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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
disc edema (typically BP>250/150
CP: For a CWS to form from HTN, the autoregulatory mechanisms must be overcome. What does the diastolic BP need to be (at least)?
110 mmHG
CP: T or F: Fluorescein angiography is not indicated in cases of hypertensive retinopathy
T
CP: T or F: Hypertensive retinopathy is mostly a wet eye condition whereas diabetic ret is mostly a dry eye condition.
FFF!!!
________: transient monocular vision loss. What is it a sign of?
amaurosis fugax; impending stroke
What artery is typically artherosclerotic in amaurosis fugax?
carotid artery
Whats the most common associated symptom with amaurosis fugax (but not CAUSED by AF)?
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)
_________: painless, total vision loss or may have no ocular involvement; contralateral hemiparesis, paresthesia (most common is in the arm)
transient ischemic attack (TIA)
What is the risk of mortality with a TIA (hemispheric) in: 1 month? 6 months? 7 years?
15%; 33%, 60%
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.
T
Pathophysiology of TIA and AF: cholesterol--> fatty streak--> _____--> ulceration--->_____---> plaques----> _____.
atheroma; thrombus; emboli
T or F: Emboli are in the venous system, not the arterial system.
F! other way around
______: 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
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)
In patients over the age of 60 with a TIA or AF, what two things must you do? What are you looking for?
ESR and C-reactive protein; GCA
What's the #1 hematological cause of transient vision loss?
sickle cell
What's the main factor assoc with retinal emboli?
smoking
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
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
CP: The patient most likely to manifest an asymptomatic retinal emboli is who? What is absolutely essential for these patients?
An older hypertensive man that smokes. Smoking cessation is absolutely essential for these patients.
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%
CP: What is the best management (according to the literature) for a person with asymptomatic retinal emboli?
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)
__________: isolated ballooning of the vessel wall (a major retinal (arterial) branch)
retinal arterial macroaneurysm (RAM) (in HTN section)
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
What are the FA results for RAM (retinal arterial macroaneurysm)?
fill in the arterial phase with late stage leaking
CP: ____________ should be considered in cases of extensive localized retinal hemorrhaging. This condition can mimic BRVO and is often found in assoc with BRVO.
retinal macroaneurysm
CP: ________ can cause subretinal, intraretinal, pre-retinal, and vitreous hemorrhage. Think of this when you see a patient that has multi-layer hemorrhages.
retinal macroaneurysm
Elschnig's spots are what? What section are they in?
subtle choroidal infarcts; HTN (old ones cause pigmentary changes)
T or F: with HTN there will be an increase in the A/V ratio
F...decrease...A/V (veins get larger)
What's the most prevalent retinopathy? second most prevalent retinopathy?
diabetic ret; retinal vascular occlusive disease
Put these in order from most common to least common:
HRVO, BRVO, CRVO
BRVO, CRVO, HRVO
CP: Main cause of vision loss in venous occlusion= ?
macular edema
__________ site is the nidus for (CRV) occlusion. Intraluminal pressure of the vein decreases rendering it susceptible to collapse.
Laminar constriction
CRVO: _____ phenomenon: properties of the blood and central retinal vein act in concert to cause ___ occlusion. Causes partial or complete blockage of venous return.
Thrombotic; thrombotic
Which vein occlusion is rarely asymptomatic?
CRVO
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?
CRVO
_______: pre-existing vascular anastomoses in vascular area
collateral vessels
Whats most common in CRVO: posterior seg or anterior seg neovascularization?
anterior seg
CP: ___ _______ may cause angle closure glaucoma due to hemorrhagic choroidal expansion
acute CRVO
______ 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.
macular edema; RPE atrophy
________ 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.
macular ischemia
CRVO: if the Acuity is better than 20/200, what does this tell us (three things)? What if it is worse?
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)
In a CRVO, what does a +RAPD tell us?
ischemic (non-perfused) state; poor prognosis (non-ischemic typically do NOT have an APD)
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.
dot and blot hemorrhages; flame hemorrhages; CWS; orange; edematous
What defines ischemic CRVO on FA?
10 or more DD of retinal non-perfusion (odds are that this pt will develop neovasc)
CP: Most clinicians generally equate an ophthalmoscopically visible CWS with ____DD of non-perfusion
one
CP: If vision is better than 20/200 and there is no APD, then the CRVO is most likely ______.
non-ischemic (however, it may convert over time)
Why is neo of the anterior segment so prevalent in ischemic CRVO while posterior seg neo is so rare?
Because there are no viable endothelial cells posteriorly in this condition
Most CRVO can be explained by what three systemic conditions?
