Vascular/Retinal Disorders Flashcards
What is important to remember when transporting a retinal detachment to referral?
patient head positioned so retinal tear is placed at lowest point of eye to minimize extension
inferior – keep head upright
temporal – keep temporal side of head down
minimize motion of eyes
What is the prognosis of retinal detachments?
90% can be cured. The worst are if the macula detaches or long time of detachment.
What are potential complications of retinal detachment?
vision loss or decreased visual acuity, recurrence, cataract formation, glaucoma
What is the development of the nonproliferative diabetic retinopathy?
asymptomatic –> symptomatic
retinopathy –> maculopathy
What types of macular degeneration are there and which is the most common?
wet and dry (much more common)
What is the clinical presentation of dry macular generation?
central vision loss, gradual, bilateral, distortion of images, scotomas, declining visual acuity
What are risk factors for macular generation (both!)?
age related, female, white, tobacco, alcohol, excessive sunlight, CAD, HTN, HLD, family Hx, hyperopia, light iris
What is the causation of dry macular degeneration?
cellular debris Densen accumulates between retina and choroid leading to scarring and atrophy
What helps in diagnosis for dry macular degeneration?
Snellen (visual acuity), Amsler grid (curvy if +), need DILATED eye exam, focused exudates called DRUSEN upon exam
What is the treatment of dry macular degeneration?
vitamins help! STOP SMOKING!!!
Pegcetacoplan & avacincaptad pegol injection
note risk of wet ARMD
What is the clinical presentation of wet macular degeneration?
RAPID onset and severe, hemorrhaging and fibrosis within the eye, bilateral CENTRAL vision loss, distortion, scotomas
What is the causation of wet macular degeneration?
new blood vessels popping up that leak blood and hemorrhage and fibrosis
What is the key on fundoscopy for wet ARMD?
fluorescein angiography can help, but really a lot of blood in eye
What does chronic steroid use cause?
glaucoma
How do you treat wet ARMD?
inhibitors of vascular endothelial growth factors (VEGF)
-mab
ranibizumab, bevacizumab, aflibercept, farcimab
brolucizumab risk of vision loss
What is the clinical presentation of retinal detachment?
curtain of vision loss, LONG LASTING, med emergency, acute onset, tunnel vision
photopsias followed by floaters
What are the risk factors for retinal detachment?
age, myopia, cataract extraction, ocular trauma, smoking, DM retinopathy
What are the two kinds of retinal detachment?
rhegmatogenous detachment “natural” MCC – fluid goes into subretinal space, detaches
tractional - scars pull on retina, exudative- fluid trapped (wet ARMD), causes detachment
What does the fundoscopy look like for retinal detachment?
retina elevated and gray/cloudy, superior temporal quadrant; wave on a beach
Positive Shafer’s sign of clumping brown pigment
What is the treatment for retinal detachment?
closing retinal holes and tears through laser photocoagulation, crypexy, pneumatic retinopexy, vitrectomy
if exudative/secondary, treat underlying cause
What is the clinical presentation of diabetic retinopathy?
blurry vision, decreased acuity, visual distortion, scotomas not always noticed
proliferative has more severe symptoms
What are risk factors for diabetic retinopathy?
Diabetes. 99% type I get it. 60% type II. 20% already have it with uncontrolled diabetes
What is the difference between nonproliferative or proliferative diabetic retinopathy?
Nonpro- circinate ring yellow exudates, cotton wool spots
pro- growth of new vessels and fibrous tissue
What is important to always do on diabetic patients?
need baseline fundoscopy after diagnosis of type II, 5 years after type I, then annual dilated exam
How do you manage diabetic retinopathy?
optimize control of BG, BP, kidney function, lipids (could worsen before getting better..initially check every 3-4 months until managed for 18-24 months)
VEGF inhibitors – Ranibizumab, bevacizumab, aflibercept, faricimab, brolucizumab may do laser photocoag, corticosteroid, virectomy
What is the treatment for severe diabetic retinopathy?
panretinal laser photocoagulation prophylatically
What is the clinical presentation and cause of acute hypertensive retinopathy?
sudden onset of severe HTN >200/110 which could be from hyperthyroidism, drugs, pregnancy
What would confirm hypertensive retinopathy on a fundoscopy?
cotton wool spots, dot blot and flame hemorrhages, papilledema
What makes chronic hypertensive retinopathy different on a fundoscopy (note: hard to see, so just good to know)?
AV nicking and crossing, hemorrhage, narrowing, copper/silver wiring (severe), macular star
How do you treat acute hypertensive retinopathy?
emergency! Treat underlying cause!
Complications: retinal detachment, optic neuropathy
What are the risks for acute hypertensive retinopathy?
older patients
what are the risks for chronic hypertensive retinopathy?
high sodium, obesity, tobacco, alcohol, family hx
What is the cause of chronic hypertensive retinopathy?
chronic HTN; atherosclerosis
How do you treat chronic hypertensive retinopathy?
increase risk of stroke -> MI, CAD, PAD, ARMD
control HTN!!!!!!!!!!!!
comps=retinal vein occlusion, retinal detachment, optic nerve atrophy
What is the clinical presentation of retinal artery occlusion?
sudden monocular vision loss – no pain, redness, UNILATERAL
this is assumed with these symptoms
What are risks for retinal artery occlusion?
diabetes, hyperlipidemia, HTN, young = migraines, oral contraceptives, vascular disease
What is the cause of retinal artery occlusions?
occlusion of CENTRAL or BRANCH artery (eye stroke), embolism/thrombosis (thrombophilic disorders, SLE, giant cell arthiritis) from atherosclerotic plaques, atrial fibrillation, endocarditis
What’s the difference between acute and chronic papilledema?
acute = no loss of acuity
chronic/severe acute = visual field loss, profound loss of acuity
What should you consider with retinal artery occlusion?
ask about neck pain, neck trauma –> carotid artery dissection
giant cell arteritis (check inflammatory mediators); if >50 yr old with central occlusion
young people check for clotting disorders!
What on the fundoscopy is key for retinal artery occlusion?
central =cherry red spot, “box car” segmentation, pale optic disk
branch= cotton wool spots, limited to area
What do you do to manage retinal artery occlusion?
work up as a stroke!!!!!!! urgent referral to ER for imaging
angiography, opthalmology referral
lay patient flat, ocular massage, high conc. of inhaled O2, IV acetazolamide, anterior chamber paracentesis
What is the clinical presentation of vein occlusion?
more common –> sudden monocular loss of vision, no pain or redness
maybe RAPD?
What is a risk for vein occlusion?
glaucoma but everything from artery too: diabetes, hyperlipidemia, HTN, young = migraines, oral contraceptives, vascular disease
What causes a retinal vein occlusion?
clot formation
Virchow’s triad: vessel damage, stasis, hypercoagulability, atherosclerosis
What is key on fundoscopy of retinal vein occlusions?
central = widespread hemorrhages, cotton-wool spots, optic disk swelling “blood & thunder”
branch = confined to area
How do you treat a retinal vein occlusion?
VEGF inhibitor injection for macular edema
Panretinal laser photocoagulation for neovascularization
or
Triamcinolone (central), implant with dexamethasone (either), focal laser coag (branch)
