Vitreoretinal Flashcards
What is peripheral retinal degeneration?
abnormalities in the peripheral retina
What is lattice degeneration?
THINNING IN THE NEUROSENSORY RETINA
WITH OVERLYING VITREOUS LIQUEFACTION
VITREORETINAL ADHESIONS CHARACTERISED BY CIRCUMFERENTIAL ZIGZAG WHITE LINES WITH OVAL HOLES WITHIN THE LESION
What is the most important degeneration predisposing to retinal tears?
lattice degeneration
In what population is lattice degeneration most common?
6-10% of normal population and more common in myopic eyes
What % of people with rhegmatogenous retinal detachment have lattice degeneration?
30%
How is lattice degeneration managed?
PROPHYLACTIC TREATMENT ONLY IN PATIENTS WITH A RETINAL DETACHMENT IN THE CONTRALATERAL EYE,
IN THE FORM OF LASER RETINOPEXY
What is degenerative retinoschisis?
MICROCYTIC DEGENERATION RESULTING IN THE SPLITTING OF THE RETINAL LAYERS BETWEEN THE OUTER PLEXIFORM AND INNER NUCLEAR LAYERS, USUALLY INFEROTEMPORALLY
Describe the distribution of retinoschisis
mostly bilateral and symmeterical
In what type of eye is retinoschisis most common?
Hypermetropic,
not frequently associated with RRD
Describe the features of retinoschisis
SMOOTH CONVEX AND IMMOBILE ELEVATION OF RETINA WITH NO DEMARCATION LINE OF CHRONICITY WITH RRD
ASSOCIATED WITH ABSOLUTE FIELD DEFECT
What is posterior vitreous detachment?
SEPARATATION OF THE POSTERIOR VITREOUS CORTEX FROM THE NSR
What factors increase the likelihood of posterior vitreous detachment?
OCCURS WITH INCREASING AGE AS THE VITREOUS BECOMES MORE LIQUEFIED (SYNCHYSIS) WHICH RESULTS IN THE CREATION OF EMPTY POCKETS OF FLUID WITHIN THE VITREOUS, LEADING TO VITREOUS COLLAPSE
Describe the pathogenesis of posterior vitreous detachment
VITREOUS BECOMES MORE LIQUEFIED (SYNCHYSIS) WHICH RESULTS IN THE CREATION OF EMPTY POCKETS OF FLUID WITHIN THE VITREOUS, LEADING TO VITREOUS COLLAPSE
EVENTUALLY FLUID ESCAPES IN THE RETROVITREOUS SPACE SEPARATING THE POSTERIOR HYALOID FROM THE NSR
What are the features of posterior vitreous detachment?
PHOTOPSIA WITH ASSOCIATED FLOATERS, VA USUALLY UNAFFECTED
WEISS RING: THICKENED VITREOUS AVULSED FROM OPTIC DISC
SHAFER SIGN (PIGMENTED PARTICLES OR ‘TOBACCO DUST’ IN THE ANTERIOR VITREOUS) NEGATIVE
How is posterior vitreous detachment managed?
DOES NOT REQUIRE TREATMENT
WARN ABOUT RISK OF Rhegomatogenous RD AND ADVICE ON PRESENTING IMMEDIATELY IF SYMPTOMS WORSEN OR VISUAL FIELD IS AFFECTED
IF COMPLICATED WITH RETINAL TEAR, TREAT WITH LASER OR CRYORETINOPEXY
What are retinal breaks?
THESE ARE FULL-THICKNESS RETINAL DEFECTS, PROGRESSION TO RD IS RARE
Under what conditions can retinal breaks be treated?
High risk of RD:
- HIGH MYOPIA > 6D
- APHAKIA
- GIANT RETINAL TEAR
- SYMPTOMATIC U-SHAPED RETINAL TEAR
- SYSTEMIC DISEASE
- STICKLER SYNDROME
What is a retinal tear?
A U-SHAPED DEFECT DUE TO VITREORETINAL TRACTION ON A STRIP OF RETINA DUE TO posterior vitreous detachment
In what percentage of cases do retinal tears progress to RRD?
1/3
What can retinal breaks be associated with?
VITREORETINAL ADHESIONS SUCH AS AT THE MARGINS OF LATTICE DEGENERATION
What are the features of retinal breaks?
