Retina/Vitreous AAO Self-Assessment Flashcards
The early manifestations of idiopathic juxtafoveolar retinal telangiectasis includes which of the following findings?
Pigmentary migration into the retina
Asymmetric presentation
A focal pattern of late staining surrounding the fovea on fluorescein angiography
Temporal whitening of the macula
Many patients with idiopathic juxtafoveolar retinal telangiectasis present with symptoms in one eye only. The early angiographic findings reveal late staining of the retina, often in an oval configuration. The earliest clinical feature is graying of the retina temporal to the fovea. Only in the later stages of the disease does pigmentary migration occur. This acquired form of idiopathic juxtafoveolar retinal telangiectasis usually presents in the middle-aged to elderly population. Most patients retain good vision in at least one eye. The most common cause of visual loss is atrophy of the retinal pigment epithelium. Choroidal neovascular membranes may also occur.
A 32-year-old man presents without complaints for routine examination. On indirect ophthalmoscopy, multiple patches of peripheral lattice degeneration containing multiple atrophic retinal holes are noted in the superior retina OD. Lattice degeneration without retinal breaks is noted inferiorly OS. Which of the following statements regarding prophylactic treatment is most correct?
The patient’s right eye should receive prophylactic treatment with laser photocoagulation or cryoretinopexy prior to cataract surgery.
Only the patient’s right eye should be prophylactically treated with laser photocoagulation or cryoretinopexy.
Both of the patient’s eyes should be prophylactically treated with laser photocoagulation or cryoretinopexy.
If there is a prior history of retinal detachment in the left eye, prophylactic laser photocoagulation or cryoretinopexy should be considered in the right eye.
Lattice degeneration occurs in 6% to 8% of the population, with 20% to 30% of patients with lattice degeneration also having coexisting retinal holes. The decision to treat prophylactically is based on the risk of developing a retinal detachment without treatment, how much the treatment will reduce the risk of retinal detachment, and the risks of treatment. The rate of retinal detachment in eyes with lattice degeneration has been estimated to be less than 1%. Retinal breaks following cataract surgery are less likely to be associated with lattice degeneration than with the development of new flap tears. There are no studies documenting the value of prophylactic treatment in eyes with lattice degeneration except in the fellow phakic eyes with lattice degeneration of previous retinal detachment patients. In untreated eyes, a 2.5 times greater risk (1.8% vs 5%) of a new tear or detachment was found than in treated eyes.
A vitreous biopsy of a 66-year-old patient demonstrates cryptococcal organisms on fungal stain and culture. Which of the following statements accurately describes endogenous ocular cryptococcal infections?
Cryptococcal meningitis is frequently associated with ocular cryptococcal infections.
Cryptococcal infections occur only in immunosuppressed patients.
Chorioretinitis is the least common intraocular presentation of Cryptococcus.
Ocular involvement is the result of direct extension along the optic nerve and not by hematogenous spread.
Cryptococcal infections are caused by Cryptococcus neoformans, an ubiquitous fungus found in bird droppings. Cryptococcal infections are more common in, but not limited to, immunocompromised patients. Chorioretinitis, with or without vitritis, is the most common intraocular presentation of cryptococcosis; cryptococcal endophthalmitis is rare. Many disorders must be considered in the differential diagnosis of chorioretinal lesions with vitritis, such as those seen in cryptococcosis. Similar lesions may be found in tuberculosis, sarcoidosis, CMV retinitis, candidiasis, and toxoplasmosis. Acute retinal necrosis syndrome also presents with retinal inflammation and vitritis, but given this patient’s age, would be unlikely. Large-cell lymphoma should also be considered in the differential diagnosis. Ocular cryptococcal organisms may gain access to the eye by hematogenous spread, by direct inoculation as in trauma, or by direct extension along the optic nerve from the often accompanying cryptococcal meningitis, which is often fatal.
A 42-year-old man has a total retinal detachment and a circumferential, 150-degree peripheral retinal tear with an inverted flap. What surgical approach would be most appropriate?
