Ocular Disease Final - Vitreous

Front 1

T/F - It is rare to get a vitreous detachment from the vitreous base.

Back 1

True - this is the strongest attachment of the vitreous (note this is different from a RETINAL detachment, which can occur at the vitreous base)

Front 2

Where is the second strongest attachment of the vitreous?

Back 2

ONH

Front 3

Where does the vitreous attach at the ONH?

Back 3

At the glial peripapillary ring (Gartner's or Vogt's ring)

Front 4

T/F - The macular region has an area of vitreous attachment that gets stronger with age.

Back 4

False - gets weaker with age

Front 5

What kind of anomalous vitreo-retinal adhesion is a common site of retinal tears (horseshoe tears) particularly in PVD?

Back 5

Lattice degeneration

Front 6

What kind of anomalous vitreo-retinal adhesion involves significant inner retinal inflammation starting at the RNFL?

Back 6

Toxoplasmosis scars (a chorioretinal scar)

Front 7

T/F - Retinal vasculature is considered only a normal vitreo-retinal adhesion.

Back 7

False - can be anomalous also

Front 8

Name the various anomalous areas of vitreo-retinal adhesions.

Back 8

Lattice degeneration, chorioretinal scars, retinal vasculature, meridional folds, granular tufts, tractional tufts, unusual posterior extensions of the vitreous base, rhegmatogenous RD

Front 9

Where are the anomalous vitreo-retinal hemorrhages typically located?

Back 9

Almost always in the equatorial region or further anteriorly

Front 10

What is a rhegmatogenous RD associated with?

Back 10

Related to retinal tears resulting from vitreoretinal traction

Front 11

What is the most common symptom of vitreous disease?

Back 11

Floaters

Front 12

What causes white cells in the vitreous?

Back 12

Uveal, vitreal, retinal, or ONH inflammation. Also iritis.

Front 13

T/F - White cells in the vitreous typically go away after the associated inflammation has resolved.

Back 13

False - remain for several months or years after inflammation has resolved

Front 14

T/F - Pigment in the vitreous is pathognemonic for a PVD.

Back 14

False - pathognemonic for a retinal tear; RPE is released into the vitreous (=Schafer's sign)

Front 15

What is Schafer's sign?

Back 15

Pigment in the vitreous

Front 16

What can cause pigment in the vitreous?

Back 16

Retinal tear, uveitis, intraocular surgery, trauma

Front 17

You note pigment in the vitreous, but after careful examination using your BIO, you can't seem to find the cause. What is your course of action at that point?

Back 17

Use scleral depression, if not found then 3-mirror lens, if not then consult with retinal specialist

Front 18

RBCs in the vitreous is a likely sign of...

Back 18

a retinal tear and/or RD

Front 19

T/F - PVDs can cause floaters

Back 19

True

Front 20

What two types of floaters are typically associated with retinal tears?

Back 20

Vitreous hemes, pigments in the vitreous

Front 21

Flashes in both eyes suggest (neurovascular/ocular) origin.

Back 21

Neurovascular (i.e. migraine, TIA)

Front 22

Quick, bright sparks are characteristic of (vitreous traction/neurovascular) type flashes.

Back 22

vitreous

Front 23

Angular/zigzag flashes = vitreous traction or neurovascular?

Back 23

neurovascular

Front 24

Longer lasting flashes of light = vitreous traction or neurovascular?

Back 24

neurovascular

Front 25

Flashes while eyes closed = vitreous traction or neurovascular?

Back 25

Can see flashes w/ eyes open or closed in both vitreous traction and neurovascular

Front 26

Flashes more apparent in dark = vitreous traction or neurovascular?

Back 26

vitreous traction

Front 27

T/F - Neurovascular flashes are more obvious in the dark.

Back 27

Neurovascular flashes are apparent in both dark and light

Front 28

Head/eye movements elicit flashes = vitreous traction or neurovascular?

Back 28

vitreous

Front 29

T/F - Moore's lightning streak usually in temporal visual field.

Back 29

True - nasal retina, temporal visual field

Front 30

What percentage of pts w/ flashes and floaters involve retinal break?

Back 30

10-34%

Front 31

What percentage of sympomatic pts w/ retinal breaks progress to RD?

Back 31

50% symptomatic pts (therefore 50% asymptomatic will lead to RD!)

Front 32

T/F - Gartner's ring can result in a decrease in VA.

Back 32

True - transient blur to clear

Front 33

Can vitreal traction cause CME? How so?

Back 33

CHRONIC vitreal traction on the macular region

Front 34

What is Mittendorf's dot? How does it appear on retro view? On direct view?

