Vascular Diseases of the Eye Flashcards
1
Q
What is high bp (for hypertensive retinopathy)
A
- bp of >140/90mmHg on at least 2 occasions
- global prevalence of 40% in adults > 25
- major risk factor for heart disease, stroke, renal problems, visual impairment
2
Q
what is malignant htn
A
- rare
- systolig >200mmHg
- diastolic >140mmHg
3
Q
risk factors for raised bp (for hypertensive retinopathy)
A
- age
- family history
- obesity
- smoking
- african - caribbean race
4
Q
ocular complications of raised bp (for hypertensive retinopathy)
A
- cranial nerve palsies
- sub conjunctival haemorrhage
- hypertensive retinopathy - visible on fundoscopy, early signs easily overlooked
- systemic diseases tend to present in bilateral retinopathy - may not be symmetrical, but are similar
5
Q
Grade 1 hypertensive retinopathy
A
- px may be asymptomatic
- mild to moderate narrowing or sclerosis of the retinal arterioles
- vasospasm of arteial walls
- refer to gp if not being treated
6
Q
grade 2 hypertensive retinopathy
A
- px may be asymptomatic
- moderate to marked narrowing of arterioles - local and or generalsied
- arteriovenous crossing changes
- increases in the light reflex
- refer to gp if not being treated
- reduced av ratio
- may see nipping or gunns sign
- may see copper wire effect
7
Q
what is nipping or gunn’s sign in grade 2 hr
A
- in nipping, the artery pushes down on the vein
- thinning of venuole at an arteriole crossing
- classic sign of systemic htn
- may persist even if htn under control
8
Q
what is copper wire effect in grade 2 hr
A
- indicates a narrow lumen
- increase in elastic and muscular componenets of artery wall
- hypertensive arteriosclerosis - increased light reflex
- can also get beading - risk of occlusion
- silver wiring - when the no column of blood can not longer be visualised
9
Q
grade 3 hr
A
- arteriole narrowing and focal constriction
- cotton wool spots
- retinal haemorrhages
- hard exudates
- retinal oedema
- typically diastolic > 110-115mmHg
- rapid referral to gp
10
Q
what are cotton wool spots
A
- occlusion of pre capillary arterioles
- micrinfarction of retinal nerve fibre layer
- axon swells and creates an opaque appearance in the retinal nerve fibre layer
11
Q
what is a vascular leakage in hr
A
- flame shaped haemorrhage
- superficial and follow the parth of the nfl
- retinal oedema
- exudates (leakage from blood vessels) - lipo proteins
12
Q
grade 4 hr
A
grade 3 plus optic disc swelling
- malignant htn diastolic > 130-140mmHg
- visual symptoms
- headaches
- refer to a&e - risk of ocular, cardiac, renal and cerebral damage
13
Q
what are occlusive vascular diseases
A
- unilateral sudden painless loss of vision - very rarely bilateral but asymmetrical with respect to time
- typically affects the elderly, but not exclusively
- may go unnnoticed by elderly px as only affects one eye so less noticeable
14
Q
central retinal artery occlusion epidemiology
A
= obstruction of central retinal artery by embolus or thrombus
- usually before surface of ONH
15
Q
crao epidemiology
A
- onset mid 60s
- male to female ratio 2:1
- rare (incidence 1.9 in 100,000 in us)
16
Q
crao presentation
A
- sudden painless profound loss of vision
- may be preceded by transient loss of vision - AMAUROSOS FUGAX
17
Q
what is amaurosis fugax
A
- transient obscuration of retinal artey by embolus (TIA) < 24 hrs
- sudden monocular loss of vision
- painless
- ‘like a blind coming down’
- repetitive - with each one, theres a risk of an artery occlusion
- optometric management - refer to gp urgentl after excluding GCA
18
Q
crao early signs
A
- visually acuity usually CF to LP - exceptions cilio retinal artery (25%) , some vision may be retained
- pale oedematous retina esp in the posterior pole
- cherry red spot at macula, due to macula blood supply from choroid via posterior ciliary arteries
- arterial attenuation
- segmentation
- emboli may be seen
- RAPD
19
Q
crao late signs
A
- optic disc atrophy - pale
- arterial atteniation and segmentation
- va usually remains markedly reduced despite treatment
- another signs is during fluorescein angiography, there is a black area ( mean there is a blockage and retina isnt being supplied in that area)
20
Q
crao causes
A
- embolus > thrombus
embolus: - carotid artery and heart disease
- cholestrol crystals from carotid arteries
- platelet fibrin emboli arising from large vessel stenosis
- calcific emboli arising from carotid valve stenosis
- thrombosis - blood clot, stenosis of carotid artery
21
Q
crao risk factors
A
- systemic htn
- diabetes mellitus
- hyperlipidemia
- carotid artery disease
- tia/cva
- giant cell arteritis
- tobacco smoking
22
Q
crao optemetric management
A
- measure va
- check pupils
- urgent referral to eye cas - if < 12 hours old
- first aid - aim to dislodge embol
- ocular digital massage
- breathe into paper bag - increase of co2 levels - to dilate blood vessels and encourage embol to move through
23
Q
crao opthal management
A
reduce iop
- anterior chamber paracentesis