360-degree peripheral laser photocoagulation
Intravitreal injection 0.3 mL of SF6 gas
Pars plana vitrectomy, retinal reattachment with perfluorocarbon liquid, laser photocoagulation, and complete fluid-gas exchange
Scleral buckle with intravitreal injection of SF6 gas
Retinal detachments from giant retinal tears, tears of greater than 90 degrees, have a high redetachment rate due to proliferative vitreoretinopathy. Because of the high risk of failure the preferred approach would usually include pars plana vitrectomy, use of perfluorocarbon liquid, laser photocoagulation demarcation and complete fluid-gas exchange. The other options, performed alone, would not be likely to temporarily flatten or reattach the retina.
A patient develops a hemorrhagic choroidal detachment following cataract surgery. Their intraocular pressure remains in the normal range. Surgical intervention is not needed in which of the following developments? Proliferative vitreoretinopathy Markedly elevated IOP and severe pain Rhegmatogenous retinal detachment Spontaneous anatomical resolution
In a patient with a hemorrhagic choroidal detachment and normal intraocular pressure, spontaneous anatomical resolution is the most likely outcome. Surgical intervention is needed for retinal tears, detachment or incarceration. As well as for PVR and severe pain with markedly elevated IOP.
A 24-year-old man with a 10-year history of insulin-dependent diabetes mellitus presents with a visual acuity of 20/25 OD and 20/200 OS. Examination of the macula in the right eye demonstrates hard exudates and retinal thickening within 500 microns of the foveal center. A small area of flat retinal neovascularization is present in the right eye off the superotemporal arcade. The vitreous in the right eye is clear. Examination of the left eye demonstrates diffuse retinal thickening throughout the macula, scattered hard exudates, and blot hemorrhages. Marked neovascularization of the disc is present in the left eye, as well as nasal retinal neovascularization with mild vitreous hemorrhage. Ignoring the use of intravitreal injections. What is the best sequence of photocoagulation treatment for this patient?
Initial focal photocoagulation OU, followed by panretinal photocoagulation OU
Initial panretinal and focal photocoagulation OS, followed by focal photocoagulation OD
Initial panretinal photocoagulation OS, followed by focal photocoagulation OU
Initial panretinal photocoagulation OU, followed by focal photocoagulation OS
According to the criteria of the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS), this patient has both high-risk proliferative diabetic retinopathy (PDR) in the left eye, and clinically significant diabetic macular edema in both eyes. Therefore, panretinal photocoagulation in the left eye, and focal photocoagulation in both eyes are needed. However, panretinal photocoagulation has been shown to exacerbate coexisting diabetic macular edema. The ETDRS found that to reduce the effects of panretinal photocoagulation on diabetic macular edema, the procedure is best delayed until focal photocoagulation is completed. However, in cases in which high-risk PDR characteristics and diabetic macular edema coexist, the ETDRS does not recommend delaying panretinal photocoagulation in lieu of focal photocoagulation. Therefore, in this patient, concurrent focal and panretinal photocoagulation would be the best choice to initiate treatment for the high-risk PDR in the left eye, while reducing the effects of panretinal photocoagulation on the diabetic macular edema.
Which one of the following represents a risk factor for the development of atrophic retinal holes?
Young age
Macular degeneration
Family history of atrophic holes or lattice degeneration
Hyperopia
Atrophic retinal holes are associated with a family history of such holes, or of lattice degeneration. In addition, they are associated with increasing age and axial myopia. There is no association with macular degeneration.
What is the most frequent complication associated with pars plana vitrectomy and membrane peeling? Glaucoma Accelerated cataractogenesis Retinal tear Retinal pigment epithelial disturbance
Cataract is the most frequent complication associated with pars plana vitrectomy for phakic patients. Accelerated cataractogenesis leads to cataract surgery in 50% of patients within 2 years of vitrectomy. Glaucoma, retinal tears, and retinal pigmented epithelial disturbances occur at a frequency of less than 5%.
What mechanism, prognosis or treatment applies to asymptomatic atrophic retinal holes?
Requires demarcation treatment
Usually caused by blunt trauma
Low likelihood to progress to symptomatic retinal detachment
Highly likely to progress to asymptomatic retinal detachment.
As asymptomatic atrophic retinal holes have a low incidence of progression to retinal detachment; treatment is not usually indicated. Atrophic retinal holes are rarely caused by traumatic. Blunt trauma is more closely associataed with retinal dialysis.
