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The Ageing Fundus Visual Recognition & Interpretation of Clinical Signs

Quiz created by Peter Chapman MCOptom FBDO & Jane Macnaughton MCOptom

www.clearviewtraining.co.uk

+ CET Accreditation C190462 2 CET Points (General)

Instructions

This VRICS poster quiz consists of a series of fundus and OCT images of the posterior segment.

You are encouraged to discuss with peers and/or use available listed materials to interpret the pictures and

come to an accurate conclusion.

To receive your CET points for this article, complete the Multiple Choice Questions.

A pass mark of 66% (8 out of 12 correct answers) must be achieved. Only one attempt is allowed.

+ Bipolar Cell

Choriocapillaris Ganglion Cell Layer

Inner Limiting Membrane Inner Nuclear Layer

Inner Plexiform Layer Retinal Pigment Epith’m

Nerve Fibre Layer Outer Limiting

Membrane Outer Nuclear Layer

Outer Plexiform Layer Photoreceptor Cell

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2

3

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7 8

9 10 12

11 Figure 1: Schematic Diagram of Retinal Histology

+ Q1. Name the retinal cells/layers from Fig1 in the correct order.

n  1. Choriocapillaris, 2. Retinal Pigment Epithelium, 3. Photoreceptor Cell, 4. Outer Limiting Membrane, 5. Outer Nuclear Layer, 6. Outer Plexiform Layer, 7. Bipolar Cell, 8. Inner Nuclear Layer, 9. Inner Plexiform Layer, 10. Ganglion Cell Layer, 11. Nerve Fibre Layer, 12. Inner Limiting Membrane

n  1. Choriocapillaris, 2. Retinal Pigment Epithelium, 3. Photoreceptor Cell, 4. Inner Limiting Membrane, 5. Inner Nuclear Layer, 6. Inner Plexiform Layer, 7. Bipolar Cell, 8. Outer Nuclear Layer, 9. Outer Plexiform Layer, 10. Ganglion Cell Layer, 11. Nerve Fibre Layer, 12. Outer Limiting Membrane

n  1. Choriocapillaris, 2. Retinal Pigment Epithelium, 3. Photoreceptor Cell, 4. Outer Limiting Membrane, 5. Outer Nuclear Layer, 6. Outer Plexiform Layer, 7. Ganglion Cell Layer, 8. Inner Nuclear Layer, 9. Inner Plexiform Layer, 10. Bipolar Cell, 11. Nerve Fibre Layer, 12. Inner Limiting Membrane

n  1. Choriocapillaris, 2. Retinal Pigment Epithelium, 3. Photoreceptor Cell, 4. Inner Limiting Membrane, 5. Inner Nuclear Layer, 6. Inner Plexiform Layer, 7. Ganglion Cell Layer, 8. Outer Nuclear Layer, 9. Outer Plexiform Layer, 10. Bipolar Cell, 11. Nerve Fibre Layer, 12. Outer Limiting Membrane

1.

2. 3. 4.

Figure 2: OCT Image of a normal Macula

+ Q2. From the OCT Image in Fig 2, name the retinal cells/layers in the correct order. n 1. Nerve Fibre Layer, 2. Retinal Pigment Epithelium,

3. Outer Limiting Membrane, 4. Choriod

n 1. Nerve Fibre Layer, 2. Photoreceptors, 3. Retinal Pigment Epithelium, 4. Choriod

n 1. Inner Limiting Membrane, 2. Photoreceptors, 3. Retinal Pigment Epithelium, 4. Choriod

n 2. Outer Limiting Membrane, 2. Retinal Pigment Epithelium, 3. Choriod, 4. Sclera

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Case History Patient TR:

n 70 year old female

n VA 6/12

n No other symptoms reported

Figure 3: OCT & Fundus Image of Patient TR

+ Q3. From the information given, what is your provisional diagnosis of the condition shown in Fig 3? n Choroidal neovascular membrane

n Macular hole

n Cystoid macula oedema

n Drusen

+ Q4. What would be the most appropriate onward management for the patient in Fig3? n Urgent referral to ophthalmologist for fluorescein

angiogram

n Give Patient an Amsler chart for self monitor and review in 1 year

n Routine referral to GP to monitor blood Glucose level

n Referral within 2 weeks to ophthalmologist for potential vitrectomy and macula hole closure

+ Figure 4 (Left): OCT & Fundus Image of Patient SP

n 86 year old female

n Reduced VA over 2 months

n VA 6/60

+ Q5. From the information given, what is your provisional diagnosis of the condition shown in Fig4? n  Central serous retinopathy

n  Wet macular degeneration

n  North Carolina macular dystrophy

n  Macula hole

+ Q6. For Patient SP in Fig4 what would be the most appropriate onward management / treatment? n Spontaneously resolves thus no treatment– monitor

in practice only.

n Refer within 1 week to ophthalmologist for potential Lucentis therapy

n Irreversible. No current treatment available. Letter to GP / routine referral for information only

n Refer within 2 weeks for ophthalmologist opinion regarding vitrectomy

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Case History Patient JM:

n 78 year old male

n Complaining of central distortion following fall and blow to the head 8 months ago

n VA 6/12+

Fig5: OCT & Fundus Image Px JM

+ Q7. From the information given, what is your provisional diagnosis of the condition shown in Fig5? n Epiretinal membrane

n Cystoid macular oedema

n Central serous retinopathy

n Bests disease

+ Q8. For Patient JM in Fig5 what would be the most appropriate onward management? n Refer for topical steroid drops

n Spontaneously resolves thus no treatment– monitor

n Refer within 1 week to ophthalmologist for potential Lucentis therapy

n Usually non progressive, refer routinely to ophthalmologist to consider peel

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Case History Patient SC

n 72 year old male

n Complains of distortion when walking down steps over past week

n  VA reduced to 6/18

Figure 6: Fundus & OCT images of Patient SC

+ Q9. From the information given, what is your provisional diagnosis of the condition shown in Fig6? n Pre proliferative-diabetic retinopathy

n Wet macular degeneration

n Geographic atrophy

n Cone dystrophy

+ Q10. For Patient SC in Fig6 what would be the most appropriate onward management? n Non Progressive Condition - refer for Low Vision

Assessment

n  Ranibizumab

n  Glicazide

n  Ramipril

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Case History Px GF

n 70 year old male

n Complaining of sudden loss of vision in Left eye

Figure 7: Fundus image of Patient GF

+ Q11. For Patient GF in Fig7 what would be the most appropriate onward management out of the following options?

n Direct to eye casualty for ocular massage, and anterior chamber paracentesis

n No treatment possible – refer to GP for Blood Glucose assessment - follow up 6 months

n Prompt referral to ophthalmologist to monitor potential neovascularisation of the angle

n Urgent referral to Ophthalmologist for laser photocoagulation

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Case History Px EW

n  78 year old female

n  Recent stress due to a family bereavement

n  VA 6/12

n  Small hyperopic shift noted on retinoscopy

n  Central distortion reported on Amsler grid

Figure 8 OCT & Fundus image of Patient EW

+ Q12. What is your provisional diagnosis of the condition shown in Fig8?

n Best’s disease

n Cystoid macular oedema

n Central serous retinopathy

n Wet macular degeneration