Vasculopathies, Herpes, Cataract Flashcards
Vasculopathy
disorder in blood vessels, commonly resulting in poor blood supply or flow to ocular tissues
What retinal finding is the result of ischemia to retinal tissue?
cotton wool spot
What does disrupted blood flow result in?
interrupted axoplasmic flow and deposition of axoplasmic debris at the level of RNFL
What diseases can CWS be associated with?
DM, HTN, RVO, emboli, GCA, HIV, infections
What is a CRAO?
blockade of the central retinal artery due to emboli, GCA, collagen-vascular disease, hypercoagulable states etc
What are symptoms of CRAO?
dramatic, painless vision loss
What are signs of CRAO?
whitening of retina/cherry red spot, APD, arteriole box-carring
What is the workup for CRAO?
ESR/CRP to rule out GCA, BP, blood work for DM and hypercoagulable states and systemic inflammatory disease, eval carotids, cardiac eval
What is the treatment of CRAO?
acute tx within 2 hours may improve VA– ocular massage, anterior chamber paracentesis, IOP decrease (orals), breath into bag for CO2
What is the goal of acute tx of CRAO?
vasodilation and clearing of the embolus by increasing pressure on retinal arteries for vasodilation or increased ventilation of CO2 which causes respiratory acidosis
When should you follow up with CRAO?
1-4 weeks to eval for neo
What is BRAO?
blockade of a branched retinal artery
What are symptoms of BRAO?
sudden, dramatic loss of partial vision/hemianopic defect
What are signs of BRAO?
whitening of retinal tissue where vasculature is impacted
Does BRAO have a lower or higher risk of neo as CRAO?
lower risk of neo
What is CRVO?
blockade of central retinal vein
What are causes of CRVO?
atherosclerosis in CRA, HTN, disc edema, glaucoma, disc drusen, hyperccoagulable stress
Where to CRVOs occur?
the area where the artery and veins share adventitia (especially lamina cribrosa) due to increased tension in artery leading to compression on vein
`What are symptoms of CRVO?
painless loss of vision or commonly asymptomatic
What are signs of CRVO?
diffuse retinal flame hemes, dilated and tortuous veins, CME, collateral vessels at disc, neovascularization
What distinguishes ischemic CRVO?
capillary non-perfusion
What is the workup for CRVO?
BP, blood work for DM, hypercoagulable ds, VDRL/FTA-AS, cardiac workup
What is the most common systemic cause of CRVO?
HTN
What increases the risk of neo in CRVO?
ischemia, NVI leads to 90 day glaucoma
What is the treatment of CRVO?
PRP or anti-VEGF for neo, anti-VEGF, kenalog or steroid implants for CME
When should you follow up for CRVO?
every 1-2 months for neo, including gonio for NVI/NVA
What are symptoms of a hemi or branch RVO?
blind spot, hemi-filed defect
How is neo in hemi RVO different that in CRVO?
neo more commonly NVD for hemi as compared to central
What is workup and tx of hemi RVO?
same as CRVO
What is Ocular ischemic syndrome?
reduction of ocular blood flow due to vascular occlusion proximal to ophthalmic artery (obstruction that occurs before the ophthalmic artery
What is the number 1 cause of OIS?
carotid occlusion, secondarily sometimes GCA
What are signs of OIS?
mid-peripheral blot hemes, dilated but non-tortuos veins, arterial attenuation
What does anterior segment ischemia lead to in OIS?
corneal edema, uveitis, and cataract
What is the vision loss like in OIS?
variable
What neo eval is needed for OIS?
eval closely for iris/angle neo, does not always originate at pupillary boarder
What vascular work up is needed for OIS?
carotid eval, blood work for GCA aka ESR CRP and temporal biopsy
What is treatment of OIS?
anti-vegf or PRP for neovascularization, also tx cataracts, uveitis and glaucoma
What 6 herpetic disease infect the eyes
simplex 1, simplex 2, varicella zoster, cytomegalovirus, epstein-barr, herpes virus 8
What is HSV 1 vs 2
1:facial lesions 2:genital
How is HSV spread?
infection from direct contact with salivary droplets or genital secreations
How long does HSV live on a tonometer?
2 hrs if dry and 8 hours if damp
What cleaning supply should be used for HSV?
