retina review - part 2
TRANSCRIPT
Retina Review
Part 2
35 yo on multiple BP meds
Hypertensive Retinopathy• Describe fundus findings associated with
hypertensive retinopathy?– Constriction of retinal arterioles
– Intraretinal hemorrhages
– Cotton wool spots
– Macular edema
– Disc edema
– Retinal neovascularization
• What are manifestations of hypertensive choroidopathy?– Elschnig spots and Siegrist streaks
47 yo 20/20 referred by internist
62 yo diabetic20/60
33 yo diabetic 20/30 OU
Diabetic Retinopathy
• WESDR– IDDM 99% have retinopathy after 20 yr– NIDDM 60% have retinopathy after 20 yr
• DCCT– Tight glucose control decreases retinopathy in IDDM
• UKPDS– Glucose control decreases retinopathy in NIDDM
Diabetic Retinopathy
• ETDRS– Focal laser indicated for CSME
• Retinal thickening at or within 500 m of the foveal center
• Retinal thickening associated with hard exudate at or within 500 m of the foveal center
• A zone of retinal thickening larger than 1 disc area within 1 disc diameter of the foveal center
– PRP indicated for high risk PDR, not for NPDR (can consider for severe NPDR)
– ASA does not affect vitreous hemorrhage
Diabetic Retinopathy
• Describe the 4:2:1 rule– 4 quadrants of diffuse intraretinal hemorrhage and
microaneurysms– 2 quadrants of venous beading– 1 quadrant of intraretinal microvascular abnormalities
• What is severe NPDR and what 1-year risk does it carry for progression to high-risk PDR?– 1 of the above criteria– 15%
• What is very severe NPDR and what 1-year risk does it carry for progression to high-risk PDR?– 2 of the above criteria– 45%
Diabetic Retinopathy
• DRS - PRP reduces severe visual loss by 50% for high risk PDR– Mild (1/4 to 1/3 disc area) NVD with vitreous hemorrhage
– Moderate to severe NVD with or w/o vitreous hemorrhage
– Moderate (1/2 disc area) NVE with vitreous hemorrhage
• DRVS - vitrectomy for nonclearing vitreous hemorrhage– Early vitrectomy beneficial for IDDM
– Early (1 mo) same as late (6 mo) for NIDDM
• Other indications for surgery– Macula involving TRD
– Combined TRD/RRD
– Refractory macular edema with taut posterior hyaloid
35 yo African American male
Sickle Cell Retinopathy• Which form of sickle cell is associated with the most serious
ocular complications?– Hb SC
• What are the findings on nonproliferative sickle cell retinopathy?– Salmon patch hemorrhage (intraretinal hemorrhage)– Refractile spot (resorbed hemorrhage)– Black sunburst (RPE hypertrophy)
• What are the stages of proliferative sickle cell retinopathy?– I: arteriolar occlusions– II: arteriovenous anastomoses– III: sea-fan neovascularization– IV: vitreous hemorrhage– V: tractional retinal detachment
• What is the preferred treatment for PSR?– Peripheral scatter photocoagulation– Vitrectomy for non-clearing vitreous hemorrhage or RD
Baby
ROP
• Describe the stages of ROP– 1: demarcation line– 2: elevated ridge– 3: ridge with extraretinal fibrovascular proliferation– 4: subtotal retinal detachment
• A extrafoveal• B involving fovea
– 5: total retinal detachment
• Define plus disease– Retinal vascular dilation and tortuosity in the posterior pole
ROP
• Define threshold ROP– Zone I or II– Extent of 5 contiguous or 8 non-contiguous clock
hours of extraretinal neovascularization– Plus disease
– Threshold benefits from cryo or laser
• STOP-ROP - oxygen level had no effect on progression
71 yo woman h/o POAG20/30
75 yo 20/80
BVOS and CVOS
• Grid laser for macular edema– Beneficial for BRVO– Not beneficial for CRVO
• PRP laser for prevention of VH, NVG– Prophylactic laser not recommended– Laser once NV (iris, disc, retina) develops
60 yo Scotoma for one wk
65 yo sudden decreased vision OU x 4hr
65 yo decreased vision x 3d
Central Retinal Artery Occlusion
• What percentage of eyes have vision <20/400?– 66%
• With NLP vision, what diagnosis must be considered?– Ophthalmic artery occlusion
• What is the leading cause of death in patients with CRAO?– Cardiovascular disease
82 yo NLP
Central Retinal Artery Occlusion
• What percentage of CRAO is accounted for by giant cell arteritis?– 1-2%
• What are some methods used as therapy for CRAO?– Ocular massage– Anterior chamber paracentesis– Administration of carbogen
85yo chronic pain and redness OD
Ocular Ischemic Syndrome
• What percent carotid obstruction is typically required to cause OIS?– 90%
