Retina Review

Part 2

35 yo on multiple BP meds

Hypertensive Retinopathy
Describe fundus findings associated with
hypertensive retinopathy?

Constriction of retinal arterioles

Intraretinal hemorrhages
Cotton wool spots
Macular edema
Disc edema
Retinal neovascularization

What are manifestations of hypertensive

choroidopathy?
Elschnig spots and Siegrist streaks

47 yo 20/20 referred by internist

62 yo diabetic
20/60

33 yo diabetic 20/30 OU

Diabetic Retinopathy
WESDR
IDDM
99% have retinopathy after 20 yr
NIDDM 60% have retinopathy after 20 yr

DCCT
Tight glucose control decreases retinopathy in IDDM

UKPDS
Glucose control decreases retinopathy in NIDDM

Diabetic Retinopathy
ETDRS
Focal laser indicated for CSME
Retinal thickening at or within 500 m of the foveal
center
Retinal thickening associated with hard exudate at or
within 500 m of the foveal center
A zone of retinal thickening larger than 1 disc area
within 1 disc diameter of the foveal center
PRP indicated for high risk PDR, not for NPDR (can
consider for severe NPDR)
ASA does not affect vitreous hemorrhage

Diabetic Retinopathy
Describe the 4:2:1 rule
4 quadrants of diffuse intraretinal hemorrhage and
microaneurysms
2 quadrants of venous beading
1 quadrant of intraretinal microvascular abnormalities

What is severe NPDR and what 1-year risk does

it carry for progression to high-risk PDR?
1 of the above criteria
15%

What is very severe NPDR and what 1-year risk

does it carry for progression to high-risk PDR?
2 of the above criteria
45%

Diabetic Retinopathy
DRS - PRP reduces severe visual loss by 50% for high risk
PDR
Mild (1/4 to 1/3 disc area) NVD with vitreous hemorrhage
Moderate to severe NVD with or w/o vitreous hemorrhage
Moderate (1/2 disc area) NVE with vitreous hemorrhage

DRVS - vitrectomy for nonclearing vitreous hemorrhage

Early vitrectomy beneficial for IDDM
Early (1 mo) same as late (6 mo) for NIDDM

Other indications for surgery

Macula involving TRD
Combined TRD/RRD
Refractory macular edema with taut posterior hyaloid

35 yo African American male

Sickle Cell Retinopathy

Which form of sickle cell is associated with the most serious
ocular complications?
Hb SC

What are the findings on nonproliferative sickle cell retinopathy?

Salmon patch hemorrhage (intraretinal hemorrhage)
Refractile spot (resorbed hemorrhage)
Black sunburst (RPE hypertrophy)

What are the stages of proliferative sickle cell retinopathy?

I: arteriolar occlusions
II:
arteriovenous anastomoses
III:
sea-fan neovascularization
IV:
vitreous hemorrhage
V:
tractional retinal detachment

What is the preferred treatment for PSR?

Peripheral scatter photocoagulation
Vitrectomy for non-clearing vitreous hemorrhage or RD

Baby

ROP
Describe the stages of ROP

1:
2:
3:
4:

demarcation line
elevated ridge
ridge with extraretinal fibrovascular proliferation
subtotal retinal detachment
A extrafoveal
B involving fovea
5: total retinal detachment

Define plus disease

Retinal vascular dilation and tortuosity in the posterior pole

ROP
Define threshold ROP
Zone I or II
Extent of 5 contiguous or 8 non-contiguous clock
hours of extraretinal neovascularization
Plus disease
Threshold benefits from cryo or laser

STOP-ROP - oxygen level had no effect on

progression

71 yo woman h/o POAG

20/30

75 yo 20/80

BVOS and CVOS

Grid laser for macular edema
Beneficial for BRVO
Not beneficial for CRVO

PRP laser for prevention of VH, NVG

Prophylactic laser not recommended
Laser once NV (iris, disc, retina) develops

60 yo
Scotoma for
one wk

65 yo sudden decreased vision OU x 4hr

65 yo decreased vision x 3d

Central Retinal Artery Occlusion

What percentage of eyes have vision <20/400?
66%

With NLP vision, what diagnosis must be

considered?
Ophthalmic artery occlusion

What is the leading cause of death in patients

with CRAO?
Cardiovascular disease

82 yo NLP

Central Retinal Artery Occlusion

What percentage of CRAO is accounted
for by giant cell arteritis?
1-2%

What are some methods used as therapy

for CRAO?
Ocular massage
Anterior chamber paracentesis
Administration of carbogen

85yo chronic pain and redness OD

Ocular Ischemic Syndrome

What percent carotid obstruction is typically
required to cause OIS?
90%

Describe the symptoms

Gradual visual loss
Aching pain
Prolonged recovery following bright light exposure

What are anterior segment findings?

