Wavy Vision Flashcards
Top differentials for floaters
PVD
Vit heme
Vitritis
Chance of there being a retinal break in a symptomatic PVD
10-15%
Chance of there being a retinal break in a symptomatic PVD with a vit heme
80%
Common differentials for metamorphopsia
ERM CSR AMD Histo Laquer cracks
Stats on ERM
More common in females and prevalence increases with age; occurs in 2% of patients over 50, and 20% of patietns over 75.
Signs of mild ERMS
Fine glistening membrane on the macular surface (cellophane maculopathy)
Signs of advanced ERMS
Thick, gray-white membranes associated with retinal folds due to contraction of the glial membrane (macular pucker)
What happens when the glial membrane in an ERM contracts on itself
Macular pucker
Lamellar hole (straight down and inwards)
CME
Pseudohole
Difference between ERM and VMT
VMT=pulling up
ERM=just wrinkling
Symptoms of ERMS
Often asymptomatic but mild metamorphopsia and/or decreased vision are the most commonly reported symptoms
CSCR
Idiopathic condition that results in RPE and/or choroidal dysfunction with resulting accumulation of submacular serous fluid. Puts often complain of unilateral sudden onset of blurred vision (20/20 to 20/200), metamorphopsia, and/or relative scotoma (if macula is involved)
Stats on CSCR
Young to middle aged men (20-50) with type A personality, the condition is also assocaited with stress, pregnancy, oral steroids, hypochondriasis, Cushing’s syndrome, SLE, organ transplant, and HTN
Fundus appearance of CSCR
Localized macula serous detachemnt; 3% of cases will have an RPE detachment as well
- FA shows gradual pooling of Fl into the pigment epithelial detachment or a “smokestack” appearance.
- OCT shows PED
- may have hyperopic shift in the refractive error and loss of the foveal light reflex
SRF + PED =
CNVM
Stats on AMD
Most common in patients over the age of 50. It is the second leading cause if blindness in patients 45-64 yo.; wet AMD is the chief cause of vision loss in pts over the age of 50
Framingham eye study: 6.4% of patients 65-74yo and 19.7% of pts older than 75 have signs of AMD.
More common in caucasians and females, additional risks
- older (esp >75)
- +Famhx
- light iris color
- SMOKING (2.5x more likely)
- hyperopia
- HTN
- HLD
- cardiovascular disease
- nutritional factors and light toxicity
Which is more common, wet or dry AMD
Dry
-85-90% of cases
Signs of dry AMD
Presence of macualr drusen (hallmark), associated RPE abnormalities (mottling, granularity, GA, focal hyperpigmentation) may also be present
Symptoms of dry AMD
Most patients do not have sever evision loss, metamorphopsia, gradual vision loss (over months to years), and blurred vision are common complaints
12% of patients with dryAMD will develop severe vision loss (>6 lines of VA); most result from GA or drusenoid PEDs
The macular photocoagulation study discovered 4 risk factors that increase the likelihood of progression to wet AMD
A. Multiple soft drusen (especially if confluent)
B. Focal hyperpigmentation
C. HTN
D. Smoking
Hard drusen in isolation are NOT a risk factor for more advanced forms of ARMD
Wet AMD
Accounts for 10-15% of cases of AMD. 88% of legal blindness attributed to ARMD is caused by the wet form
Symptoms of wetAMD
Metamorphopsia, central scotoma, and rapid vision loss
Signs of wet AMD
Drusen associated with signs of a CNVM. CNVMs can leak blood or plasma into two potential spaces, subRPE or subretinal. This creates 4 potential presentations of wet AMD
What are the 4 potential presentations of wetAMD
Subretinal hemorrhage (blood under retina, red)
Sub-RPE hemorrhage (blood under RPE, green)
Subretinal detachment (plasma under retina, AKA serous RD)
Sub-RPE detachment (plasma under RPE, AKA PED)
Incidence of involving the fellow eye in wet AMD
Is estimated to be about 28-36% during the first two years, the annual rate of bilaterality is about 6-12% per year for the next 5 years, the overall 5 year risk ranges from 40-85%
Histoplasmosis
Infection caused by histoplasma capsulatum, a fungus that grows in soil and material contaminated with bird or bat droppings. Most commonly in the Mississippi-OH river valleys.
Signs of histo
Choroiditis and a classic clinical triad of PPA, multifocal chorioretinal lesions in the periphery, and maculopagthy
NO VITRITIS
Symptoms of histo
Asymptomatic unless the macula is involved; the earliest symptom is metamorphopsia
- CNVM is a late manifestation of histoplasmosis and is most likely to occur between the ages of 20 and 45
- if the macula is involved, the chance of a symptomatic recurrence is appx 20% over 3 years
Lacquer cracks
Fine, yellow, linear, irregualr lines that represent large breaks in bruchs membrane; they occur in 5% of high myopes. CNVMS can develop in associate with these, resulting in metamorphopsia and severe vision loss. This may be one of the earliest findings in pathological myopia
Most patients with ERMS have an associated
PVD
Risk factors for ERMS
PVD Retinal breaks Cataract or other intraocular surgeries Trauma Intraocular inflammation
Cause of ERM
Glial cell proliferation on the ILM of the retina, vitreous traction can result in residual glial cells from the posterior hyaloid membrane of the vitreous on the ILM, or can cause small pores to develop in the ILM; this allows intraretinal glial cells to gain access to the anterior side of the ILM for proliferation
Cause of histo
Fungus histo capsulatum
What causes CSCR
Idiopathic dysfunction of the RPE
Cause of laquer cracks
Due to thinning and atrophy of the choroids due to increased axial length in patietns with pathological myopia
Cause of ARMD
Progressive degeneration of the RPE, BRuchs membrane and the choriocapillaris due to the accumulation of drusen within bruchs membrane
Treatment of ERMS
PPV with membrane peel
-with a VA of 20/50 or worse, or pts with intolerable metamorphopsia complaints secondary to an ERM may benefit; overall prognosis is good after sx, as 75% of pts experience an improvement in symptoms and VA. If the patients vision is better than 20/50, the fain in visual acuity after surgery is relatively insignificant.
