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Introduction to Eye Disease - Year 2 > Vascular Occlusions > Flashcards

Vascular Occlusions Flashcards

1
Q

Do vascular occlusions tend to be bilateral or unilateral?

A

Unilateral

(Very rarely bilateral)

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2
Q

In what patient may a vascualr occlusion go unnoticed?

A

In elderly patients

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3
Q

What symptoms do vascular occlusions cause?

A

They tend to cause a sudden painless loss of vision.

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4
Q

Are vascular occlusions exclusive to the elderly?

A

Vascular occlusions are not exclusive to the elderly although they typically affect the elderly.

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5
Q

What is central retinal artery occlusion?

A
  • Obstruction of central retinal artery by embolus or thrombus
  • Usually below surface of optic nerve head
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6
Q

What is the epidemiology of central retinal artery occlusion?

A
  • Onset mid-sixties
  • Male to female ratio 2:1
  • Rare (incidence 1.9 in 100,000 in U.S.)
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7
Q

How does a patient with Central Retinal Artery Occlusion present?

A

They present with a sudden painless profound (this means severe) loss of vision

This may be preceded by a transient loss of vision ( i.e. transient loss of vsion comes before profound loss of vision)

(Amaurosis Fugax)

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8
Q

What is Amaurosis fugax?

A

Transient (this means to last only for a short period of time) obscuration of retinal artery by embolus. –> This is also known as a Transient ischaemic attack (TIA).

Causes transient loss of vision.

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9
Q

What symptoms does Amaurosis Fugax have?

A

ØSudden monocular loss of vision

ØPainless

Ø“Like a blind coming down”

ØClears slowly in reverse direction (i.e. as if the blind is coming up)

ØRepetitive ( happens a few times in a period of say 24 hours)

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10
Q

What is the optometric managment for Amaurosis fugax?

A

ØRefer to G.P. urgently after excluding giant cell arteritis

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11
Q

What are the early signs of central retinal artery occlusion?

A

•Visual acuity is severly reduced to usually Counting Figures to just about Light Perecption

  • Exceptions to this are those with a cilio-retinal artery ( which makes up 25% of the population)

Signs at the back of the eye include:

  • A Pale oedematous retina especially at the posterior pole
  • Cherry red spot at macula
  • Arterial attenuation – thinner/weakened arteries
  • Segmentation – changes at the arteries
  • Emboli may be seen
  • RAPD ( thus important to do the swinging lights test)
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12
Q

Why is a cherry red spot at the macuola seen in central retinal artery occlusion?

A

The appearance of a cherry red spot , is due to Macula blood supply coming from the choroid via posterior ciliary arteries ( i.e. coming from a different artery - one that hasnt been occluded) and therefore the surrounding retina seems pale in comparison, giving the appearance of a deep red spot.

(Macula is generally thinner so you see this redness coming through)

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13
Q

What is RAPD?

How do we test for RAPD and what do we see if RAPD is present in the test?

A

Relative Afferent Pupillary Defect - Relative Afferent Pupillary Defect (RAPD) is a condition in which pupils respond differently to light stimuli shone in one eye at a time due to unilateral or asymmetrical disease of the retina or optic nerve.

We test for it using the swinging lights test.

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14
Q

What are the late signs of central retinal artery occlusion?

A
  • Optic disc atrophy ( so pale)
  • Continued Arterial attenuation and segmentation
  • VA usually remains markedly reduced despite treatment
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15
Q

What is stenosis?

A

A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure

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16
Q

What is a bifurcation?

A

The division of something into two branches or parts

i.e. if an embolus was lodged in the bifrucation - it would be lodged at the point at which the vessel branches out.

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17
Q

What are the two causes of Central Retinal Artery Occlusion and which one is more common?

A

The two causes of Central Retinal Artery Occlusion are an embolus or thrombus.

Embolus > Thrombus

The embolus is as a result of carotid artery heart disease.

The thrombus can be a result of either a blood clot or stenosis of the carotid artery.

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18
Q

What are the different ways in which an embolus may arise?

A
  • Cholesterol crystals from carotid arteries may break off and travel through the vascular system causing a blockage
  • The embolus may be from Platelet-fibrin arising from large vessel stenosis
  • Calcific emboli arising from carotid valve stenosis
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19
Q

What are the arrows pointing to in the pictures.

What technique has been used to produce the image on the right?

A

The arrow in the coloured photo is pointing to an embolus.

The black and white photo has been produced via fluorescein angiography .

The arrow on the black and white photo is showing the appearance of a darkened vessel - i.e. a vessel in which blood is not flowing through.

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20
Q

What are the risk factors for Central Retinal Artery Occlusion?

A
  • Systemic hypertension
  • Diabetes mellitus
  • Hyper-lipidemia
  • Carotid artery disease
  • Coronary artery disease
  • TIA (Transient Ischaemic attack)/CVA
  • Giant cell arteritis
  • Tobacco smoking
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21
Q

What is the optometric managment of Central Retinal Artery Occlusion?