HTN, diabetes, and eleveted homocystein levels
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?
antiphospholipid antibodies; CRVO
TQ: ____________ syndrome promotes thrombus formation and is the most common cause of CRVO in young healthy adults (under age 50).
primary antiphospholipid antibody
What is a key question to ask a patient if you suspect they have primary antiphospholipid antibody syndrome?
if the pt lost any children (recurrent miscarriages)
T or F: more detailed evaluation needs to be done in a patient who has bilateral CRVO
T
What testing/management is the least useful in an early CRVO: IOP measurement, pupil testing, retinal photography, gonioscopy, FA, co-management with PCP
FA (fluorescein is blocked by extensive hemorrhage)
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)
What is very effective for both macular edema and neovascularization in CRVO (newest tx)?
intravitreal injection of steroids and anti-VEGF drugs (Avastin, Lucentis)
What was the conclusion of the Standard care vs. Corticosteroid for Retinal Vein Occlusion (SCORE-CRVO) study?
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
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
CP: Ischemic CRVO most commonly forms neo where?
iris and angle (rarely the posterior seg)
CP:T or F: A non-ischemic CRVO (HRVO, BRVO...) can convert during their clinical course to an ischemic event.
T
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
steroids and anti-VEGF drugs
CP: What should young patients with CRVO be tested for (especially is there are no other concurrent conditions present)?
primary phospholipid antibody syndrome
For HRVO, we need to monitor how often for deterioration or resolution?
q1mos
Is FA useful in early HRVO?
No (dye blocked by hemorrhage)
CP: HRVO develops most like ____ but behaves most like ____.
CRVO; BRVO
In ischemic HRVO, why is anterior segment neovascularization so rare while posterior seg neo is much more common?
because half of the retina's capillaries (endothelial cells) are viable!
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
Where do Branch retinal vein occlusions occur in the retina? (and what quadrant)
arteriovenous crossings; superiotemporal
Ischemic BRVO is considered to be ___ DD of retinal capillary non-perfusion on FA.
5 (but fundus appearance, pupil defect, significant vision loss, and development of neo are all considered in determining ischemia status
T or F: Collateral vessel formation is very common in BRVO
T (beneficial)
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
CP: Ischemic BRVO most typically develops neo where?
the disc and retina (only rarely the iris)
CP: T or F: you can have an ischemic BRVO (and possibly HRVO) with good acuity and no RAPD
T ( (but they aren't common)
What's the most commonly assoc medical condition of BRVO (70% of cases)?
HTN
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
What treatments have studies to back them up for macular edema and neo in BRVO? What treatments have little research/are controversial?
Studied:
Mac. edema: laser photocoag
neo: PRP

Little research/controversial
Mac. edema: steroid/anti-VEGF
neo: Anti-VEGF
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
CP: There is a window of opportunity of __-__ months to tx macular edema in BRVO and HRVO.
3-18
CP: In BRVO and HRVO, only tx macular edema if vision is worse than ____.
20/40
What was the conclusion in the SCORE-BRVO trial?
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)
What was the conclusion of the BRAVO and CRUISE studies for BRVO and HRVO (previous) and CRVO (latter)?
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.
What is the name of the intravitreal steroid implant used to treat macular edema in BRVO and CRVO?
Ozurdex (it extends therapeutic effects over several months decreasing the number of re-injections)
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
Central retinal artery occlusion (CRAO) (CHERY RED MACULA = BIG GIVEAWAY)
What is the etiology of CRAO?
typically emboli from carotid artery or heart lodging in central retinal artery at laminar constriction (cardiac origin more likely)
CP: In CRAO, 2-10% of the cases are due to ____ formation due to what condition?
thrombosis; Giant Cell Arteritis
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?
bilateral; elderly (>60 years; especially caucasians who systemically don't feel well)
T or F: Vein occlusion= bloody
Artery occlusion= not bloody
T
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
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)
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.
GCA; ESR and C-reactive protein
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
F!!! all correct EXCEPT atherosclerosis=very rare
What's the main cause of death in patients with a CRAO?
Myocardial infarction (low survivorship: 9 year mortality of 56%)
T or F: neovascularization is common in CRAO
FFF!!! tissue abruptly dies and doesn't have time to send out VEGF
_______: visible retinal emboli lodged in arteriole
BRAO (from carotid/heart)
T or F: BRAO is rarely caused by GCA
T
T or F: Hemi Retinal Artery occlusion does not exist
T (you can see two BRAOs but its NOT a hemi!)
CP: BRAO has higher/lower survivorship than CRVO
lower (not known why)
CP: Why is BRAO only rarely caused by GCA?
the vessels are too small
CP: T or F: retinal vein occlusions are more likely to cause neovasc than retinal artery occlusions
T (vein occlusions starve the tissue of oxygen while in artery occlusion the tissue is destroyed)
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.
