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vascular and retinal disorders Flashcards

1
Q

progressive chronic retinal disease affecting aging eyes (central vision loss)

leading cause of vision loss globally, with adults > 50 years old

idiopathic

blurred central vision

distortion of images

scotomas (dark spots)

declining visual acuity (unable to read, distinguish faces)

A

macular degeneration (ARMD)

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2
Q

neovascular, exudative

more severe and faster progressing

10% of cases

A

wet macular degeneration

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3
Q

atrophic, geographic, non vascular, non exudative

yellow cellular debris (drusen)

90% of cases

A

dry macular degeneration

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4
Q

advancing age, female, white race, tobacco abuse, heavy alcohol use, increased sunlight exposure, cardiovascular disease, hypertension, hyperlipidemia, family history, farsightedness, light iris color

A

macular degeneration risk factors

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5
Q

new blood vessels grow up from the choroid (neovascularization) behind the retina which can leak exudate and fluid and cause hemorrhaging and fibrosis

onset more rapid and severe

A

“wet” ARMD

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6
Q

cellular debris (drusen) accumulates between retina and choroid leading to scarring and atrophy

atrophy in retina

gradual progressive bilateral visual loss of moderate severity due to atrophy and degeneration of outer retina and retinal pigment epithelium

A

“Dry” ARMD

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7
Q

macular degeneration diagnosis

A

snellen test (should see reduced visual acuity compared to previous tests)

amsler grid

opthalmolgy for definitive diagnosis

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7
Q

dry armd treatment

A

pegcetacoplan and avacincaptad pegol (inhibit complement pathway) injections

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8
Q

macular degeneration treatment

A

vitamins and STOP SMOKING

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9
Q

wet armd treatment

A

inhibitors of vascular endothelial growth factors (VEGF)

ranibizumab, bevacizumab, afilbercept injections

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10
Q

cause regression of choroidal neovascularization with resorption of sub retinal fluid and improvement or stabilization of vision

A

inhibitors of vascular endothelial growth factors (VEGF)

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11
Q

separation of neurosensory retina from underlying retinal pigment epithelium

considered medical emergency (vision loss)

can be primary or secondary

curtain vision loss

A

retinal detachment

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12
Q

most common predisposing causes for retinal detachment

A

age
nearsightedness
previous cataract extraction

also:
ocular trauma
smoking
diabetic retinopathy

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13
Q

caused by entry of liquid vitreous into subretinal space through retinal break

secondary to increasing age (>50 years old)

shrinking leads to pulling on retina (tear)

retinal detachment primary

A

rhegmatogenous detachment

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14
Q

accumulation of subretinal fluid
wet armd
choroidal tumor
fluid trapped behind retina –> detachment

A

exudative retinal detachment

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15
Q

preretinal fibrosis (scarring of retina)

proliferative retinopathy due to diabetic retinopathy

retinal vein occlusion

complication of rhegmatogenous retinal detachment

scars pull on retina –> detachment

A

traditional retinal detachment

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16
Q

acute onset

“tunnel vision” or loss of peripheral vision “curtain like”

recent onset or increase in floaters and photopsias (flashes of light)

central vision remains intact until macula becomes detached

A

retinal detachment

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17
Q

opthalmoscopic exam

retina may be seen elevated with irregular surface

retina appears gray or cloudy

superior temporal quadrant MC

A

retinal detachment diagnosis

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18
Q

when you have retinal detachment you do urgent referral to ophthalmologist. During transport how is patients head positioned?

A

patient head positioned so retinal tear is placed at lowest point of eye to minimize extension of detached retina. also try to minimize movement of eyes (patching)

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19
Q

retinal tear inferior

A

keep head upright

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20
Q

retinal tear temporal

A

keep temporal side of head down

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21
Q

retinal detachment treatment (primary)

A

closing retinal holes and tears
- laser photocoagulation
- cryopexy
- pneumatic retinopexy (gas injected into vitreous cavity)

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22
Q

retinal detachment treatment for more complicated detachments (traction)