70% isopropyl alcohol is cidal
Where does HSV remain latent?
trigeminal ganglion
What is the most common infectious cause of corneal blindness?
herpes simplex
T/F primary ocular infection is rare
true, rather ocular presentation is usually recurrence of oral infection that had been latent in trigeminal ganglion
What is the initial ocular presentation of herpes simplex?
commonly its rapidly progressing dendrites
What do dendrites stain with?
centrally with NaFl and edges/terminal edge bulbs with rose bengal or lissamine green
What form of herpes simplex is more significant in children?
recurrence and stromal disease
What is the Topical treatment of HSV?
trifluridine 9x/day; vidarabine (not US), ganciclovir 5xday, Avaclyr removed from market
What is oral treatment of HSV?
oral acylovir 400 mg 5x/day
What did HEDS find in terms of topical and oral?
no benefit in adding acyclovir to trifluridine and topical steroid aka no adjunctive therapy
In an active infection what oral therapy may reduce load in ciliary ganglion?
Famciclovir 250 mg 3x, Acyclovir 400 mg 5x, Valacyclovir 500 mg 3x
When can you use topical steroid in HSV?
with significant resolution of epithelial lesion
What does HEDS recommend for maintenance doses?
Acyclovir 400 mg BID or valacyclovir 500 mg qday
Why use a maintenance does for HSV?
1 year recurrence reduced from 32% to 19%
What amino acid can be considered with herpes?
L-lysine, essential amino acid, can inhibit viral replication in greater concentrations
What does of L-lysine is given for active disease and prophylactiv?
active- 2 gram/day, prophylactic 1 gram/day
What is herpes zoster?
shingles, reactivation of the varicella zoster virus that causes chickenpox
What is the chicken pox vaccine?
Varivax, may get zoster at a younger age
Where does herpes zoster remain latent?
trigeminal ganglion
What are the 1st and 2nd most common locations of reactivation for zoster?
1st torso and 2nd eye
What are risk factors of zoster?
increased age, caucasian, female, immune suppression, local trauma
What ocular damage can zoster cause?
corneal scars, uveitis, cataract, glaucoma, and macular edema
What is the sign on the nose indicating ocular involvement of zoster
Hutchinson’s sign
How many patients with zoster affecting V1 of the trigeminal have ocular involvement?
50-70%
What is papillovesicular rash?
rash on skin common with zoster viral prodrome
What are mucus plaques?
pseudodendrites on the cornea and conj from zoster
How do pseudodendrites differ from dendrities?
pseudo do not truly arborize and won’t have terminal end bulbs that stain with rose bengal
When might zoster cause IOP change?
if trabeculitis, IOP will increase
What is the oral treatment of zoster?
famciclovir 500 mg 3x, acyclovir 800 mg 5x, valacyclovir 1000 mg 3x
When are oral antivirals most effective in zoster?
within 48 hours of presentation of vesicles
What is post-herpetic neuralgia?
significantly painful even when skin may look resolved
What is the recommended shingles vaccine?
shringrix, recommended over 50 years, 2 shots 6 months apart, sore shoulder
T/F there are zoster strains resistent to oral antivirals
true, if resistant to one it is resistant to all
What can you use to treat resistant strains of zoster?
foscarnet, amenamevir in Japan
T/F an OD can arrange additional benefits to schedule cataract consultation with a specific provider
false
What are you looking for in pre-op cataract examination?
blepharitis, corneal health, lens, macula
Why is blepharitis important?
increased risk of infection/endophthalmitis
Why should you evaluate the cornea before cataract surgery?
phacoemulsification can exacerbate Fuchs/guttata
Why should you evaluate the macula before cataract surgery?
edema will be exacerbated in phaco, macular disease impacts BCVA, candidacy for premium IOLs
What are BCVA tests to estimate post cataract acuity?
brightness acuity test, potential acuity meter, super pinhole
What VA is recommended to go through with surgery?
20-40 to 20/50
What is femtosecond laser assisted cataract surgery?
infrared laser with extremely short pulse, photodisruption/photoionization with small plasm cloud, YAG-like but far less energy
What are advantages of infrared laser (FLACS)?
intricate incisions on cornea, astigmatism correction, capsulorhexis, lens fragments
Compare outcomes for femtosecond laser and standard incision phaco
outcomes are similar but phaco time is reduced with FLACS
What are pros of FLACS?
phaco time is reduced which is beneficial to corneal endothelium and possible less risk for RD/floaters
What are cons of FLACS?
possible more inflammation, higher concentration of prostaglandins leading to potential macular edema risk
What is the post op schedule?
1 day, 1 week, 1 month
What do you need to do before the first day post-op?
transfer of care signed form and receive op-notes
What are op-notes?
detailed documentation of how the surgical procedure was performed
What are two possible incisions?
scleral tunnel and clear cornea
What are alternative to incision sites?
laster assisted aka femtosecond laser (corneal incision, capsulorhexis), MIGS, dropless surgery
What are examples of MIGS?
iStent, Hydrus, OMNI 720
What is the pre-operative medication regimen?
3 days prior to surgery start antibiotic and NSAID drops
Expectation for day 1
may have patch and shield, slight ptosis from speculum, EOMS palsy from retrobulbar block
Day 1 acuity
SC, pinhole
Day 1 chair skills
pupils, EOMs, CVF– pupils may still be dilated
Day 1 IOP
may have spiked from trabeculitis or viscoelastic retained in AC
Day 1 A seg
corneal abrasion or edema, may have suture, descemets detachment, seidel, sub conj heme, 2-3+ AC cells
What structures should you check Day1?
IOL positioning, retina intact, no choroidal effusion
What is an appropriate day 1 IOP?
5 to 25 mmHg
What to do if low IOP day 1?
seidel, pressure patch vs bandage CL with eye shield, wound leak with shallow AC will need surgical consult
What to do if high IOP day 1?
drops in office of send drops home or oral meds
What can cause persistent dilation day 1?
pledget/sponge with mydriatic solution used in inferior cul-de-sac during surgery
What is toxic anterior segment syndrome?
acute, sterile anterior chamber reaction, occurs within 24-58 hours, inflammatory response to intraoperative fluids, instruments etc
How does toxic anterior segment syndrome present?
limbus to limbus corneal edema, potential AC reaction with mild hypopyon, minimal discomfort
What is treatment of toxic anterior segment syndrome?
steroid every 15 mins in office for an hour then every hour at home
How is toxic anterior segment syndrome different than endophthalmitis?
TASS is anterior seg only, no vitreal or p seg involvement
What is the post-op medication regimen?
topical antibiotic qid, NSAID q day, steroid qid
What does the patient need to know post op?
don’t rub eye, no heavy lifting >10 lbs, fox shield at night, no soapy or tap water in eyes
What are day 1 complications?
decreased VA, IOP, corneal abrasion or edema, seidel, AC response, choroidal effusion
Causes of day 1 acuity decrease?
cornea, refractive error, tilted IOL, mydriasis
IOP treatment day 1 cataract post-op
port release for acute IOP spike, rapid relief or sample hypotensive but not prostaglandin
Treatment of corneal abrasion/edema following cataract surgery
maintain antibiotic and steroid or start hyperosmotic
What happens if there is a small fragment of retained lens?
high pulse dose of steroid may “melt” it or they may need to go back to OR to wash out AC
Port release
anesthetize eye, instill antibiotic, use sterile currete with rounded side towards globe and place pressure peripheral to paracentesis incision
Scleral tunnel incision
incision at the superior cornea and paracentesis site made with blade to the temporal side
When does endophthalmitis present?
4-10 days post op
What is the most common cause of endophthalmitis?
organisms causing blepharitis entering the incision site during surgery
Treatment of endophthalmitis?
consult with surgery to keep in the look, commonly direct retinal consult-vitrectomy and intraocular antibiotics, fortified antibiotics, oral antibiotics, sub-conj/intravitreal antibiotics
1 Week VA
SC, pinhole, may refract/rx, vision should be doing well
1 week chair skills
core four
1 week IOP
should be doing well, steroid response usually 2 weeks
1 week A seg
look for corneal edema, AC reaction should be reducing significantly, IOL positioning, posterior capsule
1 week complications
endophthalmitis/infection, corneal edema, uveitis, elevated IOP from uveitis
What does the patient need to know at 1 week?
can stop restricted activity, taper steroids, may reduce or stop NSAID/antibiotic, may Rx spec or wait until 1 month
1 month post op
comprehensive exam
1 month a seg
if corneal edema, look for fragments or corneal endothelial disease, AC response should be gone, IOL centering
What is CME after cataract surgery?
irvine gas syndrome
Treatment of PCO
YAG PC, be mindful of globals/FUDs
What is treatment for CME?
topical steroids and NSAIDS esp nepafenac or intravitreal injection of triamcinolone or anti-vegf
What is a “dropless” surgery?
antibiotic and steroid medications are injected during surgery
What meds are used in dropless srugery?
TriMox (triamcinolone and moxifloxacin) or dex-moxi (dexamethosone and moxifloxacin
Which dropless surgery med is less cloudy but has greater risk of steroid response?
dex-moxi
What are the steroid implants?
Dextensa intracanalicular and Dexycu intracameral aka in the anterior chamber
What is the 5 year mortality of OIS?
40% because carotid blockage
YAG PC pattern
cruciate or cross-shaped pattern or circular
