midterm 1

What is the appearance of a retinal tear?

linear or horseshoe shaped

red

may have edema ring or RPE hyperplasia

What is the #1 cause of a rhegmatogenous retinal detachment?

retina break (usually retinal tear)

Why do retinal tears have a greater risk of retinal detach than retinal holes?

unequal tractional forces, posterior forces are less than the forces towards the ora, leading to a bigger hole and therefore more vitreous entering the hole increasing the risk of detachment

What is the apex of a retinal tear?

posterior side

What is the base of a retinal tear?

side toward ora

What is a flap tear?

retinal tear that is pulled anteriorly due to attached hyaloid causing a flap to form

What happens if a retinal detachment is untreated?

retina will die because it is separated from the RPE and eventually will scar

How do we manage a retinal tear?

ALWAYS REFER

When is the risk of retinal detachment after a retina tear basically 0?

6 weeks after the tear occurs, because after that the hyaloid is detached (same as retinal hole)

How many months after a PVD is the risk of retinal detachment basically 0?

6 months

What is the management for a patient with increase in F/F but with no retinal break?

1-1-6 + advise patient to come back immediately with large increase in F/F

follow up in one month, then another month, then 6 months

What is the cause of a rhegmatogenous retinal detachment?

breaks in the retina allowing vitreous to enter, separating the retina from the RPE

Where do rhegmatogenous retinal detachments usually occur?

often in the periphery

usually in area of thinned retina or strong vitreoretinal attachment

What are the symptoms of a rhegmatogenous retina detachment?

flashes + floaters

curtains (big black area in vision)

most are symptomatic

What are the risk factors for a rhegmatogenous retinal detachment?

myopia

cataract sx

trauma

If a phakic patient has a rhegmatogenous retinal detachment, what must you do?

dilate BOTH eyes (often will happen bilateral) and dilate every 6 months

What is the appearance of a rhegmatogenous retinal detachment?

undulating elevated ridges of retina that moves when the eye moves

whitish grey due to edema or scar tissue

may have hydration lines to demarcation lines/high water mark

How does the appearance of a rhegmatogenous retinal detachment change over time?

becomes more opaque with time and eventually stops undulating

What is a demarcation line/high water mark?

line of hyperplasia at posterior border of retinal detachment that is formed after ≥3 months of detachment without progression

How can a rhegmatogenous affect IOP?

cause cause increased or decreased IOP

How do you manage a rhegmatogenous retinal detachment?

must get same day appointment with retina

What are the treatments for a really small retinal detachment?

laser photocoagulation

pneumatic retinopexy

What are the treatments for a large retinal detachment?

scleral buckle surgery + adjunctive pneumatic retinopexy, laser, or cryotherapy

What is the treatment for a very complex case of retinal detachment (v. large or severe PVR)?

vitrectomy in addition to surgical options

What is the goal of scleral buckle surgery?

close retinal breaks by indenting wall of the eye, preventing vitreous from entering sub-retinal space

What are the post-op complications of scleral buckle surgery?

CME

ERM, proliferative vitreoretinopathy (PVR)

diplopia

myopic shift, irregular astigmatism

What is proliferative vitreoretinopathy (PVR)?

out of control thick ERM

What does proliferative vitreoretinopathy (PVR) cause?

distortion over macula, poor VA

strong traction which can cause a retinal break

What is proliferative vitreoretinopathy (PVR) often treated with?

vitrectomy

What is pneumatic retinopexy?

intravitreal gas bubble put ion vitreal space to push the retina against the RPE so RPE can pump out fluid + form new bonds with retina

What other treatments are often used alongslide pneumatic retinopexy?

laser/cryo therapy

What is the biggest downside to pneumatic retinopexy?

requires facial positioning as the gas bubble floats upward, must position face so gas bubble floats toward/against lesion

What is silicone oