Retina Review - Part 2

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  • Retina Review - Part 2

    1. 1. Retina Review <ul><li>Part 2 </li></ul>
    2. 2. 35 yo on multiple BP meds
    3. 4. Hypertensive Retinopathy <ul><li>Describe fundus findings associated with hypertensive retinopathy? </li></ul><ul><ul><li>Constriction of retinal arterioles </li></ul></ul><ul><ul><li>Intraretinal hemorrhages </li></ul></ul><ul><ul><li>Cotton wool spots </li></ul></ul><ul><ul><li>Macular edema </li></ul></ul><ul><ul><li>Disc edema </li></ul></ul><ul><ul><li>Retinal neovascularization </li></ul></ul><ul><li>What are manifestations of hypertensive choroidopathy? </li></ul><ul><ul><li>Elschnig spots and Siegrist streaks </li></ul></ul>
    4. 5. 47 yo 20/20 referred by internist
    5. 6. 62 yo diabetic 20/60
    6. 8. 33 yo diabetic 20/30 OU
    7. 12. Diabetic Retinopathy <ul><li>WESDR </li></ul><ul><ul><li>IDDM 99% have retinopathy after 20 yr </li></ul></ul><ul><ul><li>NIDDM 60% have retinopathy after 20 yr </li></ul></ul><ul><li>DCCT </li></ul><ul><ul><li>Tight glucose control decreases retinopathy in IDDM </li></ul></ul><ul><li>UKPDS </li></ul><ul><ul><li>Glucose control decreases retinopathy in NIDDM </li></ul></ul>
    8. 13. Diabetic Retinopathy <ul><li>ETDRS </li></ul><ul><ul><li>Focal laser indicated for CSME </li></ul></ul><ul><ul><ul><li>Retinal thickening at or within 500  m of the foveal center </li></ul></ul></ul><ul><ul><ul><li>Retinal thickening associated with hard exudate at or within 500  m of the foveal center </li></ul></ul></ul><ul><ul><ul><li>A zone of retinal thickening larger than 1 disc area within 1 disc diameter of the foveal center </li></ul></ul></ul><ul><ul><li>PRP indicated for high risk PDR, not for NPDR (can consider for severe NPDR) </li></ul></ul><ul><ul><li>ASA does not affect vitreous hemorrhage </li></ul></ul>
    9. 14. Diabetic Retinopathy <ul><li>Describe the 4:2:1 rule </li></ul><ul><ul><li>4 quadrants of diffuse intraretinal hemorrhage and microaneurysms </li></ul></ul><ul><ul><li>2 quadrants of venous beading </li></ul></ul><ul><ul><li>1 quadrant of intraretinal microvascular abnormalities </li></ul></ul><ul><li>What is severe NPDR and what 1-year risk does it carry for progression to high-risk PDR? </li></ul><ul><ul><li>1 of the above criteria </li></ul></ul><ul><ul><li>15% </li></ul></ul><ul><li>What is very severe NPDR and what 1-year risk does it carry for progression to high-risk PDR? </li></ul><ul><ul><li>2 of the above criteria </li></ul></ul><ul><ul><li>45% </li></ul></ul>
    10. 15. Diabetic Retinopathy <ul><li>DRS - PRP reduces severe visual loss by 50% for high risk PDR </li></ul><ul><ul><li>Mild (1/4 to 1/3 disc area) NVD with vitreous hemorrhage </li></ul></ul><ul><ul><li>Moderate to severe NVD with or w/o vitreous hemorrhage </li></ul></ul><ul><ul><li>Moderate (1/2 disc area) NVE with vitreous hemorrhage </li></ul></ul><ul><li>DRVS - vitrectomy for nonclearing vitreous hemorrhage </li></ul><ul><ul><li>Early vitrectomy beneficial for IDDM </li></ul></ul><ul><ul><li>Early (1 mo) same as late (6 mo) for NIDDM </li></ul></ul><ul><li>Other indications for surgery </li></ul><ul><ul><li>Macula involving TRD </li></ul></ul><ul><ul><li>Combined TRD/RRD </li></ul></ul><ul><ul><li>Refractory macular edema with taut posterior hyaloid </li></ul></ul>
    11. 16. 35 yo African American male
