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Integrative Analysis II > Vasculopathies, Herpes, Cataract > Flashcards

Vasculopathies, Herpes, Cataract Flashcards

1
Q

Vasculopathy

A

disorder in blood vessels, commonly resulting in poor blood supply or flow to ocular tissues

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2
Q

What retinal finding is the result of ischemia to retinal tissue?

A

cotton wool spot

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3
Q

What does disrupted blood flow result in?

A

interrupted axoplasmic flow and deposition of axoplasmic debris at the level of RNFL

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4
Q

What diseases can CWS be associated with?

A

DM, HTN, RVO, emboli, GCA, HIV, infections

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5
Q

What is a CRAO?

A

blockade of the central retinal artery due to emboli, GCA, collagen-vascular disease, hypercoagulable states etc

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6
Q

What are symptoms of CRAO?

A

dramatic, painless vision loss

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7
Q

What are signs of CRAO?

A

whitening of retina/cherry red spot, APD, arteriole box-carring

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8
Q

What is the workup for CRAO?

A

ESR/CRP to rule out GCA, BP, blood work for DM and hypercoagulable states and systemic inflammatory disease, eval carotids, cardiac eval

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9
Q

What is the treatment of CRAO?

A

acute tx within 2 hours may improve VA– ocular massage, anterior chamber paracentesis, IOP decrease (orals), breath into bag for CO2

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10
Q

What is the goal of acute tx of CRAO?

A

vasodilation and clearing of the embolus by increasing pressure on retinal arteries for vasodilation or increased ventilation of CO2 which causes respiratory acidosis

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11
Q

When should you follow up with CRAO?

A

1-4 weeks to eval for neo

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12
Q

What is BRAO?

A

blockade of a branched retinal artery

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13
Q

What are symptoms of BRAO?

A

sudden, dramatic loss of partial vision/hemianopic defect

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14
Q

What are signs of BRAO?

A

whitening of retinal tissue where vasculature is impacted

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15
Q

Does BRAO have a lower or higher risk of neo as CRAO?

A

lower risk of neo

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16
Q

What is CRVO?

A

blockade of central retinal vein

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17
Q

What are causes of CRVO?

A

atherosclerosis in CRA, HTN, disc edema, glaucoma, disc drusen, hyperccoagulable stress

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18
Q

Where to CRVOs occur?

A

the area where the artery and veins share adventitia (especially lamina cribrosa) due to increased tension in artery leading to compression on vein

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19
Q

`What are symptoms of CRVO?

A

painless loss of vision or commonly asymptomatic

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20
Q

What are signs of CRVO?

A

diffuse retinal flame hemes, dilated and tortuous veins, CME, collateral vessels at disc, neovascularization

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21
Q

What distinguishes ischemic CRVO?

A

capillary non-perfusion

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22
Q

What is the workup for CRVO?

A

BP, blood work for DM, hypercoagulable ds, VDRL/FTA-AS, cardiac workup

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23
Q

What is the most common systemic cause of CRVO?

A

HTN

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24
Q

What increases the risk of neo in CRVO?

A

ischemia, NVI leads to 90 day glaucoma

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25
Q

What is the treatment of CRVO?

A

PRP or anti-VEGF for neo, anti-VEGF, kenalog or steroid implants for CME

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26
Q

When should you follow up for CRVO?

A

every 1-2 months for neo, including gonio for NVI/NVA

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27
Q

What are symptoms of a hemi or branch RVO?

A

blind spot, hemi-filed defect

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28
Q

How is neo in hemi RVO different that in CRVO?

A

neo more commonly NVD for hemi as compared to central

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29
Q

What is workup and tx of hemi RVO?

A

same as CRVO

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30
Q

What is Ocular ischemic syndrome?

A

reduction of ocular blood flow due to vascular occlusion proximal to ophthalmic artery (obstruction that occurs before the ophthalmic artery

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31
Q

What is the number 1 cause of OIS?

A

carotid occlusion, secondarily sometimes GCA

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32
Q

What are signs of OIS?

A

mid-peripheral blot hemes, dilated but non-tortuos veins, arterial attenuation

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33
Q

What does anterior segment ischemia lead to in OIS?

