Ocular Disease II: Acquired Maculopathies, Retinal Vascular

T/F Drusen which is collection of HYALINE DEPOSITs  between RPE and Bruch's membrane is the #1 sign for ARMD 

• True

• False

Your 40 y/o MALE patient walks in. He just got divorced by his wife and is complaining of a central distortion in his vision. What could he possible have? 

• Wet ARMD

• Diabetic ret

• Central Serous retinopathy

• Macular hole

 T/F Arteriosclerotic retinopathy ("hardening of the arteries") alone DO NOT indicate the severity of the HTN, but it does show that the systemic HTN has been present for MANY year 

• True

• False

T/F Photodynamic Therapy (PDT) is a great 1st line treatment for Wet ARMD: 

• True

• False

NAME THAT STAGE: -Central yellow dot  -Loss of foveal reflex -OCT: Small elevated space (not a hole yet)

• Stage 1A: Macular Cyst

• Stage 2: Lamellar Hole (partial Thickness)

• Stage 3: Full thickness

• Stage 4: Full thickness

What are the 3 types of ATHEROsclerotic changes? (check 3) 

• Hollenhorst Plaques

• Hyperviscosity Plaques

• Fibrinoplatetes Plaques

• Calcific Plaques

T/F According to the SCORE study, 1 mg injection of steroid will: 1) Improve VA 2) Decrease vascular permeality  3) Decrease inflammation *Overall, there is a definite improvement with steroid injection, in treating CRVO 

• True

• False

T/F Caution with glaucoma patients prior to cataract surgery, because we need to D/C glaucoma medications for ~1month because it may facilitate CME

• True

• False

NAME THAT STAGE! -Reduced VA -Slight reddish hole  -No edema around hole  -OCT: show a depressed area 

• Stage 1A: Macular Cyst

• Stage 2: Lamellar Hole (partial Thickness)

• Stage 3: Full thickness

• Stage 4: Full thickness

T/F If you see a FLAME heme in your Hypertensive ret patient, you need to check BP because it can lead to BRVO/BRAO

• True

• False

T/F If there is overall defect in Bruch's membrane in wet AMD, there anti-VEGF injections will be helpful. 

• True

• False

T/F PVD is a good indicator of stability because if present, there is no little risk of developing a TRUE macular hole 

• True

• False

Select the FALSE statement for ARMD:

• Usually BILATERAL

• #1 cause of blindness in UA over age 65

• White is affected more than Black

• Smoking is 3X the risk due to DECREASED circulation to the retina and choroid

• Myopia is 25x higher risk due to less pigment

• Circulatory diseases such as DM and HTN are a major factor for ARMD, due to circulation issues to retina

SELECT all the TRUE statements about Treatment/Managment of CSR: 

• 80-90% will resolve spontaneously within 1-6 month, with increased VA. That's why we usually monitor monthly.

• If symptoms are STILL PRESENT after 4 months, then refer out to LASER PHOTOCOAGULATION (usually argon).

• Laser is effective and will IMPROVE vision outcome, thus is often used as an initial treatment

T/F It is WORSE to have a SUPERIOR BRVO because it can move to macula due to gravity, compared to an inferior BRVO 

• True

• False

NAME THAT STAGE: -Complete separation of vitreous  -Central round defect -WEISS ring  -Grey elevated edges around hole (donut appearance)  *You see yellowish deposits at the floor of the hole form lipids! 

• Stage 1A: Macular Cyst

• Stage 2: Lamellar Hole (partial Thickness)

• Stage 3: Full thickness

• Stage 4: Full thickness

Your patient started a new anti-psychotic medication and come in for an eye exam. Initially, you find fundus to be normal. Then he started to complain of: -Blurred VA -Central VA loss -BROWN discolored vision  What does he have?

• Plaquenil Retinopathy

• Thoridazine (Mellaril) Retinopathy

T/F According to the CRVO study, Pan-retinal photocoagulation (PRP) should only be reserved if NEO is present. Also the results show that it is EFFECTIVE in reducing edema but NO IMPROVEMENT in VISUAL OUTCOME 

• True

• False

Select the FALSE CME clinical findings: 

• Loss of foveal reflex

• Multiple cystic spaces in sensory retina, where fluid accumulates and breaks up sensory retina

• Blurring of chorodial pattern due to sensory retina thickening

• Weiss Ring

• FA: you will see "flower petal" appearance

• Slight elevated macula

So you decided to look in the back of the eye, what would you see for Thoridazine Ret?

