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140 Cards in this Set
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CP: A Patient manifesting _______ from HTN has malignant HTN and this should be considered an emergency
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disc edema (typically BP>250/150
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CP: For a CWS to form from HTN, the autoregulatory mechanisms must be overcome. What does the diastolic BP need to be (at least)?
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110 mmHG
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CP: T or F: Fluorescein angiography is not indicated in cases of hypertensive retinopathy
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T
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CP: T or F: Hypertensive retinopathy is mostly a wet eye condition whereas diabetic ret is mostly a dry eye condition.
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FFF!!!
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________: transient monocular vision loss. What is it a sign of?
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amaurosis fugax; impending stroke
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What artery is typically artherosclerotic in amaurosis fugax?
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carotid artery
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Whats the most common associated symptom with amaurosis fugax (but not CAUSED by AF)?
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contralateral weakness in the arm (others: in the leg, face and arm, arm and leg....also paresthesia in hand, foot, face, 1/2 of tongue, aphasia (these DO NOT OCCUR WITH AF but are consequences of HTN in other places)
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_________: painless, total vision loss or may have no ocular involvement; contralateral hemiparesis, paresthesia (most common is in the arm)
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transient ischemic attack (TIA)
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What is the risk of mortality with a TIA (hemispheric) in: 1 month? 6 months? 7 years?
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15%; 33%, 60%
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CP: T or F: AF is an uncomplicated loss of vision in one eye with no other neurological findings concurrent. TIA is a complicated neurological deficit, which may or may not involve vision loss.
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T
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Pathophysiology of TIA and AF: cholesterol--> fatty streak--> _____--> ulceration--->_____---> plaques----> _____.
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atheroma; thrombus; emboli
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T or F: Emboli are in the venous system, not the arterial system.
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F! other way around
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______: thrombus formation due to vessel wall and lumen obliteration from inflammation; one of the true emergencies in eye care; patient can go bilaterally blind in hours to days if you don't catch it
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Giant cell arteritis (AF in an elderly person due to a transient occlusion of the ophthalmic or central retinal artery is a sign of impending permanent, severe vision loss)
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In patients over the age of 60 with a TIA or AF, what two things must you do? What are you looking for?
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ESR and C-reactive protein; GCA
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What's the #1 hematological cause of transient vision loss?
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sickle cell
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What's the main factor assoc with retinal emboli?
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smoking
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Three types of plaques (under emboli section of HTN):
1. ________: fibrin/platelet aggregate; dull gray or white 2. ________: cholesterol; refractile, glistening, yellow 3. ________: dull white and non-refractile |
1. fischer
2. hollenhorst 3. calcific |
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Of the different plaques (in emboli section of HTN):
1. which are carotid in origin? 2. which are cardiac in origin? 3. which are most likely to cause AF? 4. Which more likely to cause artery occlusion and stroke? |
1. fischer and hollenhorst
2. calcific 3. fischer and hollenhorst 4. calcific |
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CP: The patient most likely to manifest an asymptomatic retinal emboli is who? What is absolutely essential for these patients?
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An older hypertensive man that smokes. Smoking cessation is absolutely essential for these patients.
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What's the mortality for a patient with visible retinal emboli:
1. within 1 year? 2. within 3 years? 3. within 7 years? |
1. 15%
2. 29% 3. 54% |
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CP: What is the best management (according to the literature) for a person with asymptomatic retinal emboli?
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Refer them for an atherosclerotic evaluation and let the internist decide what to do (literature doesn't support carotid eval b/c majority of pts don't have significant carotid stenosis)
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__________: isolated ballooning of the vessel wall (a major retinal (arterial) branch)
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retinal arterial macroaneurysm (RAM) (in HTN section)
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Retinal macroaneurysm management:
1. medical evaluation 2. asymptomatic cases not threatening the macula: ____? 3. localized hemorrhage and exudation not threatening the macula:____? 4. if the macula is threatened or edematous or if there is not spontaneous self-sealing after 3 months of observable bleeding: ____? 5. pulsation to the aneurysm wall: ___? |
2. monitor q6mos (use of home monitoring as well
3. monitor q1-3mos 4. photocoagulation 5. photocoagulation |
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What are the FA results for RAM (retinal arterial macroaneurysm)?