A

corneal edema, uveitis, and cataract

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34
Q

What is the vision loss like in OIS?

A

variable

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35
Q

What neo eval is needed for OIS?

A

eval closely for iris/angle neo, does not always originate at pupillary boarder

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36
Q

What vascular work up is needed for OIS?

A

carotid eval, blood work for GCA aka ESR CRP and temporal biopsy

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37
Q

What is treatment of OIS?

A

anti-vegf or PRP for neovascularization, also tx cataracts, uveitis and glaucoma

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38
Q

What 6 herpetic disease infect the eyes

A

simplex 1, simplex 2, varicella zoster, cytomegalovirus, epstein-barr, herpes virus 8

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39
Q

What is HSV 1 vs 2

A

1:facial lesions 2:genital

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40
Q

How is HSV spread?

A

infection from direct contact with salivary droplets or genital secreations

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41
Q

How long does HSV live on a tonometer?

A

2 hrs if dry and 8 hours if damp

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42
Q

What cleaning supply should be used for HSV?

A

70% isopropyl alcohol is cidal

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43
Q

Where does HSV remain latent?

A

trigeminal ganglion

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44
Q

What is the most common infectious cause of corneal blindness?

A

herpes simplex

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45
Q

T/F primary ocular infection is rare

A

true, rather ocular presentation is usually recurrence of oral infection that had been latent in trigeminal ganglion

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46
Q

What is the initial ocular presentation of herpes simplex?

A

commonly its rapidly progressing dendrites

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47
Q

What do dendrites stain with?

A

centrally with NaFl and edges/terminal edge bulbs with rose bengal or lissamine green

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48
Q

What form of herpes simplex is more significant in children?

A

recurrence and stromal disease

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49
Q

What is the Topical treatment of HSV?

A

trifluridine 9x/day; vidarabine (not US), ganciclovir 5xday, Avaclyr removed from market

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50
Q

What is oral treatment of HSV?

A

oral acylovir 400 mg 5x/day

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51
Q

What did HEDS find in terms of topical and oral?

A

no benefit in adding acyclovir to trifluridine and topical steroid aka no adjunctive therapy

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52
Q

In an active infection what oral therapy may reduce load in ciliary ganglion?

A

Famciclovir 250 mg 3x, Acyclovir 400 mg 5x, Valacyclovir 500 mg 3x

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53
Q

When can you use topical steroid in HSV?

A

with significant resolution of epithelial lesion

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54
Q

What does HEDS recommend for maintenance doses?

A

Acyclovir 400 mg BID or valacyclovir 500 mg qday

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55
Q

Why use a maintenance does for HSV?

A

1 year recurrence reduced from 32% to 19%

56
Q

What amino acid can be considered with herpes?

A

L-lysine, essential amino acid, can inhibit viral replication in greater concentrations

57
Q

What does of L-lysine is given for active disease and prophylactiv?

A

active- 2 gram/day, prophylactic 1 gram/day

58
Q

What is herpes zoster?

A

shingles, reactivation of the varicella zoster virus that causes chickenpox

59
Q

What is the chicken pox vaccine?

A

Varivax, may get zoster at a younger age

60
Q

Where does herpes zoster remain latent?

A

trigeminal ganglion

61
Q

What are the 1st and 2nd most common locations of reactivation for zoster?

A

1st torso and 2nd eye

62
Q

What are risk factors of zoster?

A

increased age, caucasian, female, immune suppression, local trauma

63
Q

What ocular damage can zoster cause?

A

corneal scars, uveitis, cataract, glaucoma, and macular edema

64
Q

What is the sign on the nose indicating ocular involvement of zoster

A

Hutchinson’s sign

65
Q

How many patients with zoster affecting V1 of the trigeminal have ocular involvement?

A

50-70%

66
Q

What is papillovesicular rash?

A

rash on skin common with zoster viral prodrome

67
Q

What are mucus plaques?

A

pseudodendrites on the cornea and conj from zoster

68
Q

How do pseudodendrites differ from dendrities?

