HEENT Eye Disorders Pt 2

Retinal pigment epithelium

single layer of pigmented cells sitting between photoreceptors and the choroid. It is a highly active

supportive system that keeps the photoreceptors alive and functioning. When it breaks down, it is central to diseases like macula degeneration.

Macula

small specialized central region of the retina responsible for sharp, detailed central and color vision. Where light is most focused

Fovea

the center of the macula, highest visual acuity of the entire eye

Bruchs Membrane

thin, acellular, multilayered structure that sits between the retinal pigment epithelium and the choroid. It is a barrier and its breakdown is central to age related macular degeneration

Optic Disk

the circular or oval spot at the back of the eye where nerve fibers leave the retina to form the optic nerve

Optic cup

the small, pale, central depression or pit located inside the optic disc at the back of the eye where nerve fibers and blood vessels exit

Retina

- Loosely lines inner globe, attaching anteriorly to the ciliary body

- Convert light energy into electrical signal

Retinal Disorders

- Macular Degeneration

- Retinal Detachment

- Retinopathy

- Retinal vascular occlusion

Age-Related Macular Degeneration

1. Nonexudative form (dry) - this is more common

2. Exudative form (wet)

Nonexudative/Dry Macular Degeneration

Accumulation of extracellular deposits called drusen underneath the retinal pigment epithelium

How does drusen cause vision loss?

Retinal pigment epithelium will detach and become atrophic,

causing visual loss by interfering with photoreceptor function

Dry Macular Degeneration: Clinical Features

PAINLESS Vision Loss

Straight lines appear wavy

Scotoma: a central blind spot

Peripheral vision REMAINS INTACT

**NO HEMORRHAGE, NO EXUDATE, NO NEOVASCULARIZATION**

How to monitor Dry Macular Degeneration at home

amsler grid testing; if new lines appear wavy they should have urgent eval and ensure it has not converted to wet

Dry Macular Degeneration Treatment

- No definitive treatment; progression can be slowed

- AREDS2 Vitamin: Vit C, E, Leutein, Zinc, Copper, Zeaxanthin

- Smoking cessation

Abnormal Amsler Grid

Exudative Macular Degeneration (Wet)

- Abnormal new blood vessel (choroidal neovascularization) growth occurs beneath the retina

- Leaking/bleeding from these vessels cause blurring or sudden vision loss

Wet Macular Degeneration: Signs and Symptoms

- Sudden progressive central vision loss

- Metamorphopsia: straight lines appear wavy or distorted

- Central Scotoma: blind or blurry spot in center of vision

Wet Macular Degeneration Treatment

Anti-VEGR intravitreal injections

• Avastin

• Lucentis

• Eylea

• Vabysmo

Retinal Detachment

Separation of the retina from the underlying retinal pigment

epithelium and choroid

How do most cases of retinal detachment form?

one or more retinal holes or tears

Retinal Detachment symptoms

- Sudden onset of flashers or floaters

- normal central vision until the macula is affected

- "dark curtain" over part of their visual field

How does the retina detach?

- Once a break has developed in the retina, liquified vitreous is free to enter the subretinal space, separating the retina from the pigment epithelium.

Retinal Detachment Risk Factors

hx of myopia, hx of cataract extraction or trauma

How is Retinal Detachment diagnosed?

made by fundoscopy of the dilated eye

Retinal Detachment Treatment

- Urgent referral to ophthalmology

- Surgical repair: permanent adhesion with laser photocoagulation to the retinal pigment epithelium

Retinopathy

- Any disease or damage to the retina

- Can be asymptomatic or with gradual or sudden vision loss

Most common types of Retinopathy

diabetic retinopathy and hypertensive retinopathy

Non-proliferative Diabetic Retinopathy

- "background" retinopathy

- Retinal capillaries leak proteins, lipids or red cells into the retina

- In macula, macular edema occurs

Non-proliferative Diabetic Retinopathy Treatment

- Optimize BP, glucose

- VEGF inhibitor therapy

Proliferative Diabetic Retinopathy

- Less common, more severe

Capillary occlusion causes retinal ischemia and release of VEGF; this is turn stimulates new vessel growth with vision loss from preretinal hemorrhages, fibrosis and retinal traction

Proliferative Diabetic Retinopathy treatment

Invitreal injection of VEGF inhibitor

Diabetic Retinopathy Screening

fundus photography including

dilated examinations of retina

Hypertensive Retinopathy

Disease of the retina due to high blood pressure.