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fill in the arterial phase with late stage leaking
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CP: ____________ should be considered in cases of extensive localized retinal hemorrhaging. This condition can mimic BRVO and is often found in assoc with BRVO.
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retinal macroaneurysm
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CP: ________ can cause subretinal, intraretinal, pre-retinal, and vitreous hemorrhage. Think of this when you see a patient that has multi-layer hemorrhages.
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retinal macroaneurysm
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Elschnig's spots are what? What section are they in?
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subtle choroidal infarcts; HTN (old ones cause pigmentary changes)
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T or F: with HTN there will be an increase in the A/V ratio
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F...decrease...A/V (veins get larger)
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What's the most prevalent retinopathy? second most prevalent retinopathy?
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diabetic ret; retinal vascular occlusive disease
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Put these in order from most common to least common:
HRVO, BRVO, CRVO |
BRVO, CRVO, HRVO
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CP: Main cause of vision loss in venous occlusion= ?
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macular edema
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__________ site is the nidus for (CRV) occlusion. Intraluminal pressure of the vein decreases rendering it susceptible to collapse.
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Laminar constriction
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CRVO: _____ phenomenon: properties of the blood and central retinal vein act in concert to cause ___ occlusion. Causes partial or complete blockage of venous return.
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Thrombotic; thrombotic
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Which vein occlusion is rarely asymptomatic?
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CRVO
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Dilated, tortuous veins, deep and supericial hemorrhages in all 4 quadrants, disc edema and macular edema, neovascularization, and collateral vessels are all clinical signs of what?
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CRVO
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_______: pre-existing vascular anastomoses in vascular area
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collateral vessels
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Whats most common in CRVO: posterior seg or anterior seg neovascularization?
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anterior seg
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CP: ___ _______ may cause angle closure glaucoma due to hemorrhagic choroidal expansion
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acute CRVO
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______ is the prime cause of vision reduction in CRVO and is potentially reversible or treatable. _____ occurs secondary to chronic (first answer) and results in permanent vision reduction.
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macular edema; RPE atrophy
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________ presents with severe, ireversible vision loss (in CRVO). This is often the cause when the vision loss is much more dramatic than the clinical picture.
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macular ischemia
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CRVO: if the Acuity is better than 20/200, what does this tell us (three things)? What if it is worse?
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better= non-ischemic and low risk for neo; good prognosis
worse= ischemic and high risk for neo; poor prognosis (an example of VA worse than 20/200 is finger counting at several feet) |
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In a CRVO, what does a +RAPD tell us?
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ischemic (non-perfused) state; poor prognosis (non-ischemic typically do NOT have an APD)
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Non-ischemic CRVO will have more _____ and _____ whereas ischemic will have retinal details obscured by _______. The presence of ______ indicates areas of retinal infarct and ischemia. The retina in non-ischemic CRVO will be relatively normal whereas it will be ____, turbid, ____ and sick-looking in ischemic CRVO.
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dot and blot hemorrhages; flame hemorrhages; CWS; orange; edematous
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What defines ischemic CRVO on FA?
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10 or more DD of retinal non-perfusion (odds are that this pt will develop neovasc)
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CP: Most clinicians generally equate an ophthalmoscopically visible CWS with ____DD of non-perfusion
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one
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CP: If vision is better than 20/200 and there is no APD, then the CRVO is most likely ______.
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non-ischemic (however, it may convert over time)
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Why is neo of the anterior segment so prevalent in ischemic CRVO while posterior seg neo is so rare?