FLASHES
FLOATERS
WEISS RING
SHAFER SIGN POSITIVE
How are symptomatic retinal breaks treated?
laser retinopexy
What is a giant retinal tear?
A RETINAL TEAR EXTENDING >/ 3 CLOCK HOURS > 90 DEGREES
Where do giant retinal tears occur?
PERIPHERAL RETINA AT POSTERIOR BORDER VITREOUS
What are giant retinal tears associated with?
TRAUMA
HIGH MYOPIA
DISEASES E.G. MARFAN / STICKLER SYNDROME
how are giant retinal tears managed?
LASER RETINOPEXY FOR BOTH EYES
in what % of cases are giant retinal tears bilateral and in what % of cases are their retinal tears in the fellow eye?
16.5% and 60%
What is retinal dialysis?
A DISINSERTION OF THE RETINA AT THE ORA SERRATA INVOLVING ANTERIOR AND POSTERIOR TO THE VITREOUS BASES
What is the most common type of retinal dialysis and where does it occur?
TRAUMATIC RETINAL DIALYSIS IS MORE COMMON AND LOCATED SUPERONASALLY
Where does idiopathic retinal dialysis occur more commonly?
inferotemporally
What is the leading cause of traumatic retinal detachment in children and young adults?
Retinal dialysis
how is retinal dialysis managed?
LASER RETINOPEXY IF THERE IS NO ASSOCIATED RD, OTHERWISE SCLERAL BUCKLE IS USED
What is retinal detachment?
SEPARATION OF THE NSR FROM THE RPE
What is shifting sub-retinal fluid?
following detachment, SUBSEQUENT SHIFT OF SUB RETINAL FLUID IN THE SPACE BETWEEN THE NSR AND THE RPE
What are the three main types of retinal detachment?
RRD, TRACTIONAL RD AND EXUDATIVE RD
What is the most common form of retinal detachment?
RRD
Describe the pathogenesis of RRD
retinal break - FLUID SEEPS IN BETWEEN THE NSR AND RPE CAUSING A DETACHMENT
this is an emergency, can cause blindess
What are the features of rhegmatogenous retinal detachment?
FLASHES AND FLOATER
CURTAIN-LIKE VISUAL FIELD LOSS (RELATIVE FIELD LOSS)
DVA IF MACULA IS INVOLVED
RAPD, WEISS RING AND SHAFER SIGN
PRESENCE OF PVD AND RETINAL BREAKS (COMMONLY A U-SHAPED RETINAL TEAR; MOST COMMON LOCATION IN SUPERTEMPORAL)
Describe fresh RRD
- CONVEX CORRUGATED DOME-SHAPED SURFACE WITH LOSS OF RPE MARKINGS
SHAPE BASED ON MOST SUPERIOR RETINAL BREAK
EXTEND FROM ORA SERRATA TO OPTIC DISC
THEY ARE PROGRESSIVE AND MAY AFFECT MACULA
Describe chronic RRD
RETINAL THINNING
DEMARCATION LINES
INTRARETINAL CYSTS
PROLIFERATIVE VITREORETINOPATHY
What investigations are used for RRD?
SLIT LAMP BIOMICROSCOPY WITH WIDE-FIELD LENS
INDIRECT OPHTHALMOSCOPY WITH SCLERAL DEPRESSION TO VISUALISE THE ORA SERRATA
B-SCAN USS IS NO VIEW OF POSTERIOR POLE SUCH AS DENSE CATARACT OR VITREOUS HAEMORRHAGE
What is the management for RRD?
VITRECTOMY: MOST COMMON PROCEDURE, INDICATED FOR POSTERIOR RETINAL BREAKS, GIANT RETINAL TEARS AND PROLIFERATIVE VITREORETINOPATHY
SCLERAL BUCKLE: VERY HIGH SUCCESS RATE, USED IN SIMPLE RRD AND RETINAL DIALYSIS WHEN THERE IS ANO PRE-EXISTING PVD
PNEUMATIC RETINOPEXY: LOWER SUCCESS RATE BUT ALSO FEWER SIDE EFFECTS; USED IN CAREFULLY SELECTED CASES WITH SMALL SUPERIOR BREAKS 1 CLOCK HOUR APART BETWEEN 11 AND 1 CLOCK HOURS
What is tractional retinal detachment?