    12. 18. Sickle Cell Retinopathy <ul><li>Which form of sickle cell is associated with the most serious ocular complications? </li></ul><ul><ul><li>Hb SC </li></ul></ul><ul><li>What are the findings on nonproliferative sickle cell retinopathy? </li></ul><ul><ul><li>Salmon patch hemorrhage (intraretinal hemorrhage) </li></ul></ul><ul><ul><li>Refractile spot (resorbed hemorrhage) </li></ul></ul><ul><ul><li>Black sunburst (RPE hypertrophy) </li></ul></ul><ul><li>What are the stages of proliferative sickle cell retinopathy? </li></ul><ul><ul><li>I: arteriolar occlusions </li></ul></ul><ul><ul><li>II: arteriovenous anastomoses </li></ul></ul><ul><ul><li>III: sea-fan neovascularization </li></ul></ul><ul><ul><li>IV: vitreous hemorrhage </li></ul></ul><ul><ul><li>V: tractional retinal detachment </li></ul></ul><ul><li>What is the preferred treatment for PSR? </li></ul><ul><ul><li>Peripheral scatter photocoagulation </li></ul></ul><ul><ul><li>Vitrectomy for non-clearing vitreous hemorrhage or RD </li></ul></ul>
    13. 19. Baby
    14. 21. ROP <ul><li>Describe the stages of ROP </li></ul><ul><ul><li>1: demarcation line </li></ul></ul><ul><ul><li>2: elevated ridge </li></ul></ul><ul><ul><li>3: ridge with extraretinal fibrovascular proliferation </li></ul></ul><ul><ul><li>4: subtotal retinal detachment </li></ul></ul><ul><ul><ul><li>A extrafoveal </li></ul></ul></ul><ul><ul><ul><li>B involving fovea </li></ul></ul></ul><ul><ul><li>5: total retinal detachment </li></ul></ul><ul><li>Define plus disease </li></ul><ul><ul><li>Retinal vascular dilation and tortuosity in the posterior pole </li></ul></ul>
    15. 22. ROP <ul><li>Define threshold ROP </li></ul><ul><ul><li>Zone I or II </li></ul></ul><ul><ul><li>Extent of 5 contiguous or 8 non-contiguous clock hours of extraretinal neovascularization </li></ul></ul><ul><ul><li>Plus disease </li></ul></ul><ul><ul><li>Threshold benefits from cryo or laser </li></ul></ul><ul><li>STOP-ROP - oxygen level had no effect on progression </li></ul>
    16. 23. 71 yo woman h/o POAG 20/30
    17. 24. 75 yo 20/80
    18. 25. BVOS and CVOS <ul><li>Grid laser for macular edema </li></ul><ul><ul><li>Beneficial for BRVO </li></ul></ul><ul><ul><li>Not beneficial for CRVO </li></ul></ul><ul><li>PRP laser for prevention of VH, NVG </li></ul><ul><ul><li>Prophylactic laser not recommended </li></ul></ul><ul><ul><li>Laser once NV (iris, disc, retina) develops </li></ul></ul>
    19. 26. 60 yo Scotoma for one wk
    20. 28. 65 yo sudden decreased vision OU x 4hr
    21. 29. 65 yo decreased vision x 3d
    22. 31. Central Retinal Artery Occlusion <ul><li>What percentage of eyes have vision <20/400? </li></ul><ul><ul><li>66% </li></ul></ul><ul><li>With NLP vision, what diagnosis must be considered? </li></ul><ul><ul><li>Ophthalmic artery occlusion </li></ul></ul><ul><li>What is the leading cause of death in patients with CRAO? </li></ul><ul><ul><li>Cardiovascular disease </li></ul></ul>
    23. 32. 82 yo NLP
    24. 34. Central Retinal Artery Occlusion <ul><li>What percentage of CRAO is accounted for by giant cell arteritis? </li></ul><ul><ul><li>1-2% </li></ul></ul><ul><li>What are some methods used as therapy for CRAO? </li></ul><ul><ul><li>Ocular massage </li></ul></ul><ul><ul><li>Anterior chamber paracentesis </li></ul></ul><ul><ul><li>Administration of carbogen </li></ul></ul>
    25. 35. 85yo chronic pain and redness OD
    26. 37. Ocular Ischemic Syndrome <ul><li>What percent carotid obstruction is typically required to cause OIS? </li></ul><ul><ul><li>90% </li></ul></ul><ul><li>Describe the symptoms </li></ul><ul><ul><li>Gradual visual loss </li></ul></ul><ul><ul><li>Aching pain </li></ul></ul><ul><ul><li>Prolonged recovery following bright light exposure </li></ul></ul><ul><li>What are anterior segment findings? </li></ul><ul><ul><li>Iris neovascularization (67%) </li></ul></ul><ul><ul><li>AC cellular reaction (20%) </li></ul></ul>