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Because there are no viable endothelial cells posteriorly in this condition
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Most CRVO can be explained by what three systemic conditions?
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HTN, diabetes, and eleveted homocystein levels
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In Lupus and Lupus-like diseases, ________ are common and interfere with endothelial cells and prevent interaction with platelets and anticoagulants, thus increasing thrombus formation. This is a systemic consideration for what condition?
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antiphospholipid antibodies; CRVO
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TQ: ____________ syndrome promotes thrombus formation and is the most common cause of CRVO in young healthy adults (under age 50).
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primary antiphospholipid antibody
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What is a key question to ask a patient if you suspect they have primary antiphospholipid antibody syndrome?
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if the pt lost any children (recurrent miscarriages)
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T or F: more detailed evaluation needs to be done in a patient who has bilateral CRVO
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T
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What testing/management is the least useful in an early CRVO: IOP measurement, pupil testing, retinal photography, gonioscopy, FA, co-management with PCP
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FA (fluorescein is blocked by extensive hemorrhage)
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Results of CRVO study (N and M):
1. when is PRP appropriate regarding neovascularization? 2. when is laser photocoagulation of macular edema appropriate? |
1. once is develops it is very effective (but prophylactically= inappropriate)
2. not appropriate in cases of CRVO (as for diabetic macular edema) |
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What is very effective for both macular edema and neovascularization in CRVO (newest tx)?
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intravitreal injection of steroids and anti-VEGF drugs (Avastin, Lucentis)
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What was the conclusion of the Standard care vs. Corticosteroid for Retinal Vein Occlusion (SCORE-CRVO) study?
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1 mg dose of intravitreal triamcinolone should be considered for one to two years to improve vision loss secondary to macular edema following a CRVO
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CP: The main cause of vision reduction in CRVO is ____?
CP:The most common causes of severe, permanent vision loss in ischemic CRVO are _______ and _______? |
macular edema; macular infarct; neovascular glaucoma
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CP: Ischemic CRVO most commonly forms neo where?
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iris and angle (rarely the posterior seg)
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CP:T or F: A non-ischemic CRVO (HRVO, BRVO...) can convert during their clinical course to an ischemic event.
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T
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CP: Intravitreal injections of ____ and ____ are being investigated and used for edema secondary to vascular occlusions, diabetes, cystoid macular lesions, and wet age-related macular degeneration
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steroids and anti-VEGF drugs
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CP: What should young patients with CRVO be tested for (especially is there are no other concurrent conditions present)?
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primary phospholipid antibody syndrome
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For HRVO, we need to monitor how often for deterioration or resolution?
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q1mos
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Is FA useful in early HRVO?
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No (dye blocked by hemorrhage)
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CP: HRVO develops most like ____ but behaves most like ____.
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CRVO; BRVO
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In ischemic HRVO, why is anterior segment neovascularization so rare while posterior seg neo is much more common?
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because half of the retina's capillaries (endothelial cells) are viable!
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CP: The main cause of vision reduction in HRVO is what?
CP: The most common cause of severe, permanent vision loss in patients with HRVO are ____ and _______. |
macular edema; macular infarct; tractional RD
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Where do Branch retinal vein occlusions occur in the retina? (and what quadrant)
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arteriovenous crossings; superiotemporal
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Ischemic BRVO is considered to be ___ DD of retinal capillary non-perfusion on FA.
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5 (but fundus appearance, pupil defect, significant vision loss, and development of neo are all considered in determining ischemia status
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T or F: Collateral vessel formation is very common in BRVO
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T (beneficial)
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CP: The main cause of vision reduction in BRVO is _______.
CP: The most common cause of severe, permanent vision loss in patients with BRVO are _____ and ______. |
macular edema; macular infarct; tractional retinal detachment
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CP: Ischemic BRVO most typically develops neo where?