What is a pertinent element in the history of a patient with suspected albinism? Absence of nystagmus Another family member affected Brown or dark colored eyes Onset in adulthood
As oculocutaneous albinism is an autosomal recessive disorder, other family members may be affected. Associated findings include childhood onset, nystagmus, and hypopigmented irides.
Branch retinal venous occlusion is most commonly associated with which systemic disease? Osteoarthritis Diabetes insipidus Arterial hypertension Hypothyroidism
Risk factors for branch retinal venous occlusion include diabetes mellitus, hypertension, hyperlipidemia, and primary open angle glaucoma. Branch retinal venous occlusion is most commonly associated with systemic hypertension.
Which of the following is the strongest indication for prophylactic treatment (cryopexy or laser surgery) to prevent rhegmatogenous retinal detachment?
An atrophic hole in a phakic patient whose other eye developed a retinal detachment
Lattice degeneration in a pseudophakic patient with a family history of retinal detachment
High myopia and lattice degeneration with new onset of floaters in a phakic patient
An asymptomatic flap tear in an eye with a cataract that is about to be rendered pseudophakic
The subject of prophylaxis for rhegmatogenous retinal detachment is an area of some controversy among vitreoretinal specialists. As with any surgical decision, the decision to treat must rest on an educated assessment of the risks of treatment versus the risk of leaving the patient untreated, as well as on knowledge of how much the treatment can actually reduce the risk of detachment. A thorough exploration is beyond the scope of this discussion, but factors that prompt treatment are evidence of acute onset of symptoms and the presence of vitreous traction. Less compelling indications are a history of detachment in the other eye and imminent cataract surgery, but the combination of the latter with evidence of traction becomes a strong indication to treat.
In which of the following quadrants are retinal dialyses most often found following blunt trauma? Inferotemporal, superonasal Inferotemporal, superotemporal Superotemporal, superonasal Superonasal, inferonasal
Blunt trauma may result in a variety of retinal breaks including retinal dialyses, macular holes, giant retinal tears, horseshoe retinal tears, operculated retinal tears, and large, necrotic, sometimes posterior retinal breaks often associated with chorioretinitis sclopetaria. Retinal dialyses, however, are the most common retinal breaks found following blunt ocular trauma. Retinal dialyses resulting from blunt trauma are most often found in the inferotemporal and superonasal quadrants. All patients with a history of blunt trauma need to be given a careful retinal examination with scleral depression to look for retinal breaks after their pain, iritis, or hyphema, if any, has resolved.
A 27-year-old woman has had a sudden onset of a dark area inferior to fixation in the left eye earlier in the day. Examination reveals a visual acuity of 20/20 in each eye and an area of retinal whitening that corresponds to a branch coming from the superotemporal retinal artery. Which of the following is likely to be associated with this condition?
An abnormality detected on cardiac echography
Evidence of alcohol abuse
An abnormality demonstrated with carotid Doppler and/or ultrasound imaging techniques
A history of cluster headaches
Branch retinal artery occlusion is an unusual occurrence in young people, and the causes are, in general, quite different from such occlusions in the elderly. Cardiac valve abnormalities and cardiac myxoma can lead to embolic phenomena, as can oral contraceptives. Exogenous emboli (talc) are seen in intravenous drug abusers. Migraine can cause true infarction and is the most common cause in someone of this age. Carotid disease is almost never involved in arterial occlusions in persons under 40 years of age.
A 58-year-old woman has no particular complaints on first-time routine examination. She has not had a dilated fundus examination before. Visual acuity is normal in each eye, but you find a peripheral area of retina that is thin and elevated in the right eye. You would like to know whether the appearance of the retina is due to retinoschisis, or a rhegmatogenous retinal detachment. Which of the following is likely to indicate retinoschisis?
No signs of a scotoma on Goldmann visual field testing
Myopia
Ophthalmoscopically a highly elevated, dome-shaped configuration
Atrophy of the underlying pigment epithelium
In retinoschisis, the pigment epithelium under the involved retina is normal and there is no atrophy, demarcation line, or subretinal strand formation, unless it is associated with a combined rhegmatogenous retinal detachment. Both rhegmatogenous retinal detachment and retinoschisis produce scotomas, but the scotoma in retinoschisis is absolute, while in rhegmatogenous retinal detachment it is relative. Retinoschisis is typically bilateral, dome-shaped, and seen more often in hyperopic eyes.