THIS IS DUE TO VITREORETINAL TRACTION
describe the pathogenesis of tractional retinal detachment
INSIDIOUS PROCESS WHERE FIBROVASCULAR MEMBRANES CAUSE PROGRESSIVE CONTRACTURE OVER AREAS OF ADHESIONS EVENTUALLY CAUSING A DETACHMENT
What are the most common causes of tractional retinal detachment?
ADVANCED PROLIFERATIVE DIABETIC RETINOPATHY AND ROP
What are the features of tractional retinal detachment?
USUALLY ASYMPTOMATIC (NO FLASHES OR FLOATERS) AS THERE IS NO PVD
VA AFFECTED ONCE MACULA IS THREATENED CAUSING DISTORTION OF VISION
DETACHMENT: SHALLOW IMMOBILE CONCAVE TENTING OF RETINA
MINIMAL SHIFTING SRF
ASSOCIATED RELATIVE VISUAL FIELD LOSS, SIGNS OF UNDERLYING DISEASE
What is the management of tractional retinal detachment?
VITRECTOMY WITH MEMBRANE PEEL
What is exudative retinal detachment?
THIS RARE FORM OF RD OCCURS DUE TO BUILDUP OF SRF FROM DAMAGE TO THE OUTER BLOOD-RETINAL BARRIER
Describe the pathogenesis of exudative retinal detachment
FLUID LEAKAGE OCCURS UNDER THE RETINA THEREBY SEPARATING THE NSR FROM THE RPE
OCCURS WHEN THE COMPENSATORY MECHANISMS OF THE RPE FAILED TO PUMP THE FLUID BACK INTO THE CHOROIDAL CIRCULATION
What are some causes of exudative retinal detachment?
TUMOURS: CHOROIDAL TUMOURS
IDIOPATHIC: NANOPTHALMIA LEADING TO UVEAL EFFUSION SYNDROME
VASCULAR: EXUDATIVE AGE-RELATED MACULAR DEGENERATION, COATS’ DISEASE, CENTRAL SEROUS CHORIORETINOPATHY
What are some inflammatory causes of exudative retinal detachment?
POSTERIOR UVEITIS: SYMPATHETIC OPTHALMIA AND Vogt-kayanadi-harada
POSTERIOR SCLERITIS, ORBITAL INFLAMMTORY DISEASE, POSTOP INFLAMMATION AND EXTENSIVE PAN RETINAL PHOTOCOAGULATION
What are some features of exudative retinal detachment?
FLOATERS IF VITRITIS PRESENT, dVA IS AFFECTED
RD: SMOOTH CONVEX THAT IS SHALLOW OR BULLOUS, LACK OF PVD AND RETINAL TEARS AND EVIDENCE OF TRACTION
EVIDENCE OF UNDERLYING CONDITION
How is exudative retinal detachment managed?
OPTHALMIC AND SYSTEMIC HISTORY AND EXAMINATION INCLUDING BLOOD PRESSURE AND URINALYSIS
TREATMENT OF UNDERLYING CAUSE TREATS THE RETINAL DETACHMENT; SURGERY NOT USUALLY INDICATED
What is vitreous haemorrhage?
THIS IS BLEEDING INTO THE VITREOUS CHAMBER
MAY BE DUE TO TWO BASIC MECHANISMS; RUPTURE OF VESSELS THORUGH TRAUMA OR BLEEDING FROM PATHOLOGICAL PROCESSES
What are some causes of vitreous haemorrhage?
TRAUMA :
- BLUNT OR PENETRATING TRAUMA CAUSING CLOSED OR OPEN GLOBE INJURY
- SHAKED BABY SYNDROME
- ACUTE PVD ASSOCIATED WITH VITREOUS HAEMORRHAGE
NEOVASCULARISATION LEADING TO HAEMORRHAGE:
- DIABETIC RETINOPATHY
- SICKLE CELL RETINOPATHY
–ROP
- WET ARMD
- RETINAL VEIN OCCLUSION
OTHER: CHOROIDAL TUMOURS
What investigations are used for vitreous haemorrhage?
ALL PATIENTS NEED A DETAILED FUNDAL EXAMINATION TO ASSESS THE SEVERITY OF HAEMORRHAGE AND EXCLUDE RETINAL TEARS
What is the management for vitreous haemorrhage?