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the disc and retina (only rarely the iris)
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CP: T or F: you can have an ischemic BRVO (and possibly HRVO) with good acuity and no RAPD
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T ( (but they aren't common)
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What's the most commonly assoc medical condition of BRVO (70% of cases)?
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HTN
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BRVO management: monitor q____ until resolution of hemorrhages...then monitor q_____ for the next three years.
___-____% will have 20/40 or better vision without tx. Refer to a retinologist only is complications develop (what two things?). |
1month; 4-6months
50-60; neo or unremitting macular edema with vision loss |
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What treatments have studies to back them up for macular edema and neo in BRVO? What treatments have little research/are controversial?
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Studied:
Mac. edema: laser photocoag neo: PRP Little research/controversial Mac. edema: steroid/anti-VEGF neo: Anti-VEGF |
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BRVO Study group findings:
1. __-___ month opportunity to tx. 2. do not tx macular _____ 3. tx only is VA < ____ and due to macular edema. 4. prophylactic tx to avoid neo: appropriate? |
1. 3-18
2. hemorrhage 3. 20/40 4. no |
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CP: There is a window of opportunity of __-__ months to tx macular edema in BRVO and HRVO.
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3-18
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CP: In BRVO and HRVO, only tx macular edema if vision is worse than ____.
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20/40
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What was the conclusion in the SCORE-BRVO trial?
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standard of care remains grid PRP for macular edema secondary to a BRVO (NOTE: THIS IS DIFFERENT THAN CRVO! CRVO= 1mg of triamcinolone for 1-2 years)
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What was the conclusion of the BRAVO and CRUISE studies for BRVO and HRVO (previous) and CRVO (latter)?
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While the therapeutically treated patients (anti-VEGF drugs) had statistically greater improvement than the sham-treated patients at 12 months, the differences were not as great as at 6 months.
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What is the name of the intravitreal steroid implant used to treat macular edema in BRVO and CRVO?
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Ozurdex (it extends therapeutic effects over several months decreasing the number of re-injections)
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What does this describe: painless, sudden loss of monocular vision (CF to HM to LP), retinal edema is causing white appearance to fundus, mean age is 60's, cherry red macula
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Central retinal artery occlusion (CRAO) (CHERY RED MACULA = BIG GIVEAWAY)
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What is the etiology of CRAO?
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typically emboli from carotid artery or heart lodging in central retinal artery at laminar constriction (cardiac origin more likely)
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CP: In CRAO, 2-10% of the cases are due to ____ formation due to what condition?
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thrombosis; Giant Cell Arteritis
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CP: If a CRAO is caused by GCA, ____ involvement can occur in hours to days. This must always be considered as a cause of CRAO in what population?
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bilateral; elderly (>60 years; especially caucasians who systemically don't feel well)
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T or F: Vein occlusion= bloody
Artery occlusion= not bloody |
T
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In _______ artery occlusion, the pt has NLP vision, cherry red spot not present and more severe retinal whitening.
In _____ artery occlusion, there's a local infarcted area, severe loss of central acuity with preservation of peripheral field, and higher incidence of GCA. |
ophthalmic artery occlusion; cilioretinal
BOTH have systemic assoc similar to CRAO |
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What are 5 "heroic treatments" for CRAO (since permanent vision loss will be permanent in 90 mins)?
Tx vs. no tx: do these measures affect final visual acuity? |
1. Paracentesis (reduce IOP)
2. Carbogen: (increases CO2 levels-->vasodilation....O2=bad!) 3. Digital massage: (transiently increase IOP-->rebound decrease of IOP) 4. Breathing into brown paper bag 5. Fibrinolytic agents (urokinase, streptokinase) No...only anecdotal success (None of these will help for GCA...no embolus to dislodge) |
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CP: In patients over the age of 60 years, CRAO may be caused by _____. You must get an ___ and ___ on every patient over the age of 60 years with CRAO because these patients can get bilateral vision loss in hours to days.