A

•Measure visual acuity

-Check pupils

•Urgent referral to Eye Casualty

-If < 12 hours old ( there is a chance we can restore vision the less time it has been)

•First Aid - aim to dislodge embolus - we do this by the following:

  • Ocular digital massage
  • Breathe into paper bag to Increase CO2 levels - to essentially dislodge the embolus
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22
Q

What is the Ophthalmological management for Central Retinal Artery Occlusion?

A

• To Reduce IOP - this is done via the following:

  • Anterior chamber paracentesis
  • Intravenous acetazolamide and ocular massage

•Dilation of arteries - this may be done via the following:

  • Ocular massage
  • Retrobulbar vasodilator drugs
  • Inhalation of carbogen

•Lysing of embolus/thrombus

•Systemic anticoagulants

•INVESTIGATION OF CAUSE

-Increased mortality ( state of being subject to death) with presence of emboli

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23
Q

In what age group is BRANCH retinal artery occlusion most common?

A

70+ pxs

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24
Q

What is normally the cause of BRANCH Retinal Artery Occlusion?

A

An embolus

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25
Q

What is the most common location for a BRANCH Retinal Artery Occlusion?

A

90% of cases are occlusion of temporal retinal arteries

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26
Q

What are the symptoms of BRANCH Retinal Artery Occlusion?

A

•Sudden painless loss of vision

  • Hemifield or sector loss of vision
  • Likely superior Visual Field loss
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27
Q

What is the prognosis of a Branch Retinal Artery like?

A

After course of treatment around 74% of px have a visual acuity around 6/12 however the visual field defect will still be there.

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28
Q

What is a central retinal vein occlusion?

A

An Obstruction of the central retinal vein below the lamina cribosa

29
Q

What is the epidemiology of Central Retinal Vein Occlusion?

A
  • More commonly affects older people in their mid-sixties, but can also occur in younger patients
  • Male to female ratio equal 5.2 in 1,000 ( so slight prefernce for males)
30
Q

What are the symptoms of Central Retinal Vein Occlusion?

A
  • Sudden painless loss of vision
  • Variable deficit (i.e. visual acuity affected is variable)
  • May go unnoticed (as it only affects one eye and to a variable degree)
31
Q

What are the signs of central retinal vein occlusion?

A
  • Blood and thunder” is the term given as there is a lot of activity in all four quadrants.
  • Flame-shaped haemorrhages in all 4 quadrants
  • Disc oedema
  • Venous dilation
  • Multiple cotton wool spots
  • Px is likely to have RAPD

[Macula oedema may occur)

32
Q

What are the two types of Central Retinal vein Occlusion?

A

Ischaemic and Non-Ischaemic.

33
Q

If untreated what percentage of Non-Ischaemic Central Retinal Vein Occlusions become Ischaemic?

A

20%

34
Q

What are the differences in signs between Ischaemic and Non-Ischaemic Central Retinal Vein Occlusions?

A
35
Q

What is the difference in fundus photography between an Ischaemic and Non-Ischaemic Central retinal Vein Occlusion?

A
36
Q

What is a possible complication of Ischaemic Central Retinal Vein Occlusion?

A

That it develops to form retinal and iris neovascularisation.

Which can cause neovascular glaucoma.

37
Q

What is neovascular glaucoma also called and why?

A

“100 day glaucoma” because it typically presents around 3 months after central retinal vein occlusion

38
Q

What is neovascular glaucoma caused by?

A

Retinal hypoxia which causes angiogensis substances to be released which induce formation of new vessels in the angle. Thus the Fibrovascular membrane develops across the trabecular meshwork.

39
Q

Why is neovascular glaucoma concerning?

A

Early intervention is required and even then the efefcts can be quite devistating.

‘Intractable’ - i.e. this condition is hard to deal with

40
Q

What are the two main types of causes of Central Retinal Vein Occlusion? - give examples of each

A

Systemic and ocular.

Systemic causes include:

  • Systemic hypertension
  • Diabetes
  • Arteriosclerosis
  • Hyperviscosity syndromes
  • Oral contraceptive pill is a risk factor

Ocular causes include:

•Raised IOP > 30mmHG

41
Q

What is the optometric managment of Central Retinal Vein Occlusion?

A

First thing to do is check the intra-ocular pressure depending on that you…

42
Q

What is the ophthalmological managment for Central Retinal vein occlusion?

A

•Fluorescein angiogram will occur to check whether it is Ischaemic or non-ischaemic.

•New vessels will be dealth with via:

  • Pan-retinal photocoagulation
  • or Intra-vitreal anti-VEGF? ( depends case by case)

•If there is the presence of Macula oedema:

  • Intravitreal steroids will be used e.g. triamcinolone acetonide, or dexamethasone bigradeable implant
  • Intravitreal anti-VEGF (eg Lucentis)

•Investigation and treatment of underlying cause will be done

43
Q

What is the cause of a Branch retinal vein occlusion?

A

Normally a systemic cardiovascular cause

44
Q

What is the symptom of a branch retinal vein occulsion?

A

Hemi-field loss

45
Q

What clinical signs will a px with a branch retinal vein occlusion present with?

