19/10/12 CET 30 Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates CET CONTINUING EDUCATION & TRAINING a Novartis company The spotty retina C-19713 O/D Mark Benson, MB, ChB, MSc, FRCS, FRCOphth There are many causes of a “spotty” appearance to the retina, which are not caused by pigmentary changes such as those discussed in the previous article (see OT, September 7 2012) (Table 1). This article discusses those abnormalities that result in hypopigmented lesions evident upon fundoscopy. Drusen Drusen are aggregates of breakdown product resulting from the recycling of photoreceptor outer segments. They are a sign of ageing in the retinal pigment epithelium (RPE) (Figure 1). They do not usually, in themselves, cause visual loss but there may be accompanying atrophy of the RPE, which can result in severe visual loss. Pigmentary disturbance is a frequent associated finding. Although generally an ageing change (age-related macular degeneration – AMD), drusen formation can be an inherited trait, with an autosomal dominant pattern of inheritance evident in the third decade. Exudates Lipoprotein exudates in the fundus are a sign of vascular leakage. They are more superficial than drusen and usually more clearly defined (Figure 2). They tend to form incomplete or partial rings (circinate retinopathy). They are not specific to any particular underlying aetiology, but often there are clues from associated physical signs, eg segmental flame haemorrhages from a retinal vascular occlusion (RVO). Microinfarcts These represent accumulations of neuronal organelles (chiefly mitochondria) in areas where neuronal axoplasmic flow has been affected by local ischaemia. Thus they are a non-specific sign of poor retinal circulation. They are often called “cotton wool spots” because of their appearance (Figure 3). They may be the only physical sign in the fundus, or they may be seen in conjunction with other abnormalities which give a clue to the underlying aetiology, eg microaneurysms and flame-shaped haemorrhages in diabetes. In general, cotton wool spots themselves do not compromise vision. The importance of microinfarcts as a physical sign should not be underestimated. There are many causes of microinfarcts and finding even a single microinfarct in a non-diabetic patient necessitates further investigation; in some 95% of cases, a serious underlying disorder may be found 1 (Table 2, page 32). Laser treatment Laser photocoagulation in the macular area is most commonly carried out as a treatment for macular oedema, particularly in the setting of diabetic retinopathy or following a branch retinal vein occlusion (BRVO). When freshly applied, laser burns produce a pale lesion with poorly-defined margins. Over time these lesions become better defined and they may become larger in size (Figure 4). The lesions often develop a pigmented border, though this is not always the case. Inflammatory conditions There are many inflammatory causes of pale fundus lesions. They may be large, solitary lesions, such as those seen following Figure 1 Drusen Figure 3 Microinfarcts Figure 2 Exudates 1 FREE CET POINT 4 4 Approved for: Optometrists Dispensing Opticians OT CET content supports Optometry Giving Sight Having trouble signing in to take an exam? View CET FAQ Go to www.optometry.co.uk
Transcript
19/1
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CET
30
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CET CONTINUING EDUCATION & TRAINING
20/0
4/12
CET
48
CET CONTINUING EDUCATION & TRAINING
1 FREE CET POINT OT CET content supports Optometry Giving Sight
Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Having trouble signing in to take an exam? View CET FAQ Go to www.optometry.co.uk
About the authorMaggie Woodhouse is senior lecturer
at the School of Optometry and Vision
Sciences, Cardiff University, where she
specialises in paediatric optometry.
She runs the Special Assessment
Clinic, which caters for patients of all
ages with disabilities. Her particular
interests are visual development in
children with Down’s syndrome and the
impact of visual defects on education.
ReferencesSee www.optometry.co.uk/
clinical. Click on the article title and
then on ‘references’ to download.
1. Diagnosing a congenital colour vision defect in early childhood has the following benefits EXCEPT:a) The defect can be treatedb) Teachers can understand a child’s colour choice in artworkc) Inappropriate career plans can be avoided d) Alternatives to colour coding can be used
2. Measuring eye movements in children is likely to be more successful if the practitioner:a) Moves the target very slowlyb) Avoids distracting the child by speaking
c) Uses a flashing colourful targetd) Uses a large target
3. Success in eye health examination of a young child may be improved if the practitioner:a) Asks the child to sit as still as possible for as long as it takesb) Asks the child to keep looking at an interesting picture on the wall, no matter whatc) Uses a slit-lamp and a Volk lensd) Examines sections of the eyes in separate intervals4. Practice preparation may include all of the following EXCEPT:
PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage on May 28, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Module questions Course code: C-18705 O/D
a Novartis company
The spotty retinaC-19713 O/D
Mark Benson, MB, ChB, MSc, FRCS, FRCOphthThere are many causes of a “spotty” appearance to the retina, which are not
caused by pigmentary changes such as those discussed in the previous
article (see OT, September 7 2012) (Table 1). This article discusses those
abnormalities that result in hypopigmented lesions evident upon fundoscopy.