A

pseudo do not truly arborize and won’t have terminal end bulbs that stain with rose bengal

69
Q

When might zoster cause IOP change?

A

if trabeculitis, IOP will increase

70
Q

What is the oral treatment of zoster?

A

famciclovir 500 mg 3x, acyclovir 800 mg 5x, valacyclovir 1000 mg 3x

71
Q

When are oral antivirals most effective in zoster?

A

within 48 hours of presentation of vesicles

72
Q

What is post-herpetic neuralgia?

A

significantly painful even when skin may look resolved

73
Q

What is the recommended shingles vaccine?

A

shringrix, recommended over 50 years, 2 shots 6 months apart, sore shoulder

74
Q

T/F there are zoster strains resistent to oral antivirals

A

true, if resistant to one it is resistant to all

75
Q

What can you use to treat resistant strains of zoster?

A

foscarnet, amenamevir in Japan

76
Q

T/F an OD can arrange additional benefits to schedule cataract consultation with a specific provider

A

false

77
Q

What are you looking for in pre-op cataract examination?

A

blepharitis, corneal health, lens, macula

78
Q

Why is blepharitis important?

A

increased risk of infection/endophthalmitis

79
Q

Why should you evaluate the cornea before cataract surgery?

A

phacoemulsification can exacerbate Fuchs/guttata

80
Q

Why should you evaluate the macula before cataract surgery?

A

edema will be exacerbated in phaco, macular disease impacts BCVA, candidacy for premium IOLs

81
Q

What are BCVA tests to estimate post cataract acuity?

A

brightness acuity test, potential acuity meter, super pinhole

82
Q

What VA is recommended to go through with surgery?

A

20-40 to 20/50

83
Q

What is femtosecond laser assisted cataract surgery?

A

infrared laser with extremely short pulse, photodisruption/photoionization with small plasm cloud, YAG-like but far less energy

84
Q

What are advantages of infrared laser (FLACS)?

A

intricate incisions on cornea, astigmatism correction, capsulorhexis, lens fragments

85
Q

Compare outcomes for femtosecond laser and standard incision phaco

A

outcomes are similar but phaco time is reduced with FLACS

86
Q

What are pros of FLACS?

A

phaco time is reduced which is beneficial to corneal endothelium and possible less risk for RD/floaters

87
Q

What are cons of FLACS?

A

possible more inflammation, higher concentration of prostaglandins leading to potential macular edema risk

88
Q

What is the post op schedule?

A

1 day, 1 week, 1 month

89
Q

What do you need to do before the first day post-op?

A

transfer of care signed form and receive op-notes

90
Q

What are op-notes?

A

detailed documentation of how the surgical procedure was performed

91
Q

What are two possible incisions?

A

scleral tunnel and clear cornea

92
Q

What are alternative to incision sites?

A

laster assisted aka femtosecond laser (corneal incision, capsulorhexis), MIGS, dropless surgery

93
Q

What are examples of MIGS?

A

iStent, Hydrus, OMNI 720

94
Q

What is the pre-operative medication regimen?

A

3 days prior to surgery start antibiotic and NSAID drops

95
Q

Expectation for day 1

A

may have patch and shield, slight ptosis from speculum, EOMS palsy from retrobulbar block

96
Q

Day 1 acuity

A

SC, pinhole

97
Q

Day 1 chair skills

A

pupils, EOMs, CVF– pupils may still be dilated

98
Q

Day 1 IOP

A

may have spiked from trabeculitis or viscoelastic retained in AC

99
Q

Day 1 A seg

A

corneal abrasion or edema, may have suture, descemets detachment, seidel, sub conj heme, 2-3+ AC cells

100
Q

What structures should you check Day1?

A

IOL positioning, retina intact, no choroidal effusion

101
Q

What is an appropriate day 1 IOP?

A

5 to 25 mmHg

102
Q

What to do if low IOP day 1?

A

seidel, pressure patch vs bandage CL with eye shield, wound leak with shallow AC will need surgical consult

103
Q

What to do if high IOP day 1?

A

drops in office of send drops home or oral meds

104
Q

What can cause persistent dilation day 1?

