, female gender, Hx of smoking

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27
Q

What would a newspaper look like to a person with age related macular degeneration?

A

Words would look missing or distorted.

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28
Q

three symptoms of age related macular degeneration

A
  1. gradual/acute painless vision loss
  2. metamorphopsia = wavy or disorted vision
  3. central scotoma
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29
Q

What is metamorphopsia and where is it seen?

A

wavy or distorted vision seen in age related macular degeneration

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30
Q

What are two physical exam signs of age related macular degeneration?

A

+/- decreased vision

Amsler grid distortion

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31
Q

dry vs. wet age related macular degeneration

A

dry = drusen, pigmented mottling and geographic atropy, wet = subretinal fluid or blood, subretinal neovascular membrane

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32
Q

What does the Amsler grid test for?

A

age related macular degeneration, used as a tool to monitor change

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33
Q

Which has the better prognosis – wet or dry age related macular degeneration?

A

dry

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34
Q

Retinal drusen appear as yellow deposits – wet or dry age related macular degeneration?

A

dry

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35
Q

Retinal pigment epithelium atrophies decreasing central visoin – wet or dry age related macular degeneration?

A

dry

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36
Q

Characterized by growth of abnormal vessels into the subretinal space; new vessels leak – wet or dry age related macular degeneration?

A

wet

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37
Q

Which accounts for 90 percent of cases of blindness of age related macular degeneration – wet or dry?

A

wet

38
Q

How do we treat age related macular degeneration?

A

ophthalmology referral, vitamins like zinc and antioxidants, smoking cessation, daily Amsler grid, photocoagulation, photodynamic therapy, intravitreal steroid/anti-angiogenic injections, low vision aids

39
Q

What is the most common cause of retinal detachment?

A

tear in retina, after which vitreous fluid can work its way under the retina to cause detachment

40
Q

most common site of retinal detachment

A

superior temporal retinal area

41
Q

What can cause retinal tears?

A

can happen spontaneously or with trauma; traction on retina by vitreous detachment; processes like diabetes

42
Q

4 risk factors for retinal detachment

A
  1. age >50 years
  2. extreme myopia
  3. previous ocular surgery
  4. FH
43
Q

symptoms of retinal detachment

A
  1. acute onset of monocular, decreased vision, like a curtain coming down over eye
  2. cloudy or smoky vision, floaters, flashes of light
  3. no pain, no redness
44
Q

signs of retinal detachment (4)

A

afferent pupillary defect, billowing or tent like elevation of rugose retina, elevated retina looks gray and out of focus, may notice vitreous hemorrhage

45
Q

What do we do if a patient comes in with a detached retina?

A

refer to ophthalmology

46
Q

On the way to the ophthalmologist, what should we advise patients to do?

A

patient should remain supine and with head turned to ipsilateral side to help retina fall back into place with gravity

47
Q

How are the tears in the retina closed?

A

cryosurgery or laser surgery

48
Q

What is amaurosis fugax?

A

fleeting blindness

49
Q

What causes amaurosis fugax?

A

retinal emboli from ipsilateral carotid disease

50
Q

How is the vision loss in amaurosis fugax described?

A

like a curtain passing vertically over visual field, with complete monoocular vision loss lasting a few minutes, and a similar curtain effect as the episode passes

51
Q

How does a amaurosis fugax compare with a retinal detachment?

A

both involve a curtain effect but the amaurosis fugax is more transient

52
Q

Why is a work up warranted in a case of amaurosis fugax?

A

to determine cause of embolus

53
Q

What diagnostic testing would we use in a patient with amaurosis fugax?

A

noninvasive evaluation of carotids, using duplex US and magnetic resonance angiography (MRA); also emboli from cardiac sources like atrial fibrillation could be the culprit, so we could do an ECG/EKG

54
Q

How is a amaurosis fugax case treated?

A

depends on cause

55
Q

Patients with HIV are at risk for developing retinal issues due to infection with __.

A

Cytomegalovirus

56
Q

In central retinal artery occlusion, what happens?

A

An emboli occludes the retinal arteries and this causes decreased blood flow and hypoxia to the retina!

57
Q

T/F. There may be repeated transient episodes before complete loss in central retinal artery occlusion.

A

T

58
Q

symptoms of central retinal artery occlusion

A

sudden painless, total monocular vision loss; no pain or redness

59
Q

signs of central retinal artery occlusion(3)

A
  1. no light perception (NLP)
  2. afferent pupillary defect
  3. pale retina with cherry spot at fovea
60
Q

How do we treat central retinal artery occlusion?

A

immediate referral!

treatment needs to be started within a few hours of onset to be effective

61
Q

T/F. Patients with central retinal artery occlusion generally have a good prognosis.

