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