DrusenDrusen are aggregates of breakdown product resulting from the recycling of photoreceptor outer segments. They are a sign of ageing in the retinal pigment epithelium (RPE) (Figure 1). They do not usually, in themselves, cause visual loss but there may be accompanying atrophy of the RPE, which can result in severe visual loss. Pigmentary disturbance is a frequent associated finding. Although generally an ageing change (age-related macular degeneration – AMD), drusen formation can be an inherited trait, with an autosomal dominant pattern of inheritance evident in the third decade.
ExudatesLipoprotein exudates in the fundus are a sign of vascular leakage. They are more superficial than
drusen and usually more clearly defined (Figure 2). They tend to form incomplete or partial rings (circinate retinopathy). They are not specific to any particular underlying aetiology, but often there are clues from associated physical signs, eg segmental flame haemorrhages from a retinal vascular occlusion (RVO).
MicroinfarctsThese represent accumulations of neuronal organelles (chiefly mitochondria) in areas where neuronal axoplasmic flow has been affected by local ischaemia. Thus they are a non-specific sign of poor retinal circulation. They are often called “cotton wool spots” because of their appearance (Figure 3). They may be the only physical sign in the fundus, or they may be seen in conjunction with other abnormalities which give a clue to
the underlying aetiology, eg microaneurysms and flame-shaped haemorrhages in diabetes. In general, cotton wool spots themselves do not compromise vision. The importance of microinfarcts as a physical sign should not be underestimated. There are many causes of microinfarcts and finding even a single microinfarct in a non-diabetic patient necessitates further investigation; in some 95% of cases, a serious underlying disorder may be found1 (Table 2, page 32).
Laser treatmentLaser photocoagulation in the macular area is most commonly carried out as a treatment for macular oedema, particularly in the setting of diabetic retinopathy or following a branch retinal vein occlusion (BRVO). When freshly applied, laser burns produce a pale lesion with poorly-defined margins. Over time these lesions become better defined and they may become larger in size (Figure 4). The lesions often develop a pigmented border, though this is not always the case.
Inflammatory conditionsThere are many inflammatory causes of pale fundus lesions. They may be large, solitary lesions, such as those seen following
Figure 1 Drusen
Figure 3 Microinfarcts
Figure 2 Exudates
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Toxoplasma infection, but sometimes they result in a “spotty” fundus appearance as seen in the presumed ocular histoplasmosis syndrome (POHS), birdshot chorioretinitis, multifocal choroiditis and punctate inner choroidopathy (PIC). The aetiology of these diseases is not well understood, and they may be multifactorial. POHS is named thus because of a suspected infective basis. The clinical diagnosis is based upon a finding of multifocal choroidal depigmented lesions (usually with some associated pigmentation at their margin) (Figure 5), peripapillary atrophy, and in more advanced cases, a macular choroidal neovascular membrane. The latter arises because inflammatory lesions create breaks in Bruch’s membrane, which allows new vessels to grow through to underlie the retina.
PIC is an inflammatory condition similar in many respects to POHS, producing similar lesions in the fundus (Figure 6). Birdshot chorioretinitis is a bilateral, idiopathic inflammatory disorder leading to vitritis and multiple hypopigmented spots at the level of the RPE (Figure 7). The disposition of these lesions is said to resemble the scatter of birdshot from a shotgun. Patients with birdshot chorioretinitis tend to be older than those with POHS or PIC, being aged 50-70.
Stargardt’s macular dystrophyStargardt’s macular dystrophy (and fundus flavimaculatus, which is a variant of the same disorder) is an inherited disorder (almost always autosomal recessive) which presents in the first or second decade with visual impairment. This condition is currently the
subject of an investigation by the Royal College of Ophthalmologists to ascertain its incidence and the characteristics of patients at presentation, thus the initial diagnosis may fall to optometrists. Initially there is a non-specific mottling at the fovea which, over time, develops a “beaten bronze” appearance. Pale flecks at the level of the RPE then develop, initially in the perifoveal region, then extending more peripherally later (Figure 8, page 33).
OxalosisPrimary hyperoxaluria is an inherited disorder of carbohydrate metabolism. It results in the widespread deposition of calcium oxalate crystals. In the eye there is a crystalline retinopathy, particularly marked in the RPE, producing a flecked retina appearance. Hyperpigmented lesions may also develop in the RPE. Those affected typically have renal complications. The diagnosis can be made by demonstrating increased urinary oxalate, and by tissue biopsy.
Tamoxifen retinopathyThe drug Tamoxifen is an anti-oestrogen drug used to treat breast cancer. It can, very rarely, produce a retinopathy characterised by bilateral fine intraretinal refractile opacities, hypopigmented lesions at the level of the RPE, and macular oedema (Figure 9, page 34). An association with a corneal epithelium “whorl” appearance has been described.
HistoryCareful history-taking will often reveal the likely aetiology of a “spotty” retinal appearance. Does the patient have diabetes? If so, they may have exudates. Have they had laser treatment? Patients with diabetes and those with macular oedema secondary to previous RVO may have had macular grid laser photocoagulation to treat their maculopathy.
Is there a family history of eye disease? This might suggest autosomal dominant drusen, or possibly Stargardt’s dystrophy, though there may be no obvious family history with the latter,
23/0
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CET
49
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(Abbott Medical Optics Inc., Santa
Ana, California, USA) for the duration
of the study. They were instructed to
maintain their regular correct cleaning
regime (rub and rinse) as well as
their normal replacement schedule.
Types of contact lenses used in
this investigation were Biofinity
(CooperVision, Fairport, New York,
USA), Acuvue Oasys, Acuvue Oasys for
Presbyopia, Acuvue Advance (all Johnson
& Johnson Visioncare Inc., Jacksonville,
Florida, USA) Air Optix, Air Optix
Night & Day (both CIBA Vision, Duluth,
Georgia, USA) and PureVision (Bausch
& Lomb, Rochester, New York, USA).
Subjects were wearing lenses for at least
five hours per day and were examined
at the following intervals: before
administration of Blink’n’Clean eye drops,
five minutes after the first instillation of
Blink’n’Clean eye drops, and 14 days
after first use of Blink’n’Clean eye drops.
The authors used the modified Rudko
validated scale10,11 (Figure 1) for
assessment of deposits on contact lenses.
Heaviness, extent and type of deposits
were compared before instillation of
Blink’n’Clean eye drops, five minutes
after the first eye drop instillation,
and 14 days after twice daily use.
Pre-lens non-invasive tear break-up
time (NIBUT) was evaluated without
application of fluorescein dye with
different types of mires, such as placido
disc of the videokeratograph or mires
of the keratometer. This allowed
calculation of the NIBUT without
interfering with tear film stability.
Corneal staining, which was analysed
with the application of fluorescein dye,
and hyperaemia were assessed according
to the Cornea and Contact Lens Research
Unit (CCLRU) grading scale (School
of Optometry and Vision Science, The
University of New South Wales, Sydney,
Australia). LIPCOF were also counted,
vertically below the temporal limbus.
A subjective questionnaire (Table 1)
was also given to wearers five minutes
after first instillation of Blink’n’Clean
and again after 14 days of twice
daily use. It is necessary to point
out that, since the questionnaire has
not been statistically validated at the
time of this publication, the results
are preliminary but not conclusive.
Analysis and resultsSubject’s gender is not a parameter to
be included in the analysis since the
distribution of values is not balanced
sufficiently (nine men and 42 women). The
age distribution in the sample was normal
(Kolmogorov-Smirnov test, p=0.66).
The distribution of NIBUT values
was normal (Kolmogorov-Smirnov
test, p>0.05 on all occasions), and
therefore parametric tests were applied
(ANOVA with post hoc analysis and
Pearson’s correlation coefficient). The
remaining parameters follow categorical
scaling and therefore non-parametric
tests were applied (Chi-square,
Friedman ANOVA, and Wilcoxon
matched-pairs signed-ranks tests).
Non-invasive break-up time Results showed significantly higher
NIBUT values after 14 days (13.4±6.7
seconds) of twice-daily use of
1. During a normal day within the last week, how often was the wearing comfort of your contact lenses unpleasant?
Never Rarely Sometimes Often Always
2.When exactly did you note this unpleasant wearing comfort?
Never Early morning Noon Evening All day
3. If you felt this unpleasant wearing comfort, how unpleasant was this feeling at the end of the contact lens wearing time?
No problem Slightly unpleasant Unpleasant Annoying Extremely annoying
4. During a normal day within the last week - how often did you have the feeling that your contact lenses are dirty?
Never Rarely Sometimes Often Always
5. How was the wearing comfort after using Blink’n’Clean?
Much worse Worse Same Better Much better
6. How was your vision after using Blink’n’Clean?
Much worse Worse Same Better Much better
Table 1 Subjective questionnaire used to evaluate the effect of Blink’n’Clean eye drop use on contact lens comfort and vision
About the authorMaggie Woodhouse is senior lecturer
at the School of Optometry and Vision
Sciences, Cardiff University, where she
specialises in paediatric optometry.
She runs the Special Assessment
Clinic, which caters for patients of all
ages with disabilities. Her particular
interests are visual development in
children with Down’s syndrome and the
impact of visual defects on education.
ReferencesSee www.optometry.co.uk/
clinical. Click on the article title and
then on ‘references’ to download.
1. Diagnosing a congenital colour vision defect in early childhood has the following benefits EXCEPT:a) The defect can be treatedb) Teachers can understand a child’s colour choice in artworkc) Inappropriate career plans can be avoided d) Alternatives to colour coding can be used
2. Measuring eye movements in children is likely to be more successful if the practitioner:a) Moves the target very slowlyb) Avoids distracting the child by speaking
c) Uses a flashing colourful targetd) Uses a large target
3. Success in eye health examination of a young child may be improved if the practitioner:a) Asks the child to sit as still as possible for as long as it takesb) Asks the child to keep looking at an interesting picture on the wall, no matter whatc) Uses a slit-lamp and a Volk lensd) Examines sections of the eyes in separate intervals4. Practice preparation may include all of the following EXCEPT:
PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage on May 28, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Module questions Course code: C-18705 O/D
a Novartis company
since it usually shows recessive inheritance.Has the patient had previous eye problems?
Many of the inflammatory conditions affecting the retina are recurrent or progressive, and when active, they may result in floaters or other visual symptoms. The patient may give a history of previous eye inflammation, which may have required treatment.
Ask specifically about the patient’s general health. Aside from diabetes, do they have renal problems? If so, what is the underlying cause? Oxalosis is a rare condition, but those who
develop the ocular signs are likely to be already affected by the associated nephropathy. Female patients may give a history of treatment for carcinoma of the breast, and many such patients take Tamoxifen as an adjunct to surgery. It is rare for this drug to lead to a retinopathy, but the drug has been very widely prescribed, so it is conceivable that practitioners might encounter someone who is affected.
If the retinal lesions are microinfarcts, then systemic vascular disease is likely. If there is a complaint of persistent headache, ask about scalp tenderness and jaw claudication (pain in the cheek on chewing), which point towards giant cell arteritis. There may be a history of general malaise, bruising and bleeding tendency (blood dyscrasia), or lethargy, tiredness and shortness of breath (cardiac disease or severe anaemia).
In practice, the most common cause of a “spotty retina” is drusen, as a result of ageing changes in the retina/RPE complex. Those affected are likely to volunteer the facts that they struggle with small print, and need more light to read. Listen for any suggestion of distortion of vision, and ask about that symptom, which may indicate the advent of neovascular change and “wet” AMD.
ExaminationExamination of the anterior segment should be performed with a slit lamp, looking for arcus in the cornea, which might reflect a high cholesterol level and associated ischaemic problems. Look for flare and cells in the anterior chamber, and cells in the vitreous, which would support the diagnosis of some form of posterior segment inflammatory disease. If there is flare but no cells, then that suggests vascular leakage without a significant inflammatory element, eg diabetic retinopathy.
Posterior segment examination should ideally be performed through a dilated pupil and using a binocular indirect technique. Look at the size, shape, location and distribution of the “spotty” lesions, and look for associated signs. Drusen are located deep in the retina and range in appearance from small, well-defined, and even calcified hypopigmented bodies to larger, softer-edge and confluent lesions. Look for associated hyperpigmented “speckles” and signs of atrophy of the RPE. There are usually similar signs in the fellow eye.
