Retinal Blood Vessel Anomalies Flashcards by Dane Wilson

What tests would you do for a minimal systemic workup?

-Blood pressure, pulse, respirations
-CBC with differential
-Auscultation of carotid artery

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What could Low RBC Count signify? (diseases/conditions) (10)

Anemia
Bone marrow failure
Chronic kidney disease
hemolysis
bleeding
leukemia
malnutrition
vitamin deficiency
Pregnancy
Medication

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What could High RBC count signify? (4 conditions)

Congenital heart disease
Dehydration
Renal cell carcinoma
Polycythemia vera

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What can cause Low WBC count?

-Severe infections that use up white blood cells faster than they can be produced.
-Medications that destroy white blood cells (chemo or radiation)
-Autoimmune disorders that destroy white blood cells or bone marrow cells (lupus or RA)
-Viral infections that temporarily disrupt the work of bone marrow
-Congenital disorders that involve diminished bone marrow function
-Reaction to medication

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What can cause High WBC count?

-An increased production of white blood cells to fight an infection (bacterial or viral)
-A disease of bone marrow, causing abnormally high production of white blood cells (leukemia)
-A reaction to a drug that increases white blood cell production
-An immune system disorder that increases white blood cell production (RA)
-Severe allergic reaction

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What do you see with micro-aneurysms?

Blood
exudative change
edema

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How big are micro-aneurysms? Are you able to see them with your 78D, 90D?

50-100 microns. No

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In order to easily observe micr-aneurysms, what test/scan would you run?

1) IVFA- IV fluorescein angiography
2) Virtual angiography

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What are micro-aneurysms a result of and associated with? Venous or artery-based disease? What capillary layer is this found in? What layer of the retina?

Result of hypoxia and associated with capillary destruction.
Associated with venous based disease
Deep capillary network
INL

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If we know micro-aneurysms are in deep capillary network in the INL, what type of hemorrhages might we appear to see?

Dot-blot, intra-retinal hemorrhage

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When you have a micro-aneurysm, what order do the signs appear in from the initial leakage of blood?

Leak from micro-aneurysm, edema, dot-blot hemorrhage, exudate

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What is the comparison of appearance for micro-aneurysm on fluorescein angiography?

“Starry night”
looks like stars in space, little white spots

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Where does the ballooning occur in micro-aneurysms?

In areas of hypoxia

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Where do the “balloons” of micro-aneurysms point?

In the direction of ischemia

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How does a micro-aneurysm start to leak? How does it stop?

The capillary endothelium begins to proliferate which weakens the capillary wall. The blood-retinal barrier then breaks which causes a leak.
It stops due to a spontaneous seal due to hyalinization

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What are the two signs of active leakage from a micro-aneurysm?

Dot-blot hemorrhage and exudate

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What do you always see with micro-aneurysms?

Edema

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What is most common disease to cause micro-aneurysms?

Diabetes

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What are the treatment options for micro-aneurysms that are vision-threatening and leaking in or very near the fovea/macula?

Intravitreal Injection (anti-VEGF)
Laser photocoagulation
Combo of the two

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In early phase fluorescein angiography, how long does the fluorescein to go from the hand to the eye? What do you look for in early phase?

Takes 16 seconds from hand to the eye.
Looking for ischemia in the superficial capillary network, “dead spots of retina/ micro-ischemic events”

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When looking for capillary drop-out/ischemia in fluorescein angiography, what capillary network is this typically associated with in the early phase?

Superficial capillary network
-Since the fluorescein is being pumped to retina, it is in the arteries which is located in the superficial capillary system.

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In late phase fluorescein angiography, do you use OCTA or structural OCT to find leakage/ micro-aneurysms?

Structural OCT, appears as “starry night” white dot on gray backgrounds,.

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What would an active leak of micro-aneurysm look like on Fluorescein angiography?

White dot with hyperfluoresce In the same area.

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What does macro-aneurysm look like?

ballooning of major retinal blood vessel or arteriole

How often are arteries involved with macro-aneurysms?

Most of the time. 2/3 of the time

What are most macro aneurysms associated with? What percent?

75% are associated with high blood pressure

Where are most macro aneurysms found? Are they unilateral or bilateral? Are you able to see them using your fundoscopy lenses? ?

Superior-temporal region Unilateral You can see them with fundoscopy lenses

What are 3 possible outcomes that can be caused by macro aneurysms?

Chronic leakage- retinal edema Rupture of aneurysm - acute hemorrhage (multiple layers of retina, vitreous) Spontaneous Resolution- will scar over on its own

What are the visual effects due to macro-aneurysms?

Depends on location, can have significant effect on vision if near macula

What are treatment options for macro aneurysms that are vision threatening?