Treatment for CSCR
Most improve without treatment in 1-3 months. 94% of pts will regain >20/30 vision, and 66% of patietns will achieve 20/20 vision. After resolution of the condition, pts often have permanent residual RPE changes within the macula, recurrences occur in up to 40-50% of cases. Although most cases of CSR are observed, laser photocoagulation should be considered in the following cases
- persistent RD after 4 months
- previous CSR episode that results in permanent vision reduction
- patient demand for more immediate visual recovery
Can also use CAIs and PDT
Laser photocoagulation and CSCR
Can expedite the recovery process, but does not result in better final VA
Treatment of dry and wet AMD
- cessation of smoking (#1 risk factor)
- daily monitoring with amsler grid
- consideration of high dose antioxidants for pts iwth cat 4 AMD
cat 1 AREDS
No ARMD (<5 small drusen), BCVA 20/32 or better in both eyes
Cat 2 AREDS
Borderline to mild ARMD (multiple small drusen/single intermediate drusen/pigment abnormalities) and BCVA 20/32 or better in both eyes
Cat 3 AREDS
Moderate ARMS with a least 1 large drusen, extensive intermediate drusen, or non central GA, BCVA 20/32 or better in 1 eye
Cat 4 AREDs
No signs of advanced ARMD in the study eye with BCVA 20/32 or better, with advanced ARMD (central GA or CNVM) or BCVA worse than 20/32 that could be attributed to ARMD in the fellow eye
What category of ARMD did AREDs 1 determine would benefit from high dose antioxidants
Cat 4 (10 year results) (5 year results say cat 3 and 4)
What is relative risk reduction
100-((incidence of the outcome in the treatment group)/(incidence of the outcome in the control group))
What is absolute risk reduction
(Incidence of the outcome in the control group)-(incidence of the outcome in the treatment group)
More meaningful stat as it takes into account the absolute incidence of the disease
Original AREDs formula
15mg beta carotene 500mg VitC 400IU Vit E 80mg Zinc 2mg copper
AREDs 2
Lutein and xeazanthine weren’t that beneficial
Omega 3 FAs proven ineffective
Eliminated beta carotene and reduced zinc (had no effect on positive outcomes)
Give low dose antioxidants for cat 1 and 2, and with strong famHx
Low vision rehab for pts with functional vision loss
Smokers should use formulation with lutein in place of beta carotene
Subfoveal CNVM
Located directly underneath the FAZ
Juxtafovea lCNVM
1-199 microns from the center of the FAZ or in extrafoveal CNVM that has leaked fluid within 1-100um of the FAZ
Extrafoveal CNVM
200-250um from the center of the FAZ
How wide is FAZ
500um in diameter
Classic CNVMs
Well defined membrane that fills with dye during the early phase of FA
Occult CNVM
Poorly defined membrane with less intense and late appearing FA leakage
Occult vs classic CNVM
Most patietns with ARMD have a CNVM that has a combination of both. The term “predominantly classic” means that over 50% of the entire leasing is composed of a classic CNVM
Treatment for wet ARMD
Thermal laser photocoagulation
Verteporfin
AntiVEGF
Thermal laser photocoagulation for ARMD
Used to treat extrafoveal and juxtafoveal CNVMs. It is no longer used to treat subfoveal CNVMs because the laser damages the retina, resulting in a permanent scar and blind spot. Patients should be carefully monitored after treatment as recurrences are common
Verteprofin for ARMD
PDT, used for subfoveal CNVMs. Effective at treating subfoveal, predominantly classic CNVMs, no longer DOC because of AntiVEGF
- injected IV and has a predilection for lipoproteins concentrated in the areas of proliferating capillaries. PDT is used to activate the molecules and destroy the CNVM
- slows the rate of progression, but does not improve the visual outcome in patients with wet AMD
- 3m intervals are required due the high recurrence of CNVMs. Patients should also be advised to avoid direct sun light or bright indoor light for at least 48 hours after treatment
ANCHOR study
Compared PDT to lucentis for treatment of predominantly classic CNVMs in patients with wet AMD; more than 1/3 of pts on lucentis had improvement in vision of more than 15 EDTRS letters, compared to only 6% of patients who received PDT
MARINA study
Effectiveness of lucentis injections for the treatment of minimally classic or occult CNVMs in patietns with wet AMD. Lucentis improved VA to 20/40 in more than 1/3 of patients at 2 years compared to sham injections; less than 5% of patients receiving lucentis suffered severe vision loss at 2 years compared to 23% of sham injections
Why is eyelea different
High binding affinity,
Can be used every 2 months
More expensive