Exudates are more superficial and generally “harder-edged” than drusen. They tend to form circles or part-circles. Occasionally they are centred on the fovea and deposited in a “star” pattern. Since they represent a breakdown of
Table 2 Systemic associations with retinal microinfarcts
Figure 5 Presumed Ocular Histoplasmosis Syndrome (POHS) (left) and early “histo” spots (right)
the blood-ocular barrier, look for associated signs of vascular disease eg microaneurysms, flame or blot haemorrhages (diabetes or RVO), emboli (hypercholesterolaemia, carotid artery disease, cardiac valvular problems), or vascular sheathing (collagen vascular disease, previous RVO).
Microinfarcts may be single or multiple, and are located in the nerve fibre layer of the retina. They have a “fluffy” edge and they are usually found in the posterior pole. Look for signs of diabetic retinopathy or other vascular disease as above.
The hypopigmented lesions of POHS can be found anywhere in the fundus. They may be ill-defined when acute, but most lesions are old, and well-defined with associated hyperpigmentation. There is usually little or no vitritis. At the posterior pole, there may be associated sub-retinal scarring from a sub-retinal neovascular membrane and there may be some atrophic lesions around the optic nerve head. Affected individuals are often picked up at routine sight tests, or present when one eye develops a macular subretinal neovascular membrane. PIC resembles POHS, but lesions tend to be more central and patients are more symptomatic (blurred vision, photopsia, scotomata) although, like POHS, vitritis is minimal or absent. Patients with birdshot chorioretinitis usually have an obvious vitritis and often macular oedema. The fundal lesions are larger and less distinct than those of POHS/PIC and they do not pigment over time.
If the macula appearance is of “beaten
bronze” Stargardt’s dystrophy should be suspected. The macula looks atrophic and is usually accompanied by the appearance of concentric whitish flecks at the level of the RPE. These have often been described as triangular or having a fish tail appearance. More flecks gradually appear in a centrifugal spread. There is no evidence of any vascular upset, and no sign of inflammation. Some patients may have quite marked flecks, with little evidence of the macular atrophy; this is the fundus flavimaculatus variant of the same disorder.
If the flecks have a crystalline appearance, calcific drusen might be the cause but they are clearly deep in the retina and accompanied by the other signs of AMD. The very rare condition oxalosis, important because of its systemic associations, especially renal disease, produces deposits at all levels in the fundus and may show hyperpigmented patches around the fovea. Tamoxifen retinopathy, by contrast, produces intraretinal crystalline deposits clustered around the fovea.
ManagementIn practice many “spotty” retinas are the result of dry macular changes. For these patients, management includes advice about lighting and magnification, a discussion of the benefits of antioxidant supplementation, and an explanation of the possible significance of metamorphopsia. Note that very minor degrees of distorted vision are quite common in dry AMD, and if you “push” such patients about the presence of metamorphopsia, they will answer in the affirmative. Unlike wet AMD, however,
Figure 6 Punctate Inner Choroidopathy (PIC). Picture courtesy of Professor I. Rennie
Figure 7 Birdshot chorioretinitis. Picture courtesy of Professor I. Rennie
Figure 8 Stargardt’s macular dystrophy. Picture courtesy of Professor I. Rennie
23/0
3/12
CET
49
For the latest CET visit www.optometry.co.uk/cet
(Abbott Medical Optics Inc., Santa
Ana, California, USA) for the duration
of the study. They were instructed to
maintain their regular correct cleaning
regime (rub and rinse) as well as
their normal replacement schedule.
Types of contact lenses used in
this investigation were Biofinity
(CooperVision, Fairport, New York,
USA), Acuvue Oasys, Acuvue Oasys for
Presbyopia, Acuvue Advance (all Johnson
& Johnson Visioncare Inc., Jacksonville,
Florida, USA) Air Optix, Air Optix
Night & Day (both CIBA Vision, Duluth,
Georgia, USA) and PureVision (Bausch
& Lomb, Rochester, New York, USA).
Subjects were wearing lenses for at least
five hours per day and were examined
at the following intervals: before
administration of Blink’n’Clean eye drops,
five minutes after the first instillation of
Blink’n’Clean eye drops, and 14 days
after first use of Blink’n’Clean eye drops.
The authors used the modified Rudko
validated scale10,11 (Figure 1) for
assessment of deposits on contact lenses.
Heaviness, extent and type of deposits
were compared before instillation of
Blink’n’Clean eye drops, five minutes
after the first eye drop instillation,
and 14 days after twice daily use.
Pre-lens non-invasive tear break-up
time (NIBUT) was evaluated without
application of fluorescein dye with
different types of mires, such as placido
disc of the videokeratograph or mires
of the keratometer. This allowed
calculation of the NIBUT without
interfering with tear film stability.
Corneal staining, which was analysed
with the application of fluorescein dye,
and hyperaemia were assessed according
to the Cornea and Contact Lens Research
Unit (CCLRU) grading scale (School
of Optometry and Vision Science, The
University of New South Wales, Sydney,
Australia). LIPCOF were also counted,
vertically below the temporal limbus.
A subjective questionnaire (Table 1)
was also given to wearers five minutes
after first instillation of Blink’n’Clean
and again after 14 days of twice
daily use. It is necessary to point
out that, since the questionnaire has
not been statistically validated at the
time of this publication, the results
are preliminary but not conclusive.
Analysis and resultsSubject’s gender is not a parameter to
be included in the analysis since the
distribution of values is not balanced
sufficiently (nine men and 42 women). The
age distribution in the sample was normal
(Kolmogorov-Smirnov test, p=0.66).
The distribution of NIBUT values
was normal (Kolmogorov-Smirnov
test, p>0.05 on all occasions), and
therefore parametric tests were applied
(ANOVA with post hoc analysis and
Pearson’s correlation coefficient). The
remaining parameters follow categorical
scaling and therefore non-parametric
tests were applied (Chi-square,
Friedman ANOVA, and Wilcoxon
matched-pairs signed-ranks tests).
Non-invasive break-up time Results showed significantly higher
NIBUT values after 14 days (13.4±6.7
seconds) of twice-daily use of
1. During a normal day within the last week, how often was the wearing comfort of your contact lenses unpleasant?
Never Rarely Sometimes Often Always
2.When exactly did you note this unpleasant wearing comfort?
Never Early morning Noon Evening All day
3. If you felt this unpleasant wearing comfort, how unpleasant was this feeling at the end of the contact lens wearing time?
No problem Slightly unpleasant Unpleasant Annoying Extremely annoying
4. During a normal day within the last week - how often did you have the feeling that your contact lenses are dirty?
Never Rarely Sometimes Often Always
5. How was the wearing comfort after using Blink’n’Clean?
Much worse Worse Same Better Much better
6. How was your vision after using Blink’n’Clean?
Much worse Worse Same Better Much better
Table 1 Subjective questionnaire used to evaluate the effect of Blink’n’Clean eye drop use on contact lens comfort and vision
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this is very minor and static. Such patients do not need referral. If the patient has presented with the symptom of distorted vision, or if you have reason to believe that there is progressive metamorphopsia, then urgent referral is necessary. An established referral route to a local secondary care unit should be present, preferably into a retina or macula clinic.
The presence of exudates suggests a potentially sight-threatening condition, and if the patient is not already undergoing treatment for this, then referral is necessary for assessment and possible treatment. If the exudates are within one disc diameter of the fovea, then treatment is required urgently, so refer accordingly, being clear about the location of the exudates.
The finding of even a single microinfarct in a non-diabetic patient is significant. It necessitates further investigation, since a high proportion of these patients turn out to have a serious underlying medical problem1 (Table 2). For most of these patients, despite the eye signs, the ophthalmic clinic may not be the most appropriate department for working up these patients. However, all ophthalmic surgeons have received general medical training prior to specialising in ophthalmology, and they are well-placed to ascertain the significance of other symptoms and signs, and to access other medical clinics and facilities quickly. It is reasonable, therefore, to make an urgent written/faxed referral to the local ophthalmic department. An alternative route is to arrange that the patient attend their General Practitioner urgently. If the patient is elderly, and gives a clear history of persistent headache
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CET CONTINUING EDUCATION & TRAINING
1 FREE CET POINT
Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
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CET
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CET CONTINUING EDUCATION & TRAINING
1 FREE CET POINT OT CET content supports Optometry Giving Sight
Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Having trouble signing in to take an exam? View CET FAQ Go to www.optometry.co.uk
About the authorMaggie Woodhouse is senior lecturer
at the School of Optometry and Vision
Sciences, Cardiff University, where she
specialises in paediatric optometry.
She runs the Special Assessment
Clinic, which caters for patients of all
ages with disabilities. Her particular
interests are visual development in
children with Down’s syndrome and the
impact of visual defects on education.
ReferencesSee www.optometry.co.uk/
clinical. Click on the article title and
then on ‘references’ to download.
1. Diagnosing a congenital colour vision defect in early childhood has the following benefits EXCEPT:a) The defect can be treatedb) Teachers can understand a child’s colour choice in artworkc) Inappropriate career plans can be avoided d) Alternatives to colour coding can be used
2. Measuring eye movements in children is likely to be more successful if the practitioner:a) Moves the target very slowlyb) Avoids distracting the child by speaking
c) Uses a flashing colourful targetd) Uses a large target
3. Success in eye health examination of a young child may be improved if the practitioner:a) Asks the child to sit as still as possible for as long as it takesb) Asks the child to keep looking at an interesting picture on the wall, no matter whatc) Uses a slit-lamp and a Volk lensd) Examines sections of the eyes in separate intervals4. Practice preparation may include all of the following EXCEPT:
PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on May 18, 2012 – You will be unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage on May 28, 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Module questions Course code: C-18705 O/D
a Novartis company
1. Which of the following statements about drusen is TRUE?a) If it is present with metamorphopsia, it indicates wet AMDb) They are not a hereditary phenomenonc) They are generally calcifiedd) None of the above
2. Which of the following statements about exudates in the retina is TRUE?a) Generally they require same-day referral to A&E for treatmentb) They are a frequent sign in diabetic retinopathyc) They require urgent referral if present within 3 disc diameters of
the fovead) They always indicate a diagnosis of wet AMD
3. Which of the following statements about microinfarcts is TRUE?a) If undiagnosed, they are an indication for urgent referralb) They are sometimes known as cotton wool exudatesc) If they are isolated they are not clinically significantd) They are often seen as a result of recent laser treatment
4. Which of the following statements about Presumed Ocular Histoplasmosis Syndrome (POHS) is TRUE?a) It is often a chance finding at a routine appointmentb) It needs prompt medical work-upc) It tends to present early with marked symptomsd) It requires same-day assessment in ophthalmology
5. Which of the following statements about Stargardt’s dystrophy is TRUE?a) It is usually inherited in an autosomal dominant mannerb) It may be caused by histoplasmac) It requires urgent referral to ophthalmologyd) It may present at any age, but mainly young adults
6. Which of the following statements about Tamoxifen retinopathy is TRUE?a) It is common among long-term users of this drugb) It requires immediate cessation of Tamoxifen therapyc) It can be associated with corneal signsd) It is associated with signs of vascular occlusion
Module questions Course code: C-19713 O/DPLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on November 16, 2012 – you will be unable to submit exams after this date. Answers to the module will be published on www.optometry.co.uk/cet/exam-archive. CET points for these exams will be uploaded to Vantage on November 26 , 2012. Find out when CET points will be uploaded to Vantage at www.optometry.co.uk/cet/vantage-dates
Figure 9 Tamoxifen retinopathy. Picture courtesy of Professor I. Rennie
with scalp tenderness, then giant cell arteritis is a distinct possibility. This potentially blinding disorder responds well to prompt steroid treatment and therefore, such patients should be referred to the local A&E department.
The finding of lesions of inflammatory
retino/choroidopathy does not necessitate
an urgent referral. It is only necessary to
make a routine referral so that the diagnosis
can be made and subsequent management
determined. There are two exceptions to this.
Firstly, if there is significant vitritis, there may
be a benefit to the patient in receiving early
treatment with an anti-inflammatory agent
to reduce symptoms and improve prognosis.
Secondly, if the macula is affected by oedema,
or acute sub-retinal neovascularisation,
then the patient should be seen urgently for
treatment. Same-day referral is not necessary.If the patient appears to have Stargardt’s
dystrophy, referral is necessary to confirm
someone who is taking Tamoxifen warrants referral to the patient’s General Practitioner on a routine basis. Such changes have usually evolved slowly. Optometrists should not make any recommendation to the patient regarding discontinuance of the drug, since this is a complex issue with serious implications.
About the authorMark Benson is a director of the Midland Eye Institute, and consultant ophthalmic surgeon to the Heart of England NHS Trust for whom he runs retinal and cataract services. He is senior clinical lecturer to the University of Birmingham, a section editor for Eye, and an examiner for the Royal College of Ophthalmologists.
ReferencesSee www.optometry.co.uk/clinical. Click on the article title and then on ‘references’ to download.
the diagnosis and to provide genetic counseling and support. Since no treatment is available, routine referral is appropriate.