Laser photocoagulation Anti-VEGF injection Combo

If macro aneurysms are not vision threatening or worsening, what is treatment?

Monitor and have them back in 3 months.

If macro aneurysms are not vision threatening but is spreading and worsening, what is the treatment?

Laser photocoagulation Anti-VEGF injection

What are the most common types of Idiopathic juxtafoveal telangiectasia?

Group2 is most common Group 1 is second most common

What are telangiectasia?

widened blood vessels that look like a web

How is idiopathic juntafoveal Telangiectasia Group 1: Aneursymal presented? How is their vision affected? is it unilateral or bilateral vision loss?

-Usually in younger males patients -Have abnormal glucose tolerance (high blood sugar, pre-diabetic, not diagnosed with diabetes) -Mild to moderate unilateral vision loss

What kind of vision loss would you expect with diabetic retinopathy? (bilateral/unilateral)

Bilateral vision loss

What are some ocular findings for Idiopathic Juxtafoveal Telangiectasia Group 1: Aneurysmal? (5)

1) Unilateral macular edema (ME) with macular cystic changes 2) Temporal foveal involved 3) Telangiectasia 4) Micro-aneurysms and venule changes(vein dives down) 5) Lipid deposition with chronic leakage

What is the visual prognosis for Idiopathic Juxtafoveal Telangiectasia Group 1: Aneurysmal?

Mild to moderate vision loss Not worse than 20/40 - 20/50

Treatment options for Idiopathic Juxtafoveal Telangiectasia Group 1?

Photocoagulation Anti-VEGF therapy - most patients want to prevent from progression

Describe Idiopathic Juxtafoveal Telangiectasia Group 2: Parafoveal presentation

-Healthy middle aged males and females -Abnormal glucose tolerance -BILATERAL vision loss with macular atrophy - More common, worse prognosis than IJT-1 -20/50 vision or worse

Ocular findings for Idiopathic Juxtafoveal Telangiectasia Group 2: Parafoveal

-Grayish loss of juxtafoveal retinal transparency Macula has opaque appearance to it; more obvious with red-free filter on BIO. -Temporal early, but then surrounds entire fovea -Fine crystalline deposits and RPE hyperplasia (black spots in left-most image) -Micro-A and neovascularization with macula edema

What technology would you use to diagnose Idiopathic Juxtafoveal Telangiectasia Group 1 and 2? (5)

1)Red-free (on SLE or BIO) or multi-color imaging (camera uses blue, green, & red lasers) – grayish macular reflex 2) Fundus Autofluorescence (FAF) – macular atrophy 3) OCT – neuro-retinal loss, structural changes 4)OCT-A – incompetent capillaries and micro-A 5)IVFA – temporal leakage

What is the Idiopathic Juxtafoveal Telangiectasia - Therapy that is currently in phase 3 clinical trial? What are side effects?

ECT- encapsulated cell therapy implant that gives continuous therapeutic NT-501 protein (neurotrophic factor) to the eye for 2 years. SE: makes vision worse than it was intitial.

Describe Idiopathic Juxtafoveal Telangiectasia Group 3: Occlusive

Rare condition Associated with systemic diseases or neurological disease Loss of central VA optic atrophy Related to capillary occlusion microaneurysms

Treatment for Describe Idiopathic Juxtafoveal Telangiectasia Group 3: Occlusive

None

cystoid macular edema that develops 30-90 days post-cataract surgery

Irvine-Gass syndrome

What are collateral blood vessels? How can they develop? Are they beneficial?

Blood vessels that develop within the framework of existing vessels. Can develop vein-vein, artery-artery , or vein-artery.

Name for collateral blood vessel that is located on the surface of the optic nerve

Optocilliary shunt

Name for AV communication without capillary obstruction or compromise

Shunt vessel (congenital)

What technology/imaging would you use for collateral blood vessels?

IVFA or OCT-A (indicated) Possible MRI

What could cause collateral blood vessels?

Orbital mass RVO Congenital

Do Intra-retinal vascular abnormalities leak? (IRMA)

True or false: IRMA (intra-retinal vascular abnormalities are a precursor to severe diabtetic retinopathy

True

3 typical locations for neovascularization

1) Neovascularization of Iris (NVI) 2) Neovascularization of the disc (NVD) 3) Neovascularization elsewhere (NVE)

Where does Neo develop?

Junction of healthy and hypoxic tissue

Expected retinal findings for neovascularization?

Edema Hemorrhage Fibrosis and traction

What kind of neovascularization is associated with the vitreous?

NVD

What is the gold standard for observing neovascularization?

IVFA- IV fluorescein angiography