Ocular Disease2 - Mt3

Front 1

What is the average age of onset of ARM?

Back 1

60-65 years of age

Front 2

List some risk factors for developing ARM

Back 2

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

Front 3

True or False: ARM is the leading cause of legal blindness in the U.S over 65 yrs

Back 3

True - 10% of pop > 52 - 33% of pop > 75

Front 4

What is the hallmark sign of ARM?

Back 4

Drusen (hyaline deposits b/w Bruch's and RPE)

Front 5

Do Drusen increase in size with age?

Back 5

Yes

Front 6

What layers of Bruch's do you typically find HARD drusen?

Back 6

Inner and Outer collagenous layers -small, well-defined -rarely a risk of neo

Front 7

Do localized zones of RPE detachment typically occur with hard drusen or soft drusen?

Back 7

Soft drusen -Larger, fluffier -Increased risk of CNVM

Front 8

Drusen and RPE atrophy are due to....

Back 8

loss of underlying choroidal circulation

Front 9

If a patient presents with hard drusen, what is the recommended follow up time and how would you manage this patient?

Back 9

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

Front 10

Wet ARMD = ? + ?

Back 10

Dry ARMD + Choroidal neovascular membrane/ subretinal neovascular membrane - 10% of all ARMD

Front 11

What is the greatest risk factor for developing macular degeneration or CRNVM?

Back 11

Confluence of drusen, one eye, with wet areas other eye = 55% to develop CRNVM

Front 12

How far does the Juxtafoveal membrane extend from center of the CFZ

Back 12

1-199 microns - Extraretinal membranes no closer than 200 microns from center of CFZ

Front 13

Is Wet ARMD easily detected with DO?

Back 13

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

Front 14

What will the appearance of a SRNVM look like on FANG?

Back 14

Plant appearance (net) seen due to leaks in the late phase -Choroidal filling phase -Venous phase = hyperfluorescent but indistinct appearance

Front 15

List the phases of filling during FANG

Back 15

1. Background fills 1st = choroid 2. Arteriole phase = CRA fills seconds later after choroid 3. Arteriole-venous phase 4. Venous phase 5. Emptying phase

Front 16

Visual prognosis is based on what?

Back 16

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

Front 17

Why are Triamcinolone (Kenalog) injections considered treatment of wet ARMD?

Back 17

Steroid injection into the vitreous decreases swelling and edema - decreases permeability of BV = drys up CNVM

Front 18

List an off-label therapy that is similar to Macugen

Back 18

Avastin - Series of injections that target protein involved in growth of abnormal BV - q 6 wks for 2 years

Front 19

List 5 other etiologies of CNVM/SRNVM

Back 19

1. DM 2. Ocular Histoplasmosis - fungal disease in river valley 3. High myopia 4. Angiod Streaks - small breaks in Bruch's 5. Trauma

Front 20

What is the pathogenesis of CSR

Back 20

Break in Bruch's allows fluid from choriocapillaries to cause the sensory retina to 'balloon' up

Front 21

Can CSR be related to increased levels of cortisol and epinephrine?

Back 21

Yes due to stress and hypertension

Front 22

What would a patient with CSR be complaining of?

Back 22

1. Acute vision loss - may be correctable to 20/20 w/ + lenses 2. Metamorphopsia 3. Relative scotoma

Front 23

List some signs of CSR

Back 23

1. Loss of FR 2. + photostress test (> 50 sec - 1 min) 3. Hyperopic shift 4. Dome shaped elevation of neurosensory retina 5. Yellow deposits

Front 24

How do you tx CSR?

Back 24

1. Usually self-resolving 80% of the time 2. Photocoagulation if reoccurs

Front 25

List 7 ocular conditions that are non-retinal that may be seen in a diabetic patient

Back 25

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

Front 26

Why are the pupils spared in a 3rd nerve paresis?

Back 26

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

Front 27

What is the normal HbA1c level?

Back 27

3-6% - above 11% is a risk factor for preproliferative DR and cardio dz -Increased Hb = decreased ability to transport oxygen

Front 28

What is the risk of DR w/ diagnosis of DM BEFORE age 30?

Back 28

1. 97% of retinopathy w/in 15 years 2. 40% of worsening retinopathy 3. PDR incidence increases with duration

Front 29

Which ethnic groups has the highest incidence rate of DM?

Back 29

Blacks > Hispanics > other ethnicities > Native Americans

Front 30

List 3 pathogenic factors that occur in DM patients

Back 30

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

Front 31

List 3 reasons for Poor circulation in DM patients?

Back 31

1. Thickened BM 2. Increased Viscosity 3. Irregular shaped RBC

Front 32

List 3 signs of decreased circulation

Back 32

1. CWS 2. IRMs 3. Venous beading -Signals poor circulation --> neovascularization --> hemes and fibrous proliferation --> PRP or Anti-Veg F

Front 33

List criteria for mild stage NON-PDR

Back 33

1. At least 1 MA 2. Occasional Dot/Blot hemes (equatorial or peripheral) 3. Hard exudates away from macula (usually at OPL)

Front 34

List the clinical signs of Moderate stage NON-PDR

Back 34

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

Front 35

Severe NPDR is classified how?

Back 35

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

Front 36

What are two reasons why NVD shows up more than NVE?

Back 36

1. Posterior Pole has higher demand 2. ONH lacks ILM

Front 37

What is the most common finding of PDR?

Back 37

NVD: as far as 1 dd from ONH - presents in ~ 2/3 -Feathery appearance of vessels

Front 38

What is the most common finding of PDR?

Back 38

NVD: as far as 1 dd from ONH - presents in ~ 2/3 -Feathery appearance of vessels

Front 39

Where does NVI occur 1st?

Back 39

At pupillary margin or in filtration angle -Usually at 10 - 2 o'clock cause of current

Front 40

What is fibrovascular proliferation?

Back 40

Connective tissue that supports neovascular vessels, attaches to areas of the retina and can lead to RD from contraction

Front 41

At what layer do superficial hemorrhages occur?

Back 41

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

Front 42

What are HIGH risk characteristics that require immediate referral to a specialist for laser tx in PDR patient

Back 42

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

Front 43

Blindness is ultimately caused by....

Back 43

1. Vitreous hemorrhage 2. Neovascular glaucoma 3. Fibrovascular traction causing RD

Front 44

What is the number 1 reason for vision loss in someone with Diabetic retinopathy?

Back 44

Macular edema (found in all stages) -Cystoid spaces can be seen in the OPL and INL if enough fluid accumulates

Front 45

CSME (defined by ETDRS) is defined by what criteria?

Back 45

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

Front 46

Photocoagulation tx was most beneficial for macular edema cases if the pre-treatment VA was...

Back 46

better than 20/60 - Triamcinolone injection is considered if worse