DEPENDENT ON CAUSE
PAN-RETINAL PHOTOCOAGULATION IF THERE IS A FUNDAL VIEW
INTRAVITREAL ANTI-VEGF IF THERE IS NO FUNDAL VIEW OR IN WET ARMD
PARS PLANA VITRECTOMY; OFTEN PRE-TREATED WITH INTRAVITREAL ANTI-VEGF FOR NON-CLEARING VITREOUS HAEMORRHAGE OR IN PRESENCE OF RETINAL DETACHMENT
What is choroidal detachment?
A DETACHMENT OF THE CHOROID FROM THE SCLERA DUE TO THE ACCUMULATION OF FLUID OR BLOOD IN THE SUPRACHOROIDAL SPACE
What are some causes of choroidal detachment?
ACUTE HYPOTONY (IOP<5mmHg), TYPICALLY FOLLOWING GLAUCOMA SURGERY
TRAUMA
what are the features of choroidal detachment?
SMOOTH, DARK AND CONVEX ELEVATION ARISING FROM THE PERIPHERY
LARGE ‘KISSING’ CHOROIDAL DETACHMENTS CAN LEAD TO RD
What is choroidal rupture?
A BREAK IN THE CHOROID MAY RESULT FROM CLOSED GLOBE INJURY DUE TO BLUNT TRAUMA
Describe the features of choroidal rupture
THERE IS USUALLY DISRUPTION OF THE CHOROID, BRUCH MEMBRANE AND RPE; HOWEVER THE NEUROSENSORY RETINAL IS UNAFFECTED
ON EXAMINATION, A CRESCENT-SHAPED YELLOW SUBRETINAL STREAK IS SEEN USUALLY ADJACENT TO THE OPTIC DISC
What is uveal effusion syndrome?
THIS IS A RARE AND BILATERAL ABNORMALITY OF THE CHOROID AND SCLERA
In what population is uveal effusion syndrome most common in?
IT IS MOST COMMONLY SEEN IN MIDDLE-AGED HYPERMETROPIC MALES AND IS ACCOAITED WITH NANOPTHALMOS (AXIAL LENGTH <20mm)
What are the features of uveal effusion syndrome?
MILD INFLAMMATION
THICKENED SCLERA
CILIOCHOROIDAL DETACHMENT
EXUDATIVE RD
RPE HYPERTROPHIC AREAS (LEOPARD SPOTS) IN CHRONIC CASES
How is uveal effusion syndrome managed?
FULL-THICKNESS SCLEROTOMIES
What is the epiretinal membrane?
THIS IS AN AVASCULAR FIBROCELLULAR SHEET OR MEMBRANE THAT DEVELOPS ON THE SURFACE OF THE RETINA
Who is the epiretinal membrane more common in?
females
What does the epiretinal membrane originate from?
PROLIFERATION OF RPE, GLIAL CELLS OR HYALOCYTES ON THE SURFACE OF THE RETINA
CONTRACTURE ON THE RETINA LEADS TO PROBLEMS SUCH AS ELEVATION OF THE RETINA AND CMO
What are some synonyms for the appearance of the epiretinal membrane?
IN APPEARANCE: CELLOPHANE MACULOPATHY, MACULAR PUCKER
What are some synonyms for the appearance of pathogenesis of the epiretinal membrane?
PREMACULAR FIBORSIS IDIOPATHIC PREMACULA GLIOSIS
What are some causes of the epiretinal membrane?
IDIOPATHIC
TRAUMA
POSTERIOR UVEITIS
BRVO
IATROGENIC (CRYTHERAPHY, PHOTOCOAGULATION, RETINAL DETACHMEN SURGERY)
What are some features of the epiretinal membrane?
ASYMPTOMATIC
METAMORPHOPSIA AND dVA
CELLOPHANE MEMBRANE: MAY BE TRANSPARENT BEST SEEN WITH RED-FREE LIGHT
MACULAR PUCKER: THICK CONTRACTED MEMBRANE WITH MILD DISTORTION OF BLOOD VESSELS
OTHER FINDINGS: MACULAR PSEUDOHOLE, CMO, RETINAL HAEMORRHAGES AND TELANGIECTASIA
What investigations are used for epiretinal membrane?
OCT
How is the epiretinal membrane managed?