A

pledget/sponge with mydriatic solution used in inferior cul-de-sac during surgery

105
Q

What is toxic anterior segment syndrome?

A

acute, sterile anterior chamber reaction, occurs within 24-58 hours, inflammatory response to intraoperative fluids, instruments etc

106
Q

How does toxic anterior segment syndrome present?

A

limbus to limbus corneal edema, potential AC reaction with mild hypopyon, minimal discomfort

107
Q

What is treatment of toxic anterior segment syndrome?

A

steroid every 15 mins in office for an hour then every hour at home

108
Q

How is toxic anterior segment syndrome different than endophthalmitis?

A

TASS is anterior seg only, no vitreal or p seg involvement

109
Q

What is the post-op medication regimen?

A

topical antibiotic qid, NSAID q day, steroid qid

110
Q

What does the patient need to know post op?

A

don’t rub eye, no heavy lifting >10 lbs, fox shield at night, no soapy or tap water in eyes

111
Q

What are day 1 complications?

A

decreased VA, IOP, corneal abrasion or edema, seidel, AC response, choroidal effusion

112
Q

Causes of day 1 acuity decrease?

A

cornea, refractive error, tilted IOL, mydriasis

113
Q

IOP treatment day 1 cataract post-op

A

port release for acute IOP spike, rapid relief or sample hypotensive but not prostaglandin

114
Q

Treatment of corneal abrasion/edema following cataract surgery

A

maintain antibiotic and steroid or start hyperosmotic

115
Q

What happens if there is a small fragment of retained lens?

A

high pulse dose of steroid may “melt” it or they may need to go back to OR to wash out AC

116
Q

Port release

A

anesthetize eye, instill antibiotic, use sterile currete with rounded side towards globe and place pressure peripheral to paracentesis incision

117
Q

Scleral tunnel incision

A

incision at the superior cornea and paracentesis site made with blade to the temporal side

118
Q

When does endophthalmitis present?

A

4-10 days post op

119
Q

What is the most common cause of endophthalmitis?

A

organisms causing blepharitis entering the incision site during surgery

120
Q

Treatment of endophthalmitis?

A

consult with surgery to keep in the look, commonly direct retinal consult-vitrectomy and intraocular antibiotics, fortified antibiotics, oral antibiotics, sub-conj/intravitreal antibiotics

121
Q

1 Week VA

A

SC, pinhole, may refract/rx, vision should be doing well

122
Q

1 week chair skills

A

core four

123
Q

1 week IOP

A

should be doing well, steroid response usually 2 weeks

124
Q

1 week A seg

A

look for corneal edema, AC reaction should be reducing significantly, IOL positioning, posterior capsule

125
Q

1 week complications

A

endophthalmitis/infection, corneal edema, uveitis, elevated IOP from uveitis

126
Q

What does the patient need to know at 1 week?

A

can stop restricted activity, taper steroids, may reduce or stop NSAID/antibiotic, may Rx spec or wait until 1 month

127
Q

1 month post op

A

comprehensive exam

128
Q

1 month a seg

A

if corneal edema, look for fragments or corneal endothelial disease, AC response should be gone, IOL centering

129
Q

What is CME after cataract surgery?

A

irvine gas syndrome

130
Q

Treatment of PCO

A

YAG PC, be mindful of globals/FUDs

131
Q

What is treatment for CME?

A

topical steroids and NSAIDS esp nepafenac or intravitreal injection of triamcinolone or anti-vegf

132
Q

What is a “dropless” surgery?

A

antibiotic and steroid medications are injected during surgery

133
Q

What meds are used in dropless srugery?

A

TriMox (triamcinolone and moxifloxacin) or dex-moxi (dexamethosone and moxifloxacin

134
Q

Which dropless surgery med is less cloudy but has greater risk of steroid response?

A

dex-moxi

135
Q

What are the steroid implants?

A

Dextensa intracanalicular and Dexycu intracameral aka in the anterior chamber

136
Q

What is the 5 year mortality of OIS?

A

40% because carotid blockage

137
Q

YAG PC pattern

A

cruciate or cross-shaped pattern or circular

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