Back 34

Remnant of attachment of hyaloid artery to posterior lens capsule. Black dot on retro, white dot on direct.

Front 35

What are the remnants of the hyaloid artery trapped within Cloquet's canal called?

Back 35

Muscae volitantes.

Front 36

T/F - Bergmeister's papilla is found on the anterior lens.

Back 36

False - found on the posterior end of the hyaloid artery

Front 37

What is a persistent hyaloid artery?

Back 37

Persistent though nonfunctional hyaloid artery without fibrous components of primary vitreous; runs from ONH to lens at Mittendorf's dot

Front 38

You see white fibrous projections jutting out of the ONH, and you suspect it is related to the hyaloid artery. What is this?

Back 38

Posterior hyperplastic primary vitreous

Front 39

You see a white fibrovascular mass just behind the pupil, and you suspect it is related to the hyaloid artery. It looks like as if the patient has leukocoria. What is this?

Back 39

Anterior hyperplastic persistent hyperplastic primary vitreous

Front 40

What characteristics are typically associated with anterior PHPV?

Back 40

Microphthalmia, long ciliary processes, shallow AC, cataract, colobomas of uveal tract

Front 41

How can anterior PHPV cause glaucoma?

Back 41

1. Capsule rupture (angle closure, phacolytic glaucoma)
2. Angle closure?

Front 42

How do you Tx anterior PHPV?

Back 42

Lensectomy

Front 43

T/F - In X-linked retinoschisis, the retina split in two at the outer plexiform layer.

Back 43

False - at the RNFL

Front 44

You see spoke-wheel appearance at the macula with the retina split in two at the RNFL - this is characteristic of...

Back 44

X-linked juvenile retinoschisis

Front 45

Besides the retina split and the macular schisis, what characteristics are assoc w/ X-linked juvenile retinoschisis?

Back 45

Peripheral retinal involvement, usually inferior temporal usually not extending to ora (50%), vitreous veils, viterous hemes, hyperopia, reduced B-wave, normal A-wave, slow progression, possible secondary RD

Front 46

Depolymerization of hyaluronic acid, freely moving collagenous fibrils, and lacunae describe...

Back 46

Normal liquefaction of the vitreous due to aging

Front 47

Clumping of collagenous fibers in the mid-vitreous describes...

Back 47

Syneresis

Front 48

T/F - Lacunae contain collagenous fibers

Back 48

False

Front 49

T/F - You can observe the Tyndall effect in lacunae

Back 49

False - no collagenase fibers therefore no effect

Front 50

What is fibrillary degeneration?

Back 50

Clinical appearance of frayed fragmented vitreous fibers due to liquefaction and syneresis

Front 51

Where does the vitreous typically collapse first?

Back 51

At the macula

Front 52

Where does liquefaction have its greatest effect?

Back 52

at the macula

Front 53

Where does the break of the post-hyaloid membrane typically occur?

Back 53

at the macula

Front 54

What is a rhegmatogenous PVD?

Back 54

Liquid vitreous moves behind the post-hyaloid face through the break; PVD is the primary cause of this in the elderly.

Front 55

Over time, the vitreous fibers tend to...

Back 55

contract towards the central vitreous

Front 56

Where is the Ring of Gartner located?

Back 56

ON the posterior hyaloid face, avulsed from ONH on PVD

Front 57

What factors contribute to more rapid "aging" of the vitreous and earlier PVD?

Back 57

Myopia, intraocular inflammation (e.g. uveitis), diabetes, vitreous heme, ocular trauma, surgery

Front 58

What defines a PVD?

Back 58

A detachment of the posterior hyaloid membrane from the retina

Front 59

T/F - A PVD is normal and most people end up getting one.

Back 59

True - it is a normal age-related change

Front 60

Clinical PVD in __% in pts older than 50 y/o in phakic eyes; about __% with patients older than 60 y/o in phakic eyes.

Back 60

50%, 66%

Front 61

PVD in __% of aphakes.

Back 61

93%

Front 62

PVD in __% at age 50 in phakic eyes

Back 62

53%

Front 63

Photopsias in ___ to ___ of acute PVDs

Back 63

1/3 to 1/2

Front 64

Photopsias tend to be (unilateral/bilateral)?

Back 64

Unilateral

Front 65

T/F - Coalesced vitreous fibers, Gartner's ring, and vitreous hemes/pigments are the types of floaters associated with retinal tears.

Back 65

False - Vitreous hemes and vireous pigments are associated with retinal tears - but all three are associated with PVD

Front 66

Syneresis = gradual or acute

Back 66

gradual

Front 67

Your patient complains of a single floater that looks like a cobweb, and is very annoying - what do you suspect is the cause?

Back 67

Gartner's ring

Front 68

What is an important difference in the patient's complaints when DDx between Gartner's ring and vitreous hemes/pigment?

Back 68

Vitreous hemes/pigment = numerous floaters

Front 69

Vitreous hemes can occur in up to __% of acute PVD, some (__ to ___%) of these do not have retinal tears.

Back 69

20, 10, 30

Front 70

T/F - Visual fields cannot detect retinal tears.

Back 70

True

Front 71

If you see the posterior hyaloid membrane, you can pretty much say that your patient has...

Back 71

a PVD

Front 72

Where is the most common location of a retinal tear due to PVD?

Back 72

Posterior edge of vitreous base

Front 73

What are the types of retinal tears?

Back 73

Operculated, Horseshoe

Front 74

T/F - If operculum free of retina, you have a small chance of RD

Back 74

True

Front 75

Horseshoe tears are more common in what part of the retina?

Back 75

Superior

Front 76

What proportion of PVDs with a retinal tear will have a vitreous heme? What proportion will have Schafer's sign?

Back 76

2/3, all

Front 77

When does an RD occur after onset of Sx from a PVD?

Back 77

6 months

Front 78

What proportion of vitreous hemes occur without a retinal break?

Back 78

1/3

Front 79

Equatorial and oral dot and/or blot hemes suggest...

Back 79

Continued vitreal traction

Front 80

If you see equatorial and oral and/or blot hemes related to PVD, what course of action should you take?

Back 80

Watch closely every month for subsequent retinal break until resolution of heme and symptoms of traction

Front 81

T/F - Peripapillary hemes due to acute trauma of PVD is benign.

Back 81

True, but must DDx vs other causes of intraretinal hemes

Front 82

How soon do you re-evaluate a PVD patient with flashes?

Back 82

1-3 months, until flashes have subsided; if many photopsias then 1-2 wk intervals until photopsias subsided and clear vitreous, no traction, tears, RD and acertain complete PVD

Front 83

If your patient sees a shower of floaters but no break or cell apparent in vitreous, how often should your patient visit?

Back 83

Weekly for 6 weeks

Front 84

If you see a gross vitreous heme obscuring your view of a possible PVD/RD, what is indicated?

Back 84

B-scan, bedrest w/ no exertion to allow settling for 2 days, then re-evaluate

Front 85

If you see a horseshoe tear, what is the next step?

Back 85

Retinal consult

Front 86

If you see significant rim edema around an operculated tear with free operculum, what do you do next?

Back 86

Retinal consult

Front 87

T/F - PVD is likely to occur in the other eye if it happens to one eye.

Back 87

True - must make patient aware of this

Front 88

T/F - Asteroid hyalosis is mostly in middle aged individuals.

Back 88

False - more in elderly

Front 89

Asteroid hyalosis = unilateral or bilateral?

Back 89

Usually unilateral (90%)

Front 90

T/F - Intravitreal hemes tend to float around the vitreous.

Back 90

False - tend to clot quickly and fixed in location

Front 91

What happens after an intravitreal heme clots?

Back 91

Dense fibrotic membranes form

Front 92

How long does an intravitreal heme take to resolve?

Back 92

Months to years

Front 93

T/F - Retrovitreal posterior hemes tend to take months to resolve.

Back 93

False - quicker resolution vs intravitreal hemes (retrovitreal = months)

Front 94

What is characteristic of retrovitreal posterior hemes?

Back 94

Behind posterior hyaloid membrane, bright red, boat shaped, shifts with shift in head position, quicker resolution

Front 95

What are the causes of vitreous hemorrhages?

Back 95

Tear in normal retinal vessel, rupture of neovascular BVs, increased BV pressure (arterial or venous), retinal angiomas

Front 96

How can you get a good view of the fundus when you have a heme in the way?

Back 96

Bedrest 24-48 hrs with slight head elevation to allow settling of hemorrhage

Front 97

T/F - Preretinal membrane = Glial cell proliferation in the NFL at the macula.

Back 97

False - at the ILM

Front 98

T/F - Preretinal membrane can affect VA.

Back 98

True - can distort macular architecture, can also have metamorphopsia (rare)

Front 99

You see a glistening, irregular reflection off the ILM in the macular region with your DO. You also see retinal striae. What do you suspect?

Back 99

Epiretinal membrane

Front 100

Don't forget about the review questions at the end of the vitreous section!

Back 100

Just a reminder

Front 101

Most common location of a retinal tear due to PVD?

Back 101

Posterior edge of vitreous base