A

vitrectomy

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23
Q

about 90% of uncomplicated primary detachments can be cured with ____ __________

A

one operation

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24
Q

retinal detachment worse prognosis

A

macula detaches
detachment of long duration

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25
Q

poorly controlled diabetes

A

diabetic retinopathy

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25
Q

damage to retina due to chronic systemic conditions (diabetes and hypertension)

can be acute or ongoing

leading cause of vision loss and blindness

early detection and management are crucial

A

retinopathy

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26
Q

leading cause of vision loss worldwide among adults aged 25-74 years

A

diabetic retinopathy

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27
Q

percentage of patients with retinopathy by 20 years after diagnosis. type 1:

A

99%

28
Q

percentage of patients with retinopathy by 20 years after diagnosis. type 2:

A

60%

28
Q

diabetic retinopathy present in about ____% of type 2 diabetic patients at diagnosis

A

20%

should be referred to ophthalmology for baseline exam with new diagnosis of type 2 diabetes

29
Q

nonproliferative

microaneurysms, retinal hemorrhages, exudates*

no changes in vision - no immediate treatment required

A

background retinopathy- asymptomatic

30
Q

two main categories of diabetic retinopathy

A

nonproliferative
proliferative

30
Q

growth of new vessels and fibrous tissue on surface of retina (neovascularization)

extends into vitreous chamber

consequence of severe capillary occlusion –> retinal ischemia –> release of VEGF

stimulates the new vessel growth with vision loss from pre retinal hemorrhage, fibrosis, and retinal traction

vision usually normal until macular edema, vitreous hemorrhage, or retinal detachment occur

A

diabetic retinopathy classification
–> proliferative

31
Q

diabetic retinopathy management

A

control of blood glucose, blood pressure, kidney function, and serum lipids

examine every 3-4 months*

32
Q

proliferative

macular edema and exudates

blurry vision, decreased acuity, visual distortion, scotomas

most common cause of legal blindness in type 2 diabetes

A

maculopathy- symptomatic

33
Q

diabetic retinopathy diagnosis

A

ophthalmology referral
- baseline fundoscopic exam at diagnosis of type 2
- type 1 diabetics should be screened 5 years after diagnosis

if visual symptoms and acuity not sufficient
- annual dilated* eye exam

34
Q

nonproliferative retinopathy management: macular edema

A

intravitreal administration of VEGF inhibitor* (mainstay of treatment for macular edema)
(ranibizumab, bevacizumab)

laser photocoagualtion

intravitreal administration of corticosteroid

vitrectomy

35
Q

nonproliferative retinopathy management: severe nonproliferative retinopathy

A

panretinal laser photocoagulation prophylactically

36
Q

disease of vessels supplying the retina and choroid

secondary to severe acute or chronic uncontrolled systemic hypertension

usually not symptomatic

primarily seen in older patients

A

hypertensive retinopathy

37
Q

can be encountered in any age group

sudden severe elevation in BP

major RF: degree of elevation of BP

A

acute malignant hypertensive retinopathy

38
Q

older patients

secondary to long standing HTN+ atherosclerosis

major RF= duration of increased BP

A

chronic hypertension retinopathy

39
Q

As BP increases, blood flow is maintained over wide range of pressures because blood vessels will constrict to maintain constant blood flow

A

autoregulation hypertensive retinopathy

40
Q

with severe or sustained elevations in BP, the walls of the blood vessels must thicken to maintain blood flow

A

atherosclerosis

hypertensive retinopathy

41
Q

typically seen in patients in hypertensive crisis (secondary HTN): BP > 200/110

damages vasculature of retina and choroid leading to ischemic necrosis

cotton wool spots
dot blot and flame hemorrhages
papilledema

A

acute hypertensive retinopathy

42
Q

acute hypertensive retinopathy diagnosis

A

fundus abnormalities are hallmark of hypertensive crisis with retinopathy – requires emergency treatment