• Describe the symptoms– Gradual visual loss– Aching pain– Prolonged recovery following bright light exposure
• What are anterior segment findings?– Iris neovascularization (67%)– AC cellular reaction (20%)
Ocular Ischemic Syndrome
• Describe the posterior segment findings– Narrowed arteries– Dilated, non-tortuous veins– Mid-peripheral retinal hemorrhages, microaneurysms– Neovascularization
• What are the fluorescein angiographic findings?– Delayed choroidal filling (60%) – Delayed arteriovenous transit (95%)– Vascular staining (85%)
• What is the 5-year mortality rate and what is the most common cause of death?– 40%– Cardiovascular disease
35 yo asymptomatic
Retinal Vasculitis
• What is the differential diagnosis of retinal vasculitis?– Giant cell arteritis Multiple sclerosis– Sarcoidosis Syphilis– Behcets disease Pars planitis– Lupus Toxoplasmosis– Polyarteritis Idiopathic– Inflammatory Bowel Dz
8 yo boy; parents noted leukocoria
Coats Disease
• Describe the clinical findings– Telangiectatic vessels, microaneurysms– Fusiform capillary dilation– Exudative retinal detachment– Capillary non-perfusion
• What is the mode of transmission?– Not hereditary
• What is the percentage of cases affecting males?– 85%
• What treatments are employed to halt progression?– Cryotherapy or photocoagulation– Retinal reattachment surgery
40 yo 20/40 OU
Idiopathic Juxtafoveal Telangiectasis
• What are the 3 clinical groups– Unilateral juxtafoveal telangiectasis– Bilateral juxtafoveal telangiectasis– Bilateral juxtafoveal telangiectasis with capillary
obliteration
45 yo h/o HTN
Retinal Arterial Macroaneurysm
• What percentage of cases are associated with systemic hypertension?– 67%
• What are causes of visual loss?– Intra- or subretinal hemorrhage– Vitreous hemorrhage– Macular edema/exudation
50 yo c/o floater
Posterior Vitreous Detachment
• What percentage of patients with acute symptomatic PVD have a retinal tear?– 15%
• What percentage of patients with vitreous hemorrhage associated with PVD have a retinal tear?– 70%
20 yo myope, asymptomatic
Lattice Degeneration• What is the prevalence of lattice degeneration in
the general population?– 6-8%
• Of patients with lattice, what is chance of RD?– 1%
• What percentage of retinal detachments have associated lattice degeneration?– 20-30%
• Describe the histopathologic features– Discontinuity of the ILM– Overlying pocket of liquefied vitreous– Adherence of vitreous at the margin– Atrophy of inner retinal layers
60 yo c/o flashes
Retinal Breaks
• What percentage of the population will develop a retinal detachment over their lifetime?– 0.07%
• What types of retinal breaks should be treated?– Symptomatic horseshoe tears– Retinal dialysis
Retinal Detachment
• What is optimal timing for surgery?– Mac on - 87% ≥ 20/50– Mac off - 30-50% ≥ 20/50
• < 1 wk 75% ≥ 20/70• 1-8 wk 50% ≥ 20/70
• Define subclinical retinal detachment– Subretinal fluid extends more than 1DD from
the break– Subretinal fluid extends no more than 2DD
posterior to the equator
60 yo asymptomatic
Retinoschisis
• What is the typical location in the fundus?– Inferotemporal
• What layer is affected in typical retinoschisis?– Outer plexiform– (reticular retinoschsis, juvenile retinoschisis in NFL)
• How can schisis be differentiated from RD?– Absolute scotoma– No associated tear/tobacco dust– Smoother surface– Laser scars
Hereditary Hyaloidoretinopathies
• Describe features of Jansen and Wagner disease– Autosomal dominant transmission– Optically empty vitreous– Equatorial and perivascular lattice– Myopia, strabismus, cataract
• Which of the above conditions is associated with retinal detachment?– Jansen disease
Stickler Syndrome
• Describe the features of Stickler Syndrome– Autosomal dominant transmission– Myopia, glaucoma, cataract– Orofacial findings
• Midfacial flattening• Pierre-Robin malformation (micrognathia,
cleft palate, glossoptosis)– Skeletal abnormalities
• Joint hyperextensibility• Arthritis• Spondyloepiphyseal dysplasia
– High incidence of RD, giant retinal tear, PVR
3 mo old term baby
FEVR
• What is the mode of inheritance of familial exudative vitreoretinopathy?– Autosomal dominant
• Describe the clinical features– Normal birth weight/gestational age– Failure of the temporal retina to completely vascularize– Peripheral fibrovascular proliferation– Traction retinal detachment– Subretinal exudate or exudative detachment– Late-onset rhegmatogenous detachment