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46 Cards in this Set

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What is the average age of onset of ARM?
60-65 years of age
List some risk factors for developing ARM
1. Light pigmented iris 2. Caucasian 3. FHx: 10-20% have FHx 4. Smoking: 3x the risk 5. UV 6. Cardio Dz 7. Hyperopia > 0.75 = 25x risk
True or False: ARM is the leading cause of legal blindness in the U.S over 65 yrs
True - 10% of pop > 52 - 33% of pop > 75
What is the hallmark sign of ARM?
Drusen (hyaline deposits b/w Bruch's and RPE)
Do Drusen increase in size with age?
What layers of Bruch's do you typically find HARD drusen?
Inner and Outer collagenous layers -small, well-defined -rarely a risk of neo
Do localized zones of RPE detachment typically occur with hard drusen or soft drusen?
Soft drusen -Larger, fluffier -Increased risk of CNVM
Drusen and RPE atrophy are due to....
loss of underlying choroidal circulation
If a patient presents with hard drusen, what is the recommended follow up time and how would you manage this patient?
F/U every 6 months -Amsler grid -UV protection -Low vision - If VA decrease -Photodocument -Nutrition 1. Antioxidants and Zinc 2. Formulation: -Vit C: 500mg -Vit E: 400 IU -Beta Carotene: 15mg (replace with Lutein if smoker) -Zinc Oxide: 80mg -Copper: 2 mg
Wet ARMD = ? + ?
Dry ARMD + Choroidal neovascular membrane/ subretinal neovascular membrane - 10% of all ARMD
What is the greatest risk factor for developing macular degeneration or CRNVM?
Confluence of drusen, one eye, with wet areas other eye = 55% to develop CRNVM
How far does the Juxtafoveal membrane extend from center of the CFZ
1-199 microns - Extraretinal membranes no closer than 200 microns from center of CFZ
Is Wet ARMD easily detected with DO?
No b/c the overlying structures are still there. Need to look for color changes, elevation, and r/o CNVM - Stereo may be needed to see pockets of fluid seen in SRNVM -Greenish-grey color if sub-RPE
What will the appearance of a SRNVM look like on FANG?
Plant appearance (net) seen due to leaks in the late phase -Choroidal filling phase -Venous phase = hyperfluorescent but indistinct appearance
List the phases of filling during FANG
1. Background fills 1st = choroid 2. Arteriole phase = CRA fills seconds later after choroid 3. Arteriole-venous phase 4. Venous phase 5. Emptying phase
Visual prognosis is based on what?
Distance of the CNVM from the center of the fovea -If edge of CNVM 1DD or more from CFZ - prognosis pretty good following photocoagulation tx
Why are Triamcinolone (Kenalog) injections considered treatment of wet ARMD?
Steroid injection into the vitreous decreases swelling and edema - decreases permeability of BV = drys up CNVM
List an off-label therapy that is similar to Macugen
Avastin - Series of injections that target protein involved in growth of abnormal BV - q 6 wks for 2 years
List 5 other etiologies of CNVM/SRNVM
1. DM 2. Ocular Histoplasmosis - fungal disease in river valley 3. High myopia 4. Angiod Streaks - small breaks in Bruch's 5. Trauma
What is the pathogenesis of CSR
Break in Bruch's allows fluid from choriocapillaries to cause the sensory retina to 'balloon' up
Can CSR be related to increased levels of cortisol and epinephrine?
Yes due to stress and hypertension
What would a patient with CSR be complaining of?
1. Acute vision loss - may be correctable to 20/20 w/ + lenses 2. Metamorphopsia 3. Relative scotoma
List some signs of CSR
1. Loss of FR 2. + photostress test (> 50 sec - 1 min) 3. Hyperopic shift 4. Dome shaped elevation of neurosensory retina 5. Yellow deposits
How do you tx CSR?
1. Usually self-resolving 80% of the time 2. Photocoagulation if reoccurs
List 7 ocular conditions that are non-retinal that may be seen in a diabetic patient
1. Xanthelasma 2. Cranial nerve palsies (rare) 3. NVI 4. Lenticular involvement- swelling - cortical vaculoes - bilateral 5. Chalazion 6. Ant. BM dystrophy or cornea 7. Tritan color defects
Why are the pupils spared in a 3rd nerve paresis?