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GCA; ESR and C-reactive protein
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T or F: in patients under 30 who get CRAO, atherosclerosis is common as well as migraine, coagulation abnormalities, primary antiphospholipid antibody syndrome, cardiac abnormalities, trauma, sickling hemoglobinopathies, and optic nerve head drusen
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F!!! all correct EXCEPT atherosclerosis=very rare
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What's the main cause of death in patients with a CRAO?
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Myocardial infarction (low survivorship: 9 year mortality of 56%)
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T or F: neovascularization is common in CRAO
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FFF!!! tissue abruptly dies and doesn't have time to send out VEGF
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_______: visible retinal emboli lodged in arteriole
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BRAO (from carotid/heart)
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T or F: BRAO is rarely caused by GCA
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T
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T or F: Hemi Retinal Artery occlusion does not exist
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T (you can see two BRAOs but its NOT a hemi!)
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CP: BRAO has higher/lower survivorship than CRVO
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lower (not known why)
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CP: Why is BRAO only rarely caused by GCA?
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the vessels are too small
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CP: T or F: retinal vein occlusions are more likely to cause neovasc than retinal artery occlusions
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T (vein occlusions starve the tissue of oxygen while in artery occlusion the tissue is destroyed)
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CP: Retinal artery occlusion management: Stat ___ and ___ if over 60 years old, ___________ measurement, fasting and 2 hour post-prandial _____ measurement, ____ Doppler and evaluation, and ____ referral.
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ESR and C-reactive protein; blood pressure; carotid; cardiology
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________: internal carotid artery atheromatous ulceration and stenosis at bifurcation of common carotid artery
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ocular ischemic syndrome (OIS)
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OIS occurs only if stenosis is > _____%. Here you have ___% perfusion in CRA.
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90; 50
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T or F: more males are affected than females in OIS and in their 60s
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T (2:1)
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What are these symptoms of: unilateral, diminished vision in bright light, pain, and progressive vision loss.
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Ocular ischemic syndrome (OIS)
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T or F: In OIS, the retinal veins are dilated but not tortuous
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T
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What are these signs of: dilated, not tortuous veins, dot/blot hemes in the mid-periphery, CWS, possible cherry red spot
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Ocular ischemic syndrome (OIS) (remember: CRVO: dilated and TORTUOUS veins!)
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T or F: Exudates are rare in OIS
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T .... one of the ways to differentiate it from diabetic ret (also the fact that it's most commonly unilateral...80%)
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CP: Whenever encountering asymmetric retinopathy, always think what two things?
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carotid occlusive disease (ex: GCA) and OIS (OIS could be due to GCA)
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Corneal edema, unilateral cataract, unilateral red eye, NVI and NVA are anterior segment signs of what condition?
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Ocular ischemic syndrome (20% also have A/C reaction
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CP: T or F: OIS can be caused by GCA in elderly patients
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T
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CP: T or F: It is impossible to diagnose OIS from the anterior segment findings
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F!!! (easily diagnosed; cataract often prevents retinal visualization in these patients)
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CP: Unexplained ocular hypotony and corneal edema is extremely suggestive of ___.
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OIS (hypotony: ciliary body not getting blood and not producing aqueous; edema: from dysfunction with the endothelial pump-NOT from pressure)
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What is the Tx/management for OIS?
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optimal tx= unknown
PRP works for angle neo; the most closure, the less it works Carotid endarterectomy is less than 99% stenosed (1/3 improve, 1/3 stable, 1/3 worsen) |
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How many people in the USA have anemia? Worldwide?
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1 in 77 or 3.5 million; 2 billion
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What type of hemorrhage is associated with anemia?
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roth spot hemorrhage
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What's the most common cause of anemia?
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malabsorption/inadequate intake of iron (iron deficiency)
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A low finding of ___ ___ is diagnostic for iron deficiency anemia.
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serum ferritin (protein that helps store iron in the body)
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What is ELEVATED in iron deficiency anemia?
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transferrin level or total iron-binding capacity (TIBC) (transferrin- a protein that carries iron in the blood) (it's not being utilized properly in this condition)
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A major cause of pernicious anemia is what?
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vitamin b12 deficiency
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What are 5 things you expect to see in anemic retinopathy?
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1. hemorrhages in all layers of the retina
2. cotton wool spots 3. dilated and tortuous vessels 4. exudates 5. roth spots |
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What's the prevalence of retinopathy among anemic patients? What about if they have thrombocytopenia as well?
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22-28%; 70%
(thrombo= low blood platelet count) |
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Usually when you send an anemic (or suspected anemic) patient to the PCP, when do you want to see them back?
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3 months (but depends...if there's lots of hemes, could be 3 weeks when the CBC comes back)
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T or F: Anemic retinopathy is always reversible with correction of the anemia
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T
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TQ: Sickle cell disease: an ____ ____ genetic disorder that results in normal hemoglobin ___ becoming rigid, crescent-like "sickle" shaped in response to low oxygen tension.
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autosomal recessive; A
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What causes red blood cells to "sickle"?
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low oxygen tension
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What percentage of African americans/mediterranean people have sickle hemoglobinopathies?
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10-14% (most prevalent genetic disorders in US)
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TQ: Which sickle cell anemia variant has mostly systemic complications? Which has mostly ocular?
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Systemic: HbSS (hemoglobin S)
Ocular: Hb SC (hemoglobin C) |
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What is the common testing done for sickle cell?
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hemoglobin electrophoresis
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What should you see in a patient with sickle cell disease:
1. in the bulbar conj? 2. iris? 3. anterior chamber? |
1. S-shaped capillary segments; subconj hemes
2. focal iris atrophy/neovascularization 3. hyphema (could be present) |
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T or F: Sickle cell retinopathy is more severe in SC and B-thal disease
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T
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What do black sunbursts and salmon patch hemorrhages describe?
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non-proliferative retinopathy assoc with sickle cell disease (sunbursts: old hemorrhage with RPE hyperplasia; salmon: intra-retinal hemorrhage)
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Sickle cell terms (non-prolif):
1. _____: glistening retractile deposits in the retinal periphery (hemosiderin-laden macrophages) 2. ____: breaks in bruch's membrane (OCT needed to r/o CNVM) 3. ____: flat, brown areas mostly in African american patients |
1. refractile deposit
2. angioid streaks 3. dark without pressure |
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In proliferative sickle cell retinopathy, prolonged ischemia--> VEGF and PEDF release which are associated with ___ ___ ___.
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sea fan formations (neovasc and fibrous proliferations)
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T or F: Prophylactic Tx of proliferative sickle cell retinopathy is effective in preventing neovascularization
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F
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What drugs do you want to avoid in sickle cell patients who have glaucoma?
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CAIs (Acetazolamide) due to resultant acidosis
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Which type of leukemia has an average survival rate of 4 months without treatment?
TQ: Types of leukemia: 1. which is most common type in young children? 2. which is most common adult leukemia? |
acute (not chronic)
1. acute lymphocytic leukemia 2. chronic lymphocytic leukemia |
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A nodular lacrimal gland, exophthalmos, ptosis, pain, infiltrates in the conj, subconj heme and petechial hemes can all be found in a person with what condition?
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leukemia
(infiltrates= leukemic plaques) |
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What's the most common type of blood cancer in the US?
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lymphomas (abnormal proliferation os T or B lymphocytes)
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A fleshy, salmon-colored lesion on the conjunctiva is indicative of what?
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a lymphoma
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What's the most common intraocular tumor of childhood? In adults? What's the most common intraocular malignancy overall?
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retinoblastoma; choroidal melanoma; metastatic tumor to the choroid
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What's a melanocytoma? Who is it most common in?
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benign optic nerve tumor; dark-skinned pts (the other tumors discussed here are more common in whites)
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