Hypertensive Retinopathy findings

- AV Nicking

- Microaneurysms and flame hemorrhages

- Cotton wool spots (retinal ischemia)

Hypertensive Retinopathy diagnosis

fundoscopic exam

Central Retinal Artery Occlusion

- "Eye stroke"

- An embolus or thrombus suddenly blocks the central retinal artery cutting off blood supply to the inner retina causing sudden, monocular, painless, vision loss

How long can retina tolerate an eye stroke before irreversible damage?

90 minutes

Central Retinal Artery Occlusion: Risk Factors

- Carotid artery atherosclerosis with embolization (most common)

- Cardiac emboli (atrial fibrillation, valvular disease, endocarditis)

- Giant cell arteritis (GCA)

- Hypercoagulable states

- Vasculitis

- HTN

- T2DM

Central Retinal Artery Occlusion symptoms

- Profound, monocular vision loss

- Only vision in temporal field

- PALE SWELLING OF REINA WITH CHERRY RED SPOT AT FOVEA

- BOX CARRING OF RETINAL VESSELS

How to diagnose Central Retinal Artery Occlusion

- ESR and CRP

- MRI of brain (rule out cerebral infarction (stroke))

- Duplex (ultrasound) of carotids

- EKG

- Echo

- CT/MR for carotid dissection

- Screen for DM, hyperlipidemia

Central Retinal Artery Occlusion

Treatment

- Emergency ER referal

- Oxygen, IV acetazolamide (IOP lowering agent), Anterior chamber paracentesis, early thrombolysis

- Check carotids for blockage

- If afib, need anticoagulation

- If valvular disease or PFO, need surgery

Branch Retinal Artery Occlusion

- Occlusion at branch rather than main trunk artery

- Partial vision loss

Branch Retinal Artery Occlusion treatment

Urgent opthal eval, stroke level work up

Central Retinal Vein Occlusion

Blockage of central retinal vein by thrombus, causing blood and

fluid to back up in the retina

Central Retinal Vein Occlusion Risk factors

- Glaucoma (major)

- Atherosclerosis (major)

- age

- DM

- HTN

- Elevated HCT

- Increased blood viscosity

Central Retinal Vein Occlusion symptoms

- Painless vision loss; usually unilateral

- causes hemorrhage and edema rather than ischemia

Central Retinal Vein Occlusion diagnosis

Fundoscopy

Central Retinal Vein Occlusion findings

- "Blood and thunder fundus"

- Retinal cotton wool spots

- Retinal veins will appear distended and torturous

- Fundus is congested and edematous

Central Retinal Vein Occlusion Treatment

No direct treatment

treat underlying complications

Branch Retinal Vein Occlusion

- Partial vision loss; can be at the time of occlusion of fovea is involved or can be later

- Hemorrhages, micro-aneurysms, venous dilation and tortuosity and cotton wool spots are confined to the area drained by the obstructed vein

What is the most common type of retinal occlusion?

Branch Retinal Vein Occlusion

Branch Retinal Vein Occlusion

Treatment

1st Line: Anti-VEGF intravitreal injections

2nd Line: Intravitreal corticosteroids

3rd Line: Focal/grid laser photocoagulation

Last Line: Panretinal or sector photocoagulation if neovascularization develops in

the ischemic territory

Neuro-opthalmologic Disorders

- Nystagmus

- Optic Neuritis

- Papilledema

Primary symptom associated with nystagmus

Vertigo

Primary direction of movement associated with nystagmus

Horizational (BPPV, neuritis,

labyrinthitis)

Optic Neuritis

Inflammation of the optic nerve causing subacute, painful, monocular vision loss

What disease is inflammatory optic neuropathy commonly associated with?

demyelinating disease, particularly multiple sclerosis

Other diseases associated with optic neuritis

Sarcoid, post viral infection, autoimmune- SLE and sjorgens, spread of inflammation by meninges, orbital tissues and paranasal sinuses

Optic Neuritis: Clinical Features

- Unilateral vision loss

- Pain behind eye

- Central field vision loss, color vision loss, pupil defect

- Improves in 2-3 weeks

Optic Neuritis Imaging

MRI if no MS for periventricular white matter demylination

Optic Neuritis Treatment

- In acute demyelinating optic neuritis: IV methylprednisolone 1g daily x 3 days followed by tapering course of oral prednisolone.

- monoclonal antibodies, cell-based therapies

When does optic neuritis have a poorer prognosis?

