Retina Review Part 2

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

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 diabetic 20/60

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

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

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%

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

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

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

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

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 POAG 20/30

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

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

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

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%)

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

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

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

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

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

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%

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

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

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

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

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

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

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

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