    27. 38. Ocular Ischemic Syndrome <ul><li>Describe the posterior segment findings </li></ul><ul><ul><li>Narrowed arteries </li></ul></ul><ul><ul><li>Dilated, non-tortuous veins </li></ul></ul><ul><ul><li>Mid-peripheral retinal hemorrhages, microaneurysms </li></ul></ul><ul><ul><li>Neovascularization </li></ul></ul><ul><li>What are the fluorescein angiographic findings? </li></ul><ul><ul><li>Delayed choroidal filling (60%) </li></ul></ul><ul><ul><li>Delayed arteriovenous transit (95%) </li></ul></ul><ul><ul><li>Vascular staining (85%) </li></ul></ul><ul><li>What is the 5-year mortality rate and what is the most common cause of death? </li></ul><ul><ul><li>40% </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul>
    28. 39. 35 yo asymptomatic
    29. 40. Retinal Vasculitis <ul><li>What is the differential diagnosis of retinal vasculitis? </li></ul><ul><ul><li>Giant cell arteritis Multiple sclerosis </li></ul></ul><ul><ul><li>Sarcoidosis Syphilis </li></ul></ul><ul><ul><li>Behcets disease Pars planitis </li></ul></ul><ul><ul><li>Lupus Toxoplasmosis </li></ul></ul><ul><ul><li>Polyarteritis Idiopathic </li></ul></ul><ul><ul><li>Inflammatory Bowel Dz </li></ul></ul>
    30. 41. 8 yo boy; parents noted leukocoria
    31. 44. Coats Disease <ul><li>Describe the clinical findings </li></ul><ul><ul><li>Telangiectatic vessels, microaneurysms </li></ul></ul><ul><ul><li>Fusiform capillary dilation </li></ul></ul><ul><ul><li>Exudative retinal detachment </li></ul></ul><ul><ul><li>Capillary non-perfusion </li></ul></ul><ul><li>What is the mode of transmission? </li></ul><ul><ul><li>Not hereditary </li></ul></ul><ul><li>What is the percentage of cases affecting males? </li></ul><ul><ul><li>85% </li></ul></ul><ul><li>What treatments are employed to halt progression? </li></ul><ul><ul><li>Cryotherapy or photocoagulation </li></ul></ul><ul><ul><li>Retinal reattachment surgery </li></ul></ul>
    32. 45. 40 yo 20/40 OU
    33. 47. Idiopathic Juxtafoveal Telangiectasis <ul><li>What are the 3 clinical groups </li></ul><ul><ul><li>Unilateral juxtafoveal telangiectasis </li></ul></ul><ul><ul><li>Bilateral juxtafoveal telangiectasis </li></ul></ul><ul><ul><li>Bilateral juxtafoveal telangiectasis with capillary obliteration </li></ul></ul>
    34. 48. 45 yo h/o HTN
    35. 51. Retinal Arterial Macroaneurysm <ul><li>What percentage of cases are associated with systemic hypertension? </li></ul><ul><ul><li>67% </li></ul></ul><ul><li>What are causes of visual loss? </li></ul><ul><ul><li>Intra- or subretinal hemorrhage </li></ul></ul><ul><ul><li>Vitreous hemorrhage </li></ul></ul><ul><ul><li>Macular edema/exudation </li></ul></ul>
    36. 52. 50 yo c/o floater
    37. 53. Posterior Vitreous Detachment <ul><li>What percentage of patients with acute symptomatic PVD have a retinal tear? </li></ul><ul><ul><li>15% </li></ul></ul><ul><li>What percentage of patients with vitreous hemorrhage associated with PVD have a retinal tear? </li></ul><ul><ul><li>70% </li></ul></ul>
    38. 54. 20 yo myope, asymptomatic
    39. 58. Lattice Degeneration <ul><li>What is the prevalence of lattice degeneration in the general population? </li></ul><ul><ul><li>6-8% </li></ul></ul><ul><li>Of patients with lattice, what is chance of RD? </li></ul><ul><ul><li>1% </li></ul></ul><ul><li>What percentage of retinal detachments have associated lattice degeneration? </li></ul><ul><ul><li>20-30% </li></ul></ul><ul><li>Describe the histopathologic features </li></ul><ul><ul><li>Discontinuity of the ILM </li></ul></ul><ul><ul><li>Overlying pocket of liquefied vitreous </li></ul></ul><ul><ul><li>Adherence of vitreous at the margin </li></ul></ul><ul><ul><li>Atrophy of inner retinal layers </li></ul></ul>