T/F If BRVO is not in a significant visual area, then refer to PCP and f/up in 1 month. But if it is, then refer to retinal specialist 

• True

• False

It is safe to prescribe Beta-carotene to chronic smokers who just quit 2 years ago. 

• True

• False

What are the 4 types of Retinal Vascular Occlusive dz that we learned about? (Select 4) 

• Central Retinal Venous Occlusion (CRVO)

• Arteriosclerotic Retinal Occlusion (ARO)

• Hemi-Central Retinal Vein Occlusion (Hemi-CRVO)

• Branch Retinal Vein Obstruction (BRVO)

• Central Retinal Artery Occlusion (CRAO)

Your patient come in and you see an elevated, discolored lesion in the retina. What should do you do first?

• Sent out for Argon laser ASAP

• Do an OCT or FA to rule out an CNVM

• Start him on a Photodynamic therapy (TDT)

• Using your 90D and stereo to see if there is elevation.

What are the 2 types of CRVO? Select the wrong one

• Venous Stasis Retinopathy (Incomplete CRVO)

• Hemorrhagic Retinopathy (Ischemic)

• Anticoagulant Retinopathy

T/F Ozurdex (Dexametasone) implant will NOT REDUCE risk of further vision loss 

• True

• False

Select the FALSE statement about Drusen: 

• Hard drusen are small, well-defined yellow deposits deep in retina while Soft drusen are LARGER and fluffy

• Dursen will HYPERfluroresence, compared to Exudate which will HYPOfluorensce with Red-free Light. used to DDX

• Hard dursen has low risk for Neo, compared to soft drusen which has a 7% risk of neo dye to more damage to sensory retina

• VA will be still be 20/20 and will have a (-) amsler grid, if it is just soft or hard drusen by itself and not true ARMD.

• All are true

T/F BRAVO study shows that there is significant improvement with LUCENTIS  INJECTION (anti-VegF), rather than observation. But LASER is still most helpful in BRVO 

• True

• False

Which patient is NOT at risk for developing CNVM (choroidal neovascular membrane or Macular degeneration in the good eye? 

• If a patient bilateral drusen, then he has a 2-4%of developing CNVM

• If one eye have AMD, there is a 10% of the other eye developing AMD

• If there is a wet AMD in one eye AND confluent dursen in the other eye= then there is 55% risk of eye with the drusen of developing WET AMD

• Focal RPE changes in one eye and NEO in the other eye--> high risk of developing wet AMD in non-affected eye

• All are true

T/F Vitrectomy (gas bubble injection to keep macula in place, to keep hole smaller), will IMPROVE VA by 2x if initial poor VA. 

• True

• False

Check all TRUE statements when it comes to ATHerosclerotic plaques: 

• Calcific plaques are the MOST common, while Hollenhorst plaques are the least

• Hollenhorst are made up of cholesterol and tends to rest at BIFURCATIONS

• Hollenhorst looks very SHINY, while Calcific are NOT shiny (look matte white)

• We don't need to do carotid bruit assessment when we see plaques

• Calcific plaques are the GREATEST risk of CRAO/BRAO because it can cause the greatest occlusion

• Calcific plaques come from heart valves or carotid arteries, which break off

• Aspirin once a day, if there is no contraindications, is a good treatment

• Due to its soft/mallable form, Hollenhorst plaques can OFTEN cause occlusion

Select the FALSE statement for Steroid injection of Triamcinolone/Kenalog for wet ARMD?

• Triamcinolone/Kenalog vitreous injection reduce inflammation and vascular permeability

• May be used in conjunction with Photodynamic therapy

• Helpful for DM macular edema and other vascular occlusive dz

• ADE of Triamcinolone/Kenalog injection is NOT enhanced, compared to Oral Triamcinolone/Kenalog

• Reduce swelling which last for UP TO 3-4MONTHS

T/F  Rubeosis iridis (along with NV of retin) is VERY RARE complication in BRVO, compared to CRVO, because much less retina is affected 

• True

• False

Select the FALSE statement about the general signs for DRY ARMD (aka Atrophic, or non-exudative) 

• Dry ARMD accounts for 90% of all ARMD

• There is a DECREASED in VA

• Underlying choroidal vessels may become more PROMINANT as the disease progress. Retina look whiter

• Coalescing drusen do NOT indicate progression to WET ARMD (aka Disciform type)

Select the FALSE clinical finding statement of Macular Hole: 

• Unilateral (usually)

• MOA: Vitreous get pulled on, which separate the retina--> create cysts--> Pull enough to get a hole ("punch out appearance")

• FA: HYPOfluorenscence in late stages (cyst)

• (+) amsler at fixation only (normal everywhere else)

• Symptoms might be hard for patient to describe (usually blurred vision, metamophoropsia, missing areas)

• Affect Female MORE

Select all TRUE STATEMENT abnout ACUTE DAMAGES signs in HT retinopathy: 

• Vasoconstriction can lead to CWS and NFL infarcts

• Leakage can leading to flame hemes, hard exudates and possible BRAIN SWELLING

• Swelling of optic disc is common and not that serious

• Macular star can occurs due to abnormal vascular permeability

Check all the Treatment/management for Dry ARMD: 

• Home Amsler grid

• Low vision devices if decreased VA

• Anti-VegF injection

• UV protection

• Vitamin C+E , beta-carotene (vitamin A), zinc

T/F SCORE study shows NO DIFFERENCE between laser and steroid tx for Retinal Vein occlusion. 

• True

• False

Which is one is Cystoid Macular Edema (which is collection of fluid in the OUTER PLEXIFORM LAYER and INNER NUCLEAR LAYER of the sensory retina around macula) NOT SECONDARY to? 

• Prostaglandins Force

• High Refractive error

• Tractional Forces

• Vascular

Which is NOT a cause for Macular Hole?

• Idiopathic

• CME

• Diabetes

• Trauma

• Myopia

• PVD

T/F Photodynamic  therapy is ONLY used in combo with: 1) VEGF injection...OR  2) Steroid such as Triamcinolone...OR 3) AREDS multi-vitamins

• True

• False

What would you do to treat Stage 3: Full thickness??

• Monitor

• Consult with retina specialist

• Retinal consult for vitrectomy

A different patient is currently taking the same medication (Plaquenil) for their RA, Lupus, Erthematosus and Anti-psy conditions. You are like wow, this guy is a eff-ed. What would you NOT do next? 

• BIO to check for Bull's eye macula

• Run a VF theshold 30-2 to determine changes in sensitivity

• Fundus photos to look for degenerative changes

• Consider a EOG, ERG, FA (in central vision loss w/o signs)

• Consult with PCP about prescribed medication

SELECT ALL the true statements about Fresh CRAO vs Old CRAO

• Both will have (+) APD

• Cherry red spot at macula seen in OLD CRAO

• Fresh will have diffuse, hazy, WHITE edematous retina

• OLD CRAO has a pretty normal looking fundus, except for optic atrophy, thinning retina (replaced by glial tissue), and irregular narrowing of arterioles

Which is NOT a typically cause of CRAO? ......EXTRA: Which one is the MOST COMMON? 

• Calcific plaques

• Fibronplatelet

• Giant Cell Arteritis (cause inflammation, not plaques)

• Hollenhorst plaques

• Migrane

• Emoli (drug, self-injected)

• Birth control pills (although rare)

SELECT THE FALSE STATEMENT that you can DDX Solar Ret from Macular Hole? 

• Solar ret patient are usually mental disabled patient who like to stare at the sun. "sun-worshippers"

• Solar ret are usually BILATERAL, compared to macular holes which are UNILATERAL

• VA are NOT reduced in Solar Ret

Select ALL TRUE STATEMENT for venous stasis ret (VSR) and Hemorrhagic Ret (HR) 

• VSR is more associated with sludging of blood, caused by LEUKEMIA, SICKLE CELL, DM

• HR tends to affect more YOUNG, while VSR affect OLDER

• VA prognosis is very POOR for HR, compared to VSR (which have good VA prognosis)

• You see SIGNIFICANT Optic disc edema in VSR

• There are more CWS seen in HR

• NVI is more common in HR, which can lead to neovascular glaucoma

• It is harder to see the retina and fundus during BIO with HR

Select all  TRUE STATEMENTS about Epi-Retinal Membrane: 

• May be related to POST-PVD process, due to more glial cells proliferating on the surface on ILM

• Causes localized areas of wrinkling in macula "Spider web appearance" (aka Macular pucker)

• Caused by unknown or retinal vascular dz

• OCT: will show ERM pulling up vitreous region--> slight elevation

• We will usually do vitrectomy to peel ILM first, because ERM usually cause a severe VA loss