A

F, prognosis is poor

62
Q

What are three possible etiologies in central retinal artery occlusion?

A

carotid plaques, cardiac emboli, temporal arteritis if patient is over 55 years old (with US)

63
Q

What is a central retinal vein occlusion?

A

occlusion of veins due to thrombi

64
Q

symptoms of central retinal vein occlusion

A

often noticed upon waking –acute, painless unilateral vision loss and no pain or redness

65
Q

signs of central retinal vein occlusion

A

variable vision, +/- APD, multiple hemorrhages, venous dilation and tortuosity, blood and thunder fundus

66
Q

How do we treat central retinal vein occlusion?

A

urgent referral!
aspirin, observation (for retinal edema), evaluate etiology if young (could be severe hypertension or hypercoagulable states)

67
Q

A two year old presents with grossly no binocular fixation. What test would be appropriate?

A

corneal light reflex (Hirschburg)

68
Q

What is the prognosis (typically) in central retinal vein occlusion?

A

variable

69
Q

What is the number one cause of blindness in the Western world in patients under 50 years?

A

diabetic retinopathy – so diabetics should have a yearly exam with dilated pupils

70
Q

When do we recommend ophthalmologist exams in type 1 vs. type 2 diabetes patients?

A

Type 1 = of more than five years duration
Type 2 = at first diagnosis
Or if ocular symptoms develop, or if there are any suspicious findings of retinopathy

71
Q

Retinopathy is present in __% of diabetes patients.

A

40%

72
Q

What are the symptoms of diabetic retinopathy?

A

often not present until later stages; then, patients may complain of blurred vision

73
Q

Why do patients with diabetic retinopathy have blurred vision?

A

increase in serum glucose causes lens swelling and a refractive shift (occurs even in the absence of retinopathy)

74
Q

What are the three types of diabetic retinopathy?

A

proliferative, non-proliferative, and diabetic macular edema

75
Q

What are three signs of non-proliferative diabetic retinopathy?

A

microaneurysms (earliest sign)
cotton wool spots
dot blot hemorrhages

76
Q

What are the signs of proliferative diabetic retinopathy?

A

all the signs of non-proliferative (like microaneurysms, cotton wool spots, dot blot hemorrhages) plus neovascularization, vitreous hemorrhage, and traction RD

77
Q

Which has a worse prognosis – proliferative or non-proliferative?

A

proliferative

78
Q

In neovascularization, where do the vessels come from?

A

some place other than the cup

79
Q

Macular edema occurs __ to the optic disc.

A

temporally

80
Q

three fundoscopic findings in macular edema

A
  1. retinal thickening
  2. microaneurysms
  3. hard exudates
81
Q

How do we treat diabetic retinopathy?

A
  1. blood sugar control
  2. reduce comorbidity
  3. ophthalmology referral for laser photocoagulation, intravitreal steroid injection, anti-angiogenic injection, vitrectomy
82
Q

What is an ideal blood sugar level for a patient with diabetic retinopathy?

A

< 7

83
Q

In patients with diabetes, which specialists should be seen regularly?

A

ophthalmologist, endocrinologist, podiatrist

84
Q

What is hypertensive retinopathy?

A

retinal vascular changes due to systemic hypertension

85
Q

symptoms of hypertensive retinopathy

A

none! (and no vision issues)

86
Q

signs of hypertensive retinopathy

A

systemic hypertension and characteristic fundoscopic findings

87
Q

What is the system we use to classify hypertensive retinopathy?

A

Keith-Wegener-Barker Classification, 4 Groups

88
Q

What are the four Keith-Wegener-Barker Classification groups?

A

Group 1 = arteriolar narrowing (copper wiring) and sclerosis (silver wiring)
Group 2 = Group 1 + A:V crossing changes/nicking
Group 3 = Group 2 + cotton wool spots, retinal hemorrhages, and retinal edema/exudates (macular star)
Group 4 = Group 3 + disk edema (papilledema)

89
Q

A patient has optic disc edema, cotton wool spots, flame and dot blot hemorrhages, arteriovenous nicking, and exudates. He is asymptomatic and has no vision changes, and his BP is 192/140. What could be going on?

A

Group 4 Hypertensive Retinopathy

90
Q

How do we treat hypertensive retinopathy?

A

systemic BP control, and ophthalmology referral if severe hypertension or if vision loss

91
Q

In what cases should we call an ophthalmologist?

A

patients with red eye if diagnosis is unclear or if not improving, or if contact lens infection
all vision loss cases
patients with diabetes, newly diagnosed hypertension, known eye conditions, new diagnosis of JIA
anytime you are worried!!

Foundations II (11 decks)

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