43
Q

hypertensive retinopathy over time

A

loss of autoregulation

arteries/arterioles become ischemic

hemorrhages, exudates, cotton wool spots, copper wiring, etc

44
Q

acute hypertensive retinopathy treatment

A

treat underlying cause
caution –> do not reduce BP too quickly or suddenly

45
Q

acute hypertensive retinopathy common complications

A

retinal detachment
optic neuropathy

46
Q

accelerates development of atherosclerosis –> if advances far enough, visual acuity decreases

focal/uniform narrowing or arterioles

AV nicking/crossing* (hallmark of chronic hypertensive retinopathy)

hemorrhage (flame, dot blot)

copper/silver wiring

macular star (advanced disease)- retinal exudates

A

chronic hypertensive retinopathy

47
Q

chronic hypertensive retinopathy risk factors

A

high sodium diet
obesity
tobacco
alcohol
family history

48
Q

occlusion of central retinal artery (eye stroke)

sudden monocular vision loss

no pain

no redness

A

central/branch retinal artery occlusion

49
Q

in patients > 50 years with central retinal artery occlusion consider

A

giant cell arteritis

50
Q

branch retinal artery occlusion presents in a similar way to central retinal artery occlusion but…

A

smaller portion of visual field

51
Q

may be due to embolism or thrombosis

emboli may arise from:
- atherosclerotic plaques (carotid artery stenosis)
- atrial fibrillation
- endocarditis

thrombosis less common cause of retinal artery occlusion but can be seen with:
- various acquired/inherited thrombophilic disorders such as SLE and giant cell arteritis

A

retinal artery occlusion

51
Q

etiologic factors for retinal artery occlusion

A

diabetes

hyperlipidemia

hypertension

young patients
- migraine
- oral contraceptives

52
Q

fundus signs of retinal swelling

sometimes adjacent cotton wool spots limited to area of retina supplied by occluded artery

extent of arterial non perfusion is best seen with fluorescein angiography

A

branch retinal artery occlusion diagnosis

52
Q

pale swelling of retina with cherry red spot at the fovea

retinal arteries are attenuated and “box car” segmentation of blood in arteries or veins (RBCs separate from serum when blood flow is slowed or arrested)

retinal swelling subsides over 4-6 weeks, leaving pale optic disk with thinning of inner retinal on optical coherence tomography scans

A

central retinal artery occlusion diagnosis

53
Q

requires ophthalmology referral

color fundus photography and fluorescein angiography

A

retinal artery occlusion diagnosis

54
Q

once retinal artery occlusion diagnosis is made

A

carotid doppler
echocardiogram
(similar work up as stroke)

55
Q

giant cell arteritis diagnosis

A

ESR, CRP, platelet count

56
Q

what do you worry about with younger patients and retinal artery occlusion

A

blood clotting disorders

57
Q

retinal artery occlusion treatment

A

urgent referral to ER for imaging and clinical assessment to prevent subsequent stroke

lay patient flat, ocular massage, high concentrations of inhaled oxygen, IV acetazolamide, anterior chamber paracentesis

early thrombolysis

58
Q

occlusion of central or branch retinal vein (branch 4x more common)

initial presentation:
no pain or redness
branch occlusion my present in variety of ways
- sudden loss of vision at time of occlusion of fovea is involved
- more gradual with development of macular edema
- retinal abnormalities confined to area drained by obstructed vein

A

retinal vein occlusion

59
Q

RF of retinal vein occlusion

A

similar to artery occlusion
glaucoma major risk

60
Q

retinal vein occlusion pathogenesis

A

virchow’s triad for thrombogenesis
- vessel damage
- stasis
- hypercoagulability

central retinal vein and artery share common sheath at AV crossing

61
Q

retinal vein occlusion diagnosis

A

ophthalmology referral

62
Q

widespread retinal hemorrhages
retinal venous dilation and tortuosity
retinal cotton wool spots
optic disk swelling

A

ophthalmoscopic signs for central

63
Q

retinal abnormalities are confined to the area drained by obstructed vein

A

ophthalmoscopic signs for branch

64
Q

retinal vein occlusion treatment: macular edema

A

intravitreal injection of VEGF inhibitors (branch or central)

and refer

65
Q

retinal vein occlusion treatment: neovascularization

A

pan retinal laser photocoagulation for retinal or anterior segment neovascualrization

and refer

eye (9 decks)

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