Optic neuritis due to sarcoid, SLE, herpes zoster

Papilledema

Bilateral optic disc swelling from raised intracranial pressure

Papilledema symptoms

- Brief episodes of graying out

- Dimming or completely black out vision, lasting only seconds.

- Also occurs with rapid positional change

- Headache, nausea, tinnitus, diplopia

Papilledema causes

-Brain mass

- Cerebral edema from head trauma, hypoxic brain injury

- Obstruction of CSF flow in ventricles

- Obstruction of cerebral venous flow

- CSF overproduction

- Idiopathic intracranial hypertension aka pseudotumor cerebri

Papilledema imaging

- MRI (exclude intracranial lesion)

- Lumbar Puncture (elevated pressure and normal CSF = pseudotumor cerebri, which is idiopathic intracranial hypertension

Papilledema Treatment

- Reduce elevated inter-cranial pressure

- If mass, surgical management

Orbital and Periorbital Cellulitis

severe infection involving the fat and muscle within the orbit

Orbital Cellulitis symptoms

- Fever

- Proptosis

- Restriction of extraocular movements

- Painful purple-red eyelid swelling

- Usually caused by infection of paranasal sinuses or dental infection -> S pneumoniae, H influenzae & S aureus

Orbital Cellulitis imaging

CT

CBC

Cultures

Opthal referral

Orbital Cellulitis Treatment

- Immediate IV antibiotics

- Anaerobic infections -> nafcillin, with metronidazole or clindamycin

- MRSA -> Vanco or Clindamycin

- PCN allergy -> Vanco, levofloxacin and metronidazole

Periorbital Cellulitis

- More common, mild infection in front of the eye socket membrane.

- This occurs anteriorly to the orbital septum

Periorbital Cellulitis symptoms

- Edema

- Painless

- Circumferential erythema of the eyelids and periorbital skin

- Normal eye movement

Periorbital Cellulitis causes

- bug bite, skin scratch, local face/eyelid wound

- S aureus and Streptococcus

Periorbital Cellulitis treatment

Oral antibiotics

Vision Abnormalities

- Amaurosis fugax

- Amblyopia

- Glaucoma

- Strabismus

- Presbyopia

Amaurosis Fugax "Fleeting blindness"

transient ischemic attack of the retina

How does Amaurosis Fugax happen?

Interruption of blood flow (due to embolus becoming stuck in retinal arteriole) to the retina for more than a few seconds will result in transient monocular blindness

How does a Amaurosis Fugax look like to the patient?

Curtain descending affecting only a portion of visual field

Amaurosis Fugax Diagnosis

Urgent neuroimaging to assess for cerebral infarction and ID source of emboli

What are patients with Amaurosis Fugax at an increased risk of?

stroke, MI and other vascular events

Amaurosis Fugax Treatment

- Oral aspirin/Plavix

- Statins to reduce LDL cholesterol

- Carotid Endarterectomy/stenting

- Lifestyle changes

Amblyopia

Eye fails to acquire its potential visual acuity because images are not properly projected onto the fovea during a formative period of cerebral development.

Amblyopia causes

strabismus, ptosis, cataract, refractive errors

Strabismus "crossed eyes"

Any ocular misalignment in which only one eye fixates with the fovea on object

6 ocular muscles

- superior rectus

- medial rectus

- inferior rectus

- lateral rectus

- superior oblique

- inferior oblique

Esotropia

inward turning, convergent axes

Exotropia

outward turning, divergent axes

Hypertropia

upward turning

Hypotropia

downward turning

Strabismus: Causes and Risk Factors

Family history

Cerebral palsy

Down syndrome

Hydrocephalus

Brain tumors

Head injuries

Graves Disease

Strabismus Diagnosis

Light reflex

Cover test

Light Reflex

The corneal light from a penlight held along a toy that the child focuses on should appear symmetric

Cover test

In an abnormal test, when the dominant eye is covered, the weaker eye will move to focus on an object

Strabismus Treatment

Esotropia - surgery

Exotropia - patching and exercise

Strabismus Complications

- amblyopia (decreased visual acuity in less dominant eye)

- diplopia

- contracture of the ocular eye muscles

Presbyopia

Normal age related condition, the eyes natural lens gradually loses its flexibility, making it hard to focus on close up objects

Presbyopia age onset

40 yo

Presbyopia symptoms

blurred near vision, holding phones, books, menus farther away to read them

Presbyopia Treatment

- Reading glasses

- Bifocals are split lenses used to visualize out of distinct sections

of the glasses