OBSERVATION: ONLY IF CONDITION IS STABLE
VITRECTOMY
What is a macular hole
A FULL THICKNESS DEFECT IN THE FOVEA WITH SPLITTING OF ALL NEUROSENSORY RETINAL LAYERS FROM THE INTERNAL LIMITING MEMBRANE TO THE RPE
In what population is a macular hole most common?
FEMALES AGED 60-70
What are some causes of the macular hole?
PRIMARY: VITREOUS TRACTION ON THE FOVEA FROM A PVD (VITREOMACULAR TRACTION)
SECONDARY: DOES NOT HAVE VITREOMACULAR TRACTION
E.G. CASES CAUSED BY TRAUMA OR HIGH MYOPIA
What are some features of the macular hole?
METAMORPHOPSIA WITH CENTRA dVA
How is the macular hole classified?
USED TO BE CLASSIFIED BY THE GASS CLASSIFICATION BUT THIS HAS BEEN REPLACED BY THE OCT CLASSIFICATION
Describe the stages of classification for macular hole
VITREMACULAR ADHESION
VITREOMACULAR TRACTION
SMALL OR MEDIUM MACULAR HOLE WITH VMT
MEDIUM OR LARGE MACULAR HOLE WITH VMT
SMALL, MEDIUM OR LARGE MACULAR HOLE WITHOUT VMT
How are macuular holes managed?
USUALLY PATIENTS ARE oBSERVED IN STAGE 1
STAGE 2 MACULAR HOLES CAN BE MANAGED WITH EITHER VITRECTOMY OR INTRAVITREAL VITREOLYSIS WITH OCRIPLASMIN
STAGES 3 AND 4 CAN BE MANAGED WITH VTRECTOMY, INTERNAL LIMITING MEMBRANE PEEL AND GAS TAMPONADE
What are hereditary vitreoretinal degenerations?
THESE ARE RARE CONGENITAL CONDITIONS CHARACTERISED BY EARLY RETINAL AND VITREAL DEGENERATION
What is x-linked retinoschisis?
DIFFERENT FROM DEGENERATIVE RETINOSCHISIS
DUE TO INTRACELLULAR ADHESION ABNORMALITIES WHICH LEAD TO SPLITTING OF THE RETINA AT THE NERVE FIBRE LAYER
What are the features of x-linked retinoschisis?
TYPICALLY PRESENTES IN EARLY CHILDHOOD: HYPERMETROPIC BOYS PRESENT WITH READING DIFFICULTIES AT PRIMARY SCHOOL
ON EXAMINATION: BILATERAL MACULOPATHY, FOVEAL SCHISIS WITH SPOKE-LIKE FOLDS WITH CYSTOID CHANGES
RESEMBLING CMO WITHOUT LEAKAGE ON FA
What investigations are used for x-linked retinoschisis?
SCOTOPIC ERG (-ERG):NORMAL a WAVE, LOSS OF b WAVE WITH OSCILLATORY POTENTIALS
What is stickler syndrome?
MOST COMMON INHERITED CAUSE OF RD
CONDITION IS AD AND OCCURS DUE TO DEFECT IN COLLAGE SYNTHESIS
Describe the features of stickler syndrome
OPTHALMIC: HIGH MYOPIA, CORTICAL CATARACTS, ECTOPIA LENTIS, GLAUCOMA, OPTICALLY EMPTY VITREOUS, RADIAL LATTICE-LIKE RETINAL DEGENERATION AND RRD
SENSORINEURAL DEAFNESS
PIERRE ROBIN FEATURES: MICROGNATHIA, GLOSSOPTOSIS, CLEFT PALATA, FLAT NASAL BRIDGE AND MAXILLARY HYPOPLASIA
MARFANOID FEATURES
Describe the management of stickler syndrome
PROPHYLACTIC 360 RETINAL LASER
VITRECTOMY IF RD OCCURS
What is wagner syndrome?
AD DISORDER SIMILAR TO STICKLER SYNDROME WITHOUT SYSTEMIC FEATURES
What are the features of wagner syndrome?
LOW MYOPIA
CORTICAL CATARACTS
OPTICALLY EMPTY VITREOUS
When is RD treated in wagner syndrome?
RD IS LINKED TO THIS CONDITION BUT IT LESS COMMON THAT IN STICKLER SYNDROME SO THEY ARE TREATED IF THEY OCCUR (I.E. NOT PROPHYLACTICALLY)