A
  • An Obstructed vein which is dilated and tortuous
  • Retinal oedema
  • Scattered superficial and deep retinal haemorrhages- that respect the horizontal midline, and are confined to one quadrant
46
Q

What is the optometric management of Branch Retinal Vein Occlusion?

A
  • Measure visual acuity
  • Fundus examination (Dilated BIO)
  • Check Pupil reactions
  • Check Visual field

•

  • Refer to GP cardiovascular investigation
  • Ophthalmological referral
47
Q

What is the ophthalmological management of Branch retinal vein occlusion?

A
  • Fluorescein angiogram
  • Grid laser coagulation if macula oedema persistent
  • Retinal neovascularisation rarer in BRVO
  • Prognosis good if treated VA ≥6/12

ØBut 25% will have VA <6/60

48
Q

Which image shows a central retinal vein occlusion and which image shows a branch retinal vein occlusion?

A

The branch retinal vein occlusion is where the haemorrhaging is restricted to one quadrant.

49
Q

What is anterior Ischaemic Optic Neuropathy?

A

Ischaemia of the anterior optic nerve head by occlusion of the posterior ciliary arteries.

50
Q

What is the epidemiology of Anterior Ischaemic Optic Neuropathy?

A
  • Almost exclusively after the age of 50 years
  • Incidence 18 per 100,000 after 50 years
  • Woman > men (2:1 ratio)
51
Q

What are the two types of anterior Ischaemic optic neuropathy?

A

Arteritic (A-AION)

and

Non-Arteritic (NA-AION)

52
Q

Which type of Anterior Ischaemic Optic Neuropathy is most common?

A

Non-Arteritic Anterior Optic Neuropathy (NA-AION)

It accounts for about 90-95% of cases

53
Q

What is Arteritic Anterior Ischaemic Optic Neuropathy (A-AION) associated with?

A

(Temporal) Artertitis

54
Q

What are the symptoms of Arteritic Anterior Ischaemic Optic Neuropathy (A-AION)?

A

Profound Loss of vision ( to the point where the px has either no light perception , light perception, or can just about see hand movements).

55
Q

What is the typical age group for Arteritic Anterior Ischaemic Optic neuropathy (A-AION)?

A

70-80 age group (i.e. Older Pxs)

56
Q

What are the clinical signs of Arteritic Anterior Ischaemic Optic Neuropathy?

A
  • Pale oedematous optic nerve head
  • There may be Splinter haemorrhages on the optic disc
  • RAPD
57
Q

What are the complications/risks of Arteritic Anterior Ischaemic Optic Neuropathy (A-AION)?

A
  • Risk of visual loss in other eye
  • Myocardial infarction
  • Renal failure
  • Aortic aneurysm
58
Q

What is temporal arteritis and what is it also known as?

A

It is the inflammation of medium and large arteries.

It is also known as Giant cell arteritis (GCA)

59
Q

What are the symptoms of Temporal/Giant cell arteritis?

A

•Headache which is:

  • normally constant
  • has a gradual onset to a diffuse severe aching
  • superficial scalp tenderness - temporally
  • worse at night and in the cold

•General malaise, weight loss, jaw claudication, amaurosis fugax

•

•Polymyalgia rheumatica

60
Q

What is malaise?

A

A general feeling of discomfort, illness, or unease whose exact cause is difficult to identify.

61
Q

What is jaw claudication?

A

Pain in the jaw associated with chewing

62
Q

What are the symptoms of Non-Arteritic Anterior Ischaemic Optic neuropathy ?

A

•Sudden loss of vision

ØMild to severe

ØUsually on waking

ØVision loss either static or progressive

63
Q

What is Non-Arteritic Anterior Ischameic Optic Neuropathy associated with?

A

Hypertension and diabetes

64
Q

What are the clinical signs of Non-Arteritic Anterior Ischaemic Optic Neuropathy?

A

•Oedematous optic nerve head

ØDiffuse or segmental

ØHyperaemic or pale

i.e. shows an ‘at risk’ disc

•Visual field loss

ØUsually altitudinal

•Contralateral eye ( i.e. eye not affected) shows:

ØSmall disc

ØSmall or absent cup

65
Q

True or false - 20% of Pxs with Non-Arteritic Anterior Optic Neuropathy lose vision in the other eye within 5 years.

A

True

66
Q

What’s the prognosis like for Non-Arteritic Anterior Ischaemic Optic Neuropathy?

A

Only a third of Pxs are left with near normal vision after treatment.

67
Q

What is the optometric management for Anterior Ischaemic Optic Neuropathy?

A

To investigate:

  • VA, Pupils, Colour vision, VFs, IOP
  • Dilated fundus examination?

EMERGENCY REFERRAL TO CASUALTY - contact ophthalmologist

[Assume arteritic until proven wrong]

68
Q

What is the ophthalmological management for Anterior Ischaemic Optic Neuropathy?

A

Investigation:

  • Blood Tests
  • Temporal Artery Biopsy
  • Scans (Doppler, MRI)

Management:

  • Aspirin, treatment of cardiovascular problem
  • If arteritic high doses of systemic steroids for years
69
Q
A

Introduction to Eye Disease - Year 2 (40 decks)

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