- intra venous acetazolamide and ocular massage
dilation of arteries
- ocular massage
- retrobulbar vasodilator drugs
- inhalation of carbogen - lysing of embolus/ thrombus, sytemic anticoagulants
investigation of cause
- increased mortality with presence of emboli
24
Q
crao with cilio retinal artery
A
20% of pop have cilio retinal artery
- va preserved - some, and wont be great
- functionally useful
visual field defect
25
what is a branch retinal artery occlusion
- occur in 7th decade
- results from ebolus
- 90% temporal arteries
- sudden painless loss of vision - hemifield or sector loss of vision
- prognosis good - 74% VA 6/12 + VF defect
26
central retinal vein occlusion epidemiology
= obstruction of central retinal vein below lamina cribosa
- more commonly affect older people in their mid 60s but can also occur in younger pxs
- male to female ratio equal - 5.2 in 1000
27
crvo presentation
- sudden painless loss of vision
- variable deficit
- may go unnoticed
28
crvo general signs
- 'blood and thunder' ie lots of activity
- flame shaped haemorrhages in all 4 quadrants
- disc oedema
- venous dilation
- cotton wool spots
- rapd
29
crvo non ischaemic signs
- va is better than 6/60
- rapd is not marked
- less haemorrhages
- no cotton wool spots
- 20% become ischaemic
30
crvo ischaemic signs
- visual acuity < 6/60 less
- marked rapd
- extensive haemorrhages in 4 quadrants
- disc swelling
- venous tortuosity
- cotton wool spots
- risk of developing retinal and iris neovascularisation
31
crvo: neovascular glaucoma
```
'100 day' glaucoma
= new bv in iris, which can develop in angle and stop aqueous outflow and iop increase = secondary glauc
- retinal hypoxia
- angiogenesis substance released
- new vessels develop in angle
- fibrovascular membrane develops across trabecular meshwork
- early intervention required
- intractable and devastating
```
32
crvo causes systemic and ocular
systemic
- systemic htn
- diabetes
- arteriosclerosis
- hyperviscosity syndromes
- oral contraceptive pill
ocular
- raised iop > 30mmHg
33
crvo optometric management
- if normal iop, refer to opthalmologist within 2 weeks, refer to gp for full cardiovascular investigation
- if iop > 30mmHg, refer to opthalmologist within 24 hrs, refer to gp for full cv investigation - more risk of neovascular glaucoma
34
crvo opthalmological management
- fluoroscein angiogram - ischaemic or non ischaemic
- pan retinal photocoagulation
- investigation and treatment of underlying cause
35
what is a branch retinal vein occlusion
- hemi field visual loss
- obstructed vein dilated and tortuous
- retinal oedema
- scattered superficial and deep retinal haemorrhages - respect the horizontal midline, confined to one quadrant
- causes - systemic cardiovascular
36
brvo optometric management
- measure va
- fundus examination - dilated bio
- pupil reactions
- visual field
- refer to gp cardiovascular investigation
37
brvo opthalmogical management
- fluorescein angiogram
- grid laser coagulation if macula oedema persistent
- retinal neovascularisation rarer in brvo
- prognosis good if untreated va is equal or more than 6/12 - but 25% will have va <6/60
38
anterior ischaemic optic neuropathy description
- ischaemia of anterior optic nerve head
- occlusion of the posterior ciliary arteries
arteritic
- associated with temporal arteritis
- 5-10% cases
- older age group (70%)
non arteriric
- 90-95 % cases
- younger age group (60%)
39
aion epidemiology
- almost exclusively after the age of 50 years
- incidence 18 per 100,000 after 50 years
- woman > men (2:1) ratio
40
arteritic aion
- older px than NA-AION - typically 7 to 8th decades
- profound loss of vision - nlp, lp or hm
- pale oedematous optic nerve head
- splinter haemorrhages
- rapd
41
what is temporal arteritis
- giant cell arteritis
| - inflammation of medium and large arteries
42
temporal arteritis symptoms
1) headache
- normally constant
- gradual onset to a diffuse severe aching
- superficial scalp tenderness
- worse at night and in the cold
2) general malaise, weight loss, jaw claudication, amaurosis fugax
3) polymyalgia rheumatica
43
na-aion presentation
1) sudden loss of vision
- mild to severe
- usually on walking
- vision loss either static or progressive
2) 20% lose vision in other eye within 5 years
3) 'at risk' disc
4) associated with htn, dm
44
na-aion signs
1) oedematous optic nerve head
- diffuse or segmental
- hyperaemic or pale
2) visual field loss
- usually altitudinal
3) contralateral eye
- small disc
- small or absent cup
- subsequent optic atrophy
4) 33% left with near normal v/a
45
aion optometric management and investigation
investigation:
- va, pupils, colour vision, vfs, iop
- dilated examination
management:
- emergency referral to casualty - contact opthalmologist
46
aion opthalmological investigation and management
investigation:
- blood tests
- tenporal artery biopsy
- scans (doppler, mri)
management:
- aspirin
- if arteritic high doses of systemic steroids for years
