Ocular Abnormality- Vitreous And Maculopathies

Front 1

Describe the structure of the vitreous?

Back 1

• Virtually acellular

• Viscous

• Collagen framework, reinforces with hyaluronate

Front 2

What percentage of the vitreous is water?

Back 2

98%

Front 3

What is the volume of the vitreous in an emmertropic eye?

Back 3

4.5 ml

Front 4

What are the Condensations of vitreous?

Back 4

• Anterior hyaloid membrane

• Posterior hyaloid membrane

• Cloquet’s canal

Front 5

Where are the attachments of the vitreous?

Back 5

• Vitreous base- ora serrata

• Weigert’s ligament - attachment to posterior lens surface (anterior end of Cloquet’s)

• Vitreopapillary adhesions- Weiss ring

• Vascular adhesions (hence bleeds with PVD)

• Areas of vitreoretinal degeneration- Lattice degeneration, cystic retinal tufts

Front 6

What are the changes that occur to the vitreous with age?

Back 6

• Vitreous gel liquefaction (syneresis)

• Fluid filled cavities

• Fluid dissects posterior hyaloid face from ILM

• Remaining solid vitreous detaches inferiorly

• Posterior Vitreous Detachment

• Prevalence increases with age

Front 7

What are the causes of posterior vitreous detatchement PVD?

Back 7

• myopia

• ageing

• trauma

• inflammations

• hereditary causes

Front 8

What are the symptoms with PVD?

Back 8

• Photopsia

• Blurred vision- Haemorrhage

• Floaters- Spots, cobwebs or flies

Front 9

What are some of the vitreous opactities that may be seen?

Back 9

• Muscae volitantes: remnants of hyaloid system

• Syneresis

• Weiss ring

• Haemorrhage- Red blood cells

• Tobacco dust: pigment cells

• Inflammatory cells

• Floaters seen more frequently against a bright background, are common

Front 10

What percentage of

Back 10

• Without vitreous haemorrhage, 4% develop retinal breaks

• With vitreous haemorrhage,20% develop retinal breaks

Front 11

How do you investigate a PVD?

Back 11

• Full symptoms & history

• Risk factors for retinal detachment

• Visual acuity

• Look fo rRAPD– absent

• Look for cells in AC– absent

• Measure IOP– equal between two eyes

• Dilated fundus examination

• Look for pigment in anterior vitreous

• Ocular Coherence Tomograph OCT

Front 12

What is shafer's sign?

Back 12

alludes to the clinical finding of pigment cells in the vitreous.

Front 13

When might you see shafer's sign?

Back 13

• Symptoms of flashing lights and/or floaters of recent onset

• Suspect retinal tear/detachment

Front 14

What is the set up to look for/at shafer's sign?

Back 14

• Dilated pupil

• Direct focal illumination

• Illumination normal to the cornea

• Narrow slit-beam, small angle between observation and illumination

• Moderate magnification ~ 15-24x

Front 15

How would you examine the eye to look for shafer's sign?

Back 15

• Patient looks straight ahead

• Focus on anterior vitreous

• Ask patient to make horizontal and vertical saccades

• Look for small, regular, brown particles

Front 16

When looking at shafer's sign, what must you distinguish between?

Back 16

White cells

Pigment cells

Front 17

When looking at shafer's sign, whites cells are suggestive of what?

Back 17

Inflammation posterior uveitis

Front 18

What would help to distinguish between white cells and pigment cells?

Back 18

Red free filter

Red blood cells appear black

Front 19

State the management of PVD.

Back 19

Education

• give leaflets

• if symptoms get worse or change return immediately

Front 20

How do you manage PVD if there is a medium risk to retinal detatchement?

Back 20

Review in 6/12 time

Education them on signs and symptoms to look our for

Front 21

How do you manage PVD if there is a large risk to retinal detatchement?

Back 21

Refer as an emergency

Front 22

What can cause vitreous haemorrhage?

Back 22

• Proliferative retinopathies

• PVD

• Trauma

• Disciform macular degeneration

Front 23

What are Proliferative rerinopathies?

Back 23

• Diabetes Mellitus

• Retinal vein occlusion

• Sickle cell retinopathy

• Eale’s disease

Front 24

What are the complications of vitreous haemorrhage?

Back 24

• Syneresis

• Fibrosis→traction retinal detachment

• Haemolytic (ghost cell) glaucoma

• Synchisis scintillans

• Ochre membrane

Front 25

What is Asteroid Hyalosis?

Back 25

• Common degenerative condition

• Calcium salts in vitreous

• Highly mobile

• Do not settle inferiorly whenpatient is immobile

Front 26

When does asteroid Hyalosis increase?

Back 26

Increases with age

3% of those aged 75-86

Front 27

Who is Asteroid Hyalosis more common in?

Back 27

Men

Front 28

What are the symptoms of asteroid Hyalosis?

Back 28

Usually asymptomatic

Front 29

How would you investigate asteroid Hyalosis?

Back 29

• Visual acuity

• Usually only slightly reduced

• Dilated fundus examination

• Association with diabetes?

• Refer to GP for vascular workup

Front 30

When would you refer a case of asteroid Hyalosis to the ophthalmologist?

Back 30

• Refer to ophthalmologist if visual acuity markedly reduced

• Rare

Front 31

What is Synchysis Scintillans?

Back 31

• Cholesterol crystals settle inferiorly when patient immobile

• May spill over into anterior chamber

Front 32

What is Synchysis Scintillans associated with?

Back 32

Associated with long-standing vitreous haemorrhage in a blind eye

Front 33

What are the symptoms of Acquired Maculopathies?