    40. 59. 60 yo c/o flashes
    41. 60. Retinal Breaks <ul><li>What percentage of the population will develop a retinal detachment over their lifetime? </li></ul><ul><ul><li>0.07% </li></ul></ul><ul><li>What types of retinal breaks should be treated? </li></ul><ul><ul><li>Symptomatic horseshoe tears </li></ul></ul><ul><ul><li>Retinal dialysis </li></ul></ul>
    42. 63. Retinal Detachment <ul><li>What is optimal timing for surgery? </li></ul><ul><ul><li>Mac on - 87% ≥ 20/50 </li></ul></ul><ul><ul><li>Mac off - 30-50% ≥ 20/50 </li></ul></ul><ul><ul><ul><li>< 1 wk 75% ≥ 20/70 </li></ul></ul></ul><ul><ul><ul><li>1-8 wk 50% ≥ 20/70 </li></ul></ul></ul><ul><li>Define subclinical retinal detachment </li></ul><ul><ul><li>Subretinal fluid extends more than 1DD from the break </li></ul></ul><ul><ul><li>Subretinal fluid extends no more than 2DD posterior to the equator </li></ul></ul>
    43. 64. 60 yo asymptomatic
    44. 65. Retinoschisis <ul><li>What is the typical location in the fundus? </li></ul><ul><ul><li>Inferotemporal </li></ul></ul><ul><li>What layer is affected in typical retinoschisis? </li></ul><ul><ul><li>Outer plexiform </li></ul></ul><ul><ul><li>(reticular retinoschsis, juvenile retinoschisis in NFL) </li></ul></ul><ul><li>How can schisis be differentiated from RD? </li></ul><ul><ul><li>Absolute scotoma </li></ul></ul><ul><ul><li>No associated tear/tobacco dust </li></ul></ul><ul><ul><li>Smoother surface </li></ul></ul><ul><ul><li>Laser scars </li></ul></ul>
    45. 70. Hereditary Hyaloidoretinopathies <ul><li>Describe features of Jansen and Wagner disease </li></ul><ul><ul><li>Autosomal dominant transmission </li></ul></ul><ul><ul><li>Optically empty vitreous </li></ul></ul><ul><ul><li>Equatorial and perivascular lattice </li></ul></ul><ul><ul><li>Myopia, strabismus, cataract </li></ul></ul><ul><li>Which of the above conditions is associated with retinal detachment? </li></ul><ul><ul><li>Jansen disease </li></ul></ul>
    46. 71. Stickler Syndrome <ul><li>Describe the features of Stickler Syndrome </li></ul><ul><ul><li>Autosomal dominant transmission </li></ul></ul><ul><ul><li>Myopia, glaucoma, cataract </li></ul></ul><ul><ul><li>Orofacial findings </li></ul></ul><ul><ul><ul><li>Midfacial flattening </li></ul></ul></ul><ul><ul><ul><li>Pierre-Robin malformation (micrognathia, cleft palate, glossoptosis) </li></ul></ul></ul><ul><ul><li>Skeletal abnormalities </li></ul></ul><ul><ul><ul><li>Joint hyperextensibility </li></ul></ul></ul><ul><ul><ul><li>Arthritis </li></ul></ul></ul><ul><ul><ul><li>Spondyloepiphyseal dysplasia </li></ul></ul></ul><ul><ul><li>High incidence of RD, giant retinal tear, PVR </li></ul></ul>
    47. 72. 3 mo old term baby
    48. 74. FEVR <ul><li>What is the mode of inheritance of familial exudative vitreoretinopathy? </li></ul><ul><ul><li>Autosomal dominant </li></ul></ul><ul><li>Describe the clinical features </li></ul><ul><ul><li>Normal birth weight/gestational age </li></ul></ul><ul><ul><li>Failure of the temporal retina to completely vascularize </li></ul></ul><ul><ul><li>Peripheral fibrovascular proliferation </li></ul></ul><ul><ul><li>Traction retinal detachment </li></ul></ul><ul><ul><li>Subretinal exudate or exudative detachment </li></ul></ul><ul><ul><li>Late-onset rhegmatogenous detachment </li></ul></ul>

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