VASCULAR OCCLUSIONS AND HYPERTENSIVE RETINOPATHY Flashcards
what is the inner retina supplied by
the retinal artery and veins
what is the outer retina supplied via
the choroidal vasculature
which circulation does the cilio retinal artery come from and how many % of people have one
choroidal circulation
10-20%
name 2 types of artery occlusions
Retinal artery occlusion
Cerebrovascular
list 4 types of retinal artery occlusions
- Central retinal artery occlusion
- Branch retinal artery occlusion
- Transient ischaemic event – Amaurosis Fugax
- Cilioretinal artery occlusion
what type of artery occlusion does this demonstrate and what type of field defect would this px have
CRAO
this px has a cilio retinal artery - the fovea will still remain perfused hence can still see centrally as coming from the choroidal circulation
what type of artery occlusion does this represent
superior hemi retinal artery occlusion
superior trunk is affected
which type of artery occlusion does this represent
superior branch temporal artery occlusion
what type of elderly px’s are affected with a cilio retinal artery occlusion and which type of young px’s
elderly with GCA
young - usually a flow problem as opposed to an occlusion
what does this photo signify
CRAO cherry red spot with retinal and macula thickening/oedema
the fovea is not thickened hence the difference in colour
list 5 risk factors of a CRAO
• Age
• Cardiovascular risk factors
• GCA
• IVDU - drug takers
• Cosmetic fillers
list 5 GCA symptoms
• Headache – temporal
• Temporal tenderness
• Jaw claudication / ‘angina’
• Weight loss / loss of appetite
• PMR - shoulder aches
where should a px presenting with a CRAO be referred to
Refer to stroke team
GP/A&E
what 5 actions should be carried out for a px with a CRAO acute <4 hrs
Thrombolysis
re-breathing bag
ocular massage
Diamox
paracentesis
what is the management of someone presenting with a CRAO >4 hrs
Manage risks – refer stroke team/TIA clinic
list 3 variants of a BRVO
• Hemi
• Quadrant – superior temporal, inferior temporal, inf nasal, sup nasal
• Macular branch
list the 5 effects of a vein occlusion
• Venous outflow is reduced
• Flow within the retinal vessels reduced
• Resistance to arterial flow into the occluded system – (see video)
• Results in overall poor circulation within the affected area
• Retinal cell injury - Ischaemia - VEGF - which causes oedema
what is this FA image showing
BRVO
what can a cilio retinal artery be secondary to
secondary to CRVO
what condition does this OCT image show
CRVO
OCT shows thickening and hyper reflectivity in that region
in which type of patients will you see a Central Retinal Vein Occlusion (CRVO) with associated cilioretinal artery occlusion and what type of prognosis will you expect
what will you want investigated for as a possible underlying cause for this px
Usually in young patients with CRVO
Good outcome in young patients - vision eventually recovers ~ in 6 months
Blood investigations - thrombophilia screen, vasculitis screen e.g. for suspect behcets disease
what does this FA show
Retinal Vein Occlusion – macular BRVO
can see vessels above the fovea are tortuous with aneurysm which leak
list 4 risk factors of a vein occlusion
Hypertension
Hypercholesteraemia
Age
Thrombophilia/inflammatory (in younger patients)
name 2 complications from a retinal vein occlusion
• Macular oedema
• Neovascularisation
In history taking, what question will you ask an older px and what 5 things will you ask a younger px
Older px: Cardiovascular risk factors – BP, cholesterol, CVA, MI
Young patients
• DVT/PE
• Miscarriages
• contraceptive pills
• family history
• oral ulcers
list 6 investigations you will want to carry out on a suspect Vein Occlusion
• VA
• RAPD
• IOP
• gonioscopy
• Inflammation
• central venous pressure
which 2 types of imaging will help with assessing a vein occlusion and why
• OCT
DRIL (Disorganization of Retinal Inner Layers)
CMO
• Angiography (FFA)
Confirm diagnosis
Assess perfusion – ischaemic/non-ischaemic
what is the 2 management options for ischaemic crvo
- monthly anti VEGF injections for 6 months and observe
or - if very ischaemic , prophylactic PRP can be considered
what will significantly large areas of ischaemia / non-perfusion result in - when seen in a crvo
high risk of neovascular complications
> 10DA in the posterior pole
what 3 signs will you usually but not necessarily see in your clinical examination of an ischaemic crvo
RAPD
VA <3/60
multiple deep blot haem throughout retina
what anterior segment sign can you seen from an ischaemic crvo and what can this lead to
Iris - rubeosis
Angle – causes neovascular glaucoma
when is anti VEGF tx given to a person with ischaemic crvo and what needs to be controlled first
Given in NVG but control IOP before injecting
what is the longer lasting tx option for neovascularisation due to ischaemic crvo
panretinal photocoagulation
what is a common complication of ischaemic crvo
macula oedema
what are the 2 tx options to treat macula oedema for a crvo and possible tx for a brvo
intravitreal steroids
anti VEGF
possible macula laser for brvo
name 2 types of intravitreal steroidal injections used to treat a crvo
Ozurdex
IVTA
what is the outcome of taking Intravitreal anti-VEGF to manage macula oedema due to ischaemic crvo
50% - 15 letter improvement
what is the outcome of someone taking Intravitreal dexamethasone to treat macular oedema due to ischaemic crvo and name 2 disadvantages
40% - 15 letter improvement
Risk cataract (30%) / IOP rise (12-15%)
name 3 signs of mild Hypertensive Retinopathy
Focal arteriolar narrowing
AV nipping
Copper wiring
name 2 signs additional of moderate Hypertensive Retinopathy
Haemorrhages and cotton wool spots
in addition to
Focal arteriolar narrowing
AV nipping
Copper wiring
name the 3 main signs of MALIGNANT Hypertensive Retinopathy
Haemorrhages
CWS
&
disc swelling
in which types of patients will you find Hypertensive choroidopathy
name 3 conditions they can be suffering from
Usually in young patients with acute hypertension
Eclampsia/pre-eclampsia
Renal hypertension
Phaechromocytoma
what causes Ocular Ischaemic Syndrome and what vessel is this a disease of
Poor perfusion to eye
Carotid artery occlusive disease
• >90% closure
• Reduces perfusion by 50%
name 6 ways ocular ischaemic syndrome can be presented/detected
Sudden vision loss (41-66%)
Gradual vision loss (28%)
Amaurosis fugax (15%)
ocular pain (13%)
Bright light amaurosis (20%)
Incidental finding
list 7 anterior signs of ocular ischaemic syndrome
AC activity
Iris atrophy
NVI/NVA/NVG
Corneal oedema
Cataract
Dilated episcleral vessels
IOP: 4-60mmHg - either v low or v high
list 6 posterior signs of ocular ischaemic syndrome
Mid-peripheral ret haem
Venous dilataion
Mas
Easily inducible arterial pulsation
Arteriolar narrowing
NVD
what 4 signs does FA show in an eye with ocular ischaemic syndrome
Patchy choroidal filling
Increased AV transit time
Capillary non-perfusion
Late leakage from arterioles
what signs does an ultra sound show in ocular ischaemic syndrome
Reversal of flow / retrograde flow