Iris neovascularization (67%)
AC cellular reaction (20%)

Ocular Ischemic Syndrome

Describe the posterior segment findings

Narrowed arteries
Dilated, non-tortuous veins
Mid-peripheral retinal hemorrhages, microaneurysms
Neovascularization

What are the fluorescein angiographic findings?

Delayed choroidal filling (60%)
Delayed arteriovenous transit (95%)
Vascular staining (85%)

What is the 5-year mortality rate and what is the

most common cause of death?
40%
Cardiovascular disease

35 yo asymptomatic

Retinal Vasculitis
What is the differential diagnosis of retinal
vasculitis?

Giant cell arteritis

Sarcoidosis
Behcets disease
Lupus
Polyarteritis
Inflammatory Bowel Dz

Multiple sclerosis
Syphilis
Pars planitis
Toxoplasmosis
Idiopathic

8 yo boy; parents noted leukocoria

Coats Disease
Describe the clinical findings

Telangiectatic vessels, microaneurysms

Fusiform capillary dilation
Exudative retinal detachment
Capillary non-perfusion

What is the mode of transmission?

Not hereditary

What is the percentage of cases affecting males?

85%

What treatments are employed to halt

progression?
Cryotherapy or photocoagulation
Retinal reattachment surgery

40 yo 20/40 OU

Idiopathic Juxtafoveal
Telangiectasis
What are the 3 clinical groups
Unilateral juxtafoveal telangiectasis
Bilateral juxtafoveal telangiectasis
Bilateral juxtafoveal telangiectasis with capillary
obliteration

45 yo h/o HTN

Retinal Arterial Macroaneurysm

What percentage of cases are associated with
systemic hypertension?
67%

What are causes of visual loss?

Intra- or subretinal hemorrhage
Vitreous hemorrhage
Macular edema/exudation

50 yo c/o floater

Posterior Vitreous
Detachment
What percentage of patients with acute
symptomatic PVD have a retinal tear?
15%

What percentage of patients with vitreous

hemorrhage associated with PVD have a
retinal tear?
70%

20 yo myope, asymptomatic

Lattice Degeneration
What is the prevalence of lattice degeneration in
the general population?
6-8%

Of patients with lattice, what is chance of RD?

1%

What percentage of retinal detachments have

associated lattice degeneration?
20-30%

Describe the histopathologic features

Discontinuity of the ILM

Overlying pocket of liquefied vitreous
Adherence of vitreous at the margin
Atrophy of inner retinal layers

60 yo c/o flashes

Retinal Breaks
What percentage of the population will
develop a retinal detachment over their
lifetime?
0.07%

What types of retinal breaks should be

treated?
Symptomatic horseshoe tears
Retinal dialysis

Retinal Detachment
What is optimal timing for surgery?
Mac on - 87% 20/50
Mac off - 30-50% 20/50
< 1 wk 75% 20/70
1-8 wk 50% 20/70

Define subclinical retinal detachment

Subretinal fluid extends more than 1DD from
the break
Subretinal fluid extends no more than 2DD
posterior to the equator

60 yo asymptomatic

Retinoschisis
What is the typical location in the fundus?
Inferotemporal

What layer is affected in typical

retinoschisis?
Outer plexiform
(reticular retinoschsis, juvenile retinoschisis in NFL)

How can schisis be differentiated from

RD?

Absolute scotoma
No associated tear/tobacco dust
Smoother surface
Laser scars

Hereditary
Hyaloidoretinopathies
Describe features of Jansen and Wagner
disease

Autosomal dominant transmission

Optically empty vitreous
Equatorial and perivascular lattice
Myopia, strabismus, cataract

Which of the above conditions is

associated with retinal detachment?
Jansen disease

Stickler Syndrome
Describe the features of Stickler
Syndrome
Autosomal dominant transmission
Myopia, glaucoma, cataract
Orofacial findings
Midfacial flattening
Pierre-Robin malformation (micrognathia,
cleft palate, glossoptosis)
Skeletal abnormalities
Joint hyperextensibility
Arthritis
Spondyloepiphyseal dysplasia
High incidence of RD, giant retinal tear, PVR

3 mo old term baby

FEVR
What is the mode of inheritance of familial
exudative vitreoretinopathy?
Autosomal dominant

Describe the clinical features

Normal birth weight/gestational age

Failure of the temporal retina to completely vascularize
Peripheral fibrovascular proliferation
Traction retinal detachment
Subretinal exudate or exudative detachment
Late-onset rhegmatogenous detachment