Because the EOMs are centrally located in the nerve and when the BV is blocked they are affected while the Pupil fibers lie on the outside of the nerve and are supplied from outside
What is the normal HbA1c level?
3-6% - above 11% is a risk factor for preproliferative DR and cardio dz -Increased Hb = decreased ability to transport oxygen
What is the risk of DR w/ diagnosis of DM BEFORE age 30?
1. 97% of retinopathy w/in 15 years 2. 40% of worsening retinopathy 3. PDR incidence increases with duration
Which ethnic groups has the highest incidence rate of DM?
Blacks > Hispanics > other ethnicities > Native Americans
List 3 pathogenic factors that occur in DM patients
1. Capillary wall changes = loss of pericytes decreases wall integrity --> leakage, MAs, Hemes 2. Blood flow hemodynamics: increased platelet adherence, imbalance of coagulation mech, RBC more dumb-bell shaped, slowed blood flow 3. Ischemia: Due to wall changes, BM thickening and intravascular factors -Result: ischemia, CWS, interrupted micro circulation
List 3 reasons for Poor circulation in DM patients?
1. Thickened BM 2. Increased Viscosity 3. Irregular shaped RBC
List 3 signs of decreased circulation
1. CWS 2. IRMs 3. Venous beading -Signals poor circulation --> neovascularization --> hemes and fibrous proliferation --> PRP or Anti-Veg F
List criteria for mild stage NON-PDR
1. At least 1 MA 2. Occasional Dot/Blot hemes (equatorial or peripheral) 3. Hard exudates away from macula (usually at OPL)
List the clinical signs of Moderate stage NON-PDR
1. More leakage and early hypoxia 2. Hemes and MA (H/MA) in 4 retinal fields 3. CWS: rule 1dd of hypoxia = 1 CWS 4. Venous Beading (VB)/Tortuosity: sausage-linked 5. IRMA: w/in sensory retina and associated with ischemia --> shunt around ischemic retina
Severe NPDR is classified how?
CWS, VB, IRMA in at least 2 of fields 4-7 w/ at least 1 field > than standard photo 2A OR 1 IRMA in one of the fields 4-7 that exceed standard photo 2A -10-40% of patients at this level progress to PDR
What are two reasons why NVD shows up more than NVE?
1. Posterior Pole has higher demand 2. ONH lacks ILM
What is the most common finding of PDR?
NVD: as far as 1 dd from ONH - presents in ~ 2/3 -Feathery appearance of vessels
What is the most common finding of PDR?
NVD: as far as 1 dd from ONH - presents in ~ 2/3 -Feathery appearance of vessels
Where does NVI occur 1st?
At pupillary margin or in filtration angle -Usually at 10 - 2 o'clock cause of current
What is fibrovascular proliferation?
Connective tissue that supports neovascular vessels, attaches to areas of the retina and can lead to RD from contraction
At what layer do superficial hemorrhages occur?
Separate the ILM from the rest of the retina - if it bursts it makes it hard to see underneath -Keel/boat appearance -If BV gets past ILM and bursts - blood gets into vitreous and causes underlying vessels to be blurry
What are HIGH risk characteristics that require immediate referral to a specialist for laser tx in PDR patient
1. NVD (1/4-1/3) of disc area 2. NVE and fresh vitreous or preretinal heme present in retina 3. New vessels on disc < 1/4 of disc area covered if fresh vitreous or preretinal heme present
Blindness is ultimately caused by....
1. Vitreous hemorrhage 2. Neovascular glaucoma 3. Fibrovascular traction causing RD
What is the number 1 reason for vision loss in someone with Diabetic retinopathy?
Macular edema (found in all stages) -Cystoid spaces can be seen in the OPL and INL if enough fluid accumulates
CSME (defined by ETDRS) is defined by what criteria?
1. Thickening of retina at or within 500 microns or 2. hard exudates at or withiin 500 microns of the macular or 3. Zone/s or retinal thickening 1 dd or > within 1 dd of the center of the macula
Photocoagulation tx was most beneficial for macular edema cases if the pre-treatment VA was...
better than 20/60 - Triamcinolone injection is considered if worse