Back 33

• Reduced visual acuity

- Particularly at near

• Positive scotoma

• Metamorphopsia

- Micropsia

- Macropsia

• Colour vision?

• Dark adaptation

Front 34

How would you investigate symptoms of Acquired Maculopathies?

Back 34

• Visualacuity

- Distance and near

• Amsler chart

• Colour vision

• Dilated fundus examination

- Volk lens (66D ideal)

• Optical coherence tomography

Front 35

Name some macula diseases.

Back 35

• Angioid streaks

• ARMD

• Central serous retinopathy

• Choroidal folds

• Cystoid macular oedema

• Epiretinal membranes

• Macular dystrophies

• Macular holes

• Myopic maculopathy

• Sub-retinal Neovascular Membranes

• Traumatic maculopathy

Front 36

What is Angioid Streaks?

Back 36

• Small breaks in Bruch's membrane, that may become calcified and crack.

• Usually bilateral

• 50% related to systemic disorders of connective tissue

Front 37

Describe what Angioid Streaks may look like.

Back 37

• Dark, irregular lines radiating from ONH which end abruptly posterior to the equator

• May interlink around ONH

• May cause sub-retinal neovascular membranes which may bleed

Front 38

What are Angioid Streaks associated with?

Back 38

• Pseudoxanthoma elasticum

• Marfan’s syndrome

• Paget’s disease

• Sickle cell anaemia & thalassaemia

• Lead poisoning

• Acromegaly

Front 39

How would you manage/treat Angioid Streaks?

Back 39

• Systemic evaluation

- If not already diagnosed

• Observation

• Advice - Avoid contact sports

- Wear safety spectacles

• Intravitreal Anti-VEGF if choroidal new vessels

Front 40

What is Central serous retinopathy?

Back 40

A condition where fluid builds up behind the retina in the eye.

It can cause sudden or gradual vision loss as the central retina detaches.

Front 41

At what age would you see central serious retinopathy?

Back 41

20-45 yrs

Front 42

Who is central serous retinopathy more common in?

Back 42

Males

Myopia

Front 43

What is the pathogenesis of central serous retinopathy?

Back 43

• Breakdown of blood retinal barrier

• Fluid accumulates in subretinal

space

• Sometimes associated with RPE detachment

Front 44

What are the symptoms of central serous retinopathy?

Back 44

• Blurred central vision

• Metamorphopsia & micropsia

Front 45

What are the signs of central serous retinopathy?

Back 45

• VA 6/9 – 6/18

- often improves with a +1D lens

• Positive central or paracentral scotoma

• Red desaturation

• Small serous sensory retinal detachment of macula

• Sometimes associated with an optic pit

Front 46

What is Central Serous Chorioretinopathy?

Back 46

when fluid builds up under the retina.

This can distort vision. The fluid leakage comes the choroid.

Front 47

What is the prognosis of Central Serous Chorioretinopathy?

Back 47

• 90% spontaneously resolve

• 33% recur

Front 48

What is the treatment/management for Central Serous Chorioretinopathy?

Back 48

• Refer to an Ophthalmologist routinely

Treatment

• Usually conservative

• Occasionally photocoagulation indicated

Front 49

What are the Choroidal folds?

Back 49

• Hypermetropia

• Ocular disease

• Orbital disease

Front 50

What are the ocular diseases that cause choroidal folds?

Back 50

• Scleral buckling

• Scleritis

• choroidal masses

• Oculartrauma

• Papilloedema

Front 51

What are the orbital diseases that cause choroidal folds?

Back 51

• Thyroid eye disease

• Tumours

• Cellulitis

Front 52

What is this?

Back 52

Cystoid Macular Oedema

Front 53

What is Cystoid Macular Oedema?

Back 53

Henle’s layer is unsupported around macula allowing extracellular fluid to accumulate

Front 54

What is the source of leak in Cystoid Macular Oedema?

Back 54

• Maular capillaries

• Forms “flower-petal” arrangement as a result of radiation of cone fibres

Front 55

What might Cystoid Macular Oedema develop?

Back 55

Intreretinal cysts

Front 56

What are the symptoms of Cystoid Macular Oedema?

Back 56

• Reduced visual acuity

• Metamorphopsia

• Micropsia

Front 57

What are the signs of Cystoid Macular Oedema?

Back 57

• Loss of the foveal depression, thickening of the retina.

• Multiple cystoid areas in the sensory retina

• Red-free light using a fundus contact lens

Front 58

What are the causes of Cystoid Macular Oedema?

Back 58

• Diabetic & hypertensive retinopathy

• Macroaneurysms & telangiectasia

• Tumours

• Retinitis pigmentosa

• Irvine-Gass syndrome

Front 59

What is the prevalence of macular hole?

Back 59

3 : 1000

F >M

Aged 60 - 70

Front 60

What are the symptoms of macular hole?

Back 60

• Present as visual loss when one eye is covered

• Minimal symptoms otherwise metamorphopsia

Front 61

What are the signs of macular hole?

Back 61

• Full thickness retinal hole

• Cuff surrounding subretinal fluid

• Deposits at base

Front 62

What are the causes of macular hole?

Back 62

• Idiopathic

• Myopia

• Trauma

Front 63

What is this?

Back 63

Myopic degeneration

Front 64

What is Myopic degeneration?

Back 64

• In very large eyes, retina & choriocapillaris are thinned

• Myopic macular degeneration results

Front 65

What are the early findings of Myopic degeneration?

Back 65

• PPA

• Thinned macular RPE

• Tilted disc

Front 66

What are the late findings of Myopic degeneration?

Back 66

• Lacquer cracks (breaks in Bruch’s membrane)

• Macular haemorrhages

• CNV

• Macular atrophy

• Peripheral & macular holes predispose to RD