ESR and C-reactive protein; blood pressure; carotid; cardiology
________: internal carotid artery atheromatous ulceration and stenosis at bifurcation of common carotid artery
ocular ischemic syndrome (OIS)
OIS occurs only if stenosis is > _____%. Here you have ___% perfusion in CRA.
90; 50
T or F: more males are affected than females in OIS and in their 60s
T (2:1)
What are these symptoms of: unilateral, diminished vision in bright light, pain, and progressive vision loss.
Ocular ischemic syndrome (OIS)
T or F: In OIS, the retinal veins are dilated but not tortuous
T
What are these signs of: dilated, not tortuous veins, dot/blot hemes in the mid-periphery, CWS, possible cherry red spot
Ocular ischemic syndrome (OIS) (remember: CRVO: dilated and TORTUOUS veins!)
T or F: Exudates are rare in OIS
T .... one of the ways to differentiate it from diabetic ret (also the fact that it's most commonly unilateral...80%)
CP: Whenever encountering asymmetric retinopathy, always think what two things?
carotid occlusive disease (ex: GCA) and OIS (OIS could be due to GCA)
Corneal edema, unilateral cataract, unilateral red eye, NVI and NVA are anterior segment signs of what condition?
Ocular ischemic syndrome (20% also have A/C reaction
CP: T or F: OIS can be caused by GCA in elderly patients
T
CP: T or F: It is impossible to diagnose OIS from the anterior segment findings
F!!! (easily diagnosed; cataract often prevents retinal visualization in these patients)
CP: Unexplained ocular hypotony and corneal edema is extremely suggestive of ___.
OIS (hypotony: ciliary body not getting blood and not producing aqueous; edema: from dysfunction with the endothelial pump-NOT from pressure)
What is the Tx/management for OIS?
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)
How many people in the USA have anemia? Worldwide?
1 in 77 or 3.5 million; 2 billion
What type of hemorrhage is associated with anemia?
roth spot hemorrhage
What's the most common cause of anemia?
malabsorption/inadequate intake of iron (iron deficiency)
A low finding of ___ ___ is diagnostic for iron deficiency anemia.
serum ferritin (protein that helps store iron in the body)
What is ELEVATED in iron deficiency anemia?
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)
A major cause of pernicious anemia is what?
vitamin b12 deficiency
What are 5 things you expect to see in anemic retinopathy?
1. hemorrhages in all layers of the retina
2. cotton wool spots
3. dilated and tortuous vessels
4. exudates
5. roth spots
What's the prevalence of retinopathy among anemic patients? What about if they have thrombocytopenia as well?
22-28%; 70%

(thrombo= low blood platelet count)
Usually when you send an anemic (or suspected anemic) patient to the PCP, when do you want to see them back?
3 months (but depends...if there's lots of hemes, could be 3 weeks when the CBC comes back)
T or F: Anemic retinopathy is always reversible with correction of the anemia
T
TQ: Sickle cell disease: an ____ ____ genetic disorder that results in normal hemoglobin ___ becoming rigid, crescent-like "sickle" shaped in response to low oxygen tension.
autosomal recessive; A
What causes red blood cells to "sickle"?
low oxygen tension
What percentage of African americans/mediterranean people have sickle hemoglobinopathies?
10-14% (most prevalent genetic disorders in US)
TQ: Which sickle cell anemia variant has mostly systemic complications? Which has mostly ocular?
Systemic: HbSS (hemoglobin S)
Ocular: Hb SC (hemoglobin C)
What is the common testing done for sickle cell?
hemoglobin electrophoresis
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)
T or F: Sickle cell retinopathy is more severe in SC and B-thal disease
T
What do black sunbursts and salmon patch hemorrhages describe?
non-proliferative retinopathy assoc with sickle cell disease (sunbursts: old hemorrhage with RPE hyperplasia; salmon: intra-retinal hemorrhage)
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
In proliferative sickle cell retinopathy, prolonged ischemia--> VEGF and PEDF release which are associated with ___ ___ ___.
sea fan formations (neovasc and fibrous proliferations)
T or F: Prophylactic Tx of proliferative sickle cell retinopathy is effective in preventing neovascularization
F
What drugs do you want to avoid in sickle cell patients who have glaucoma?
CAIs (Acetazolamide) due to resultant acidosis
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
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?
leukemia

(infiltrates= leukemic plaques)
What's the most common type of blood cancer in the US?
lymphomas (abnormal proliferation os T or B lymphocytes)
A fleshy, salmon-colored lesion on the conjunctiva is indicative of what?
a lymphoma
What's the most common intraocular tumor of childhood? In adults? What's the most common intraocular malignancy overall?
retinoblastoma; choroidal melanoma; metastatic tumor to the choroid
What's a melanocytoma? Who is it most common in?
benign optic nerve tumor; dark-skinned pts (the other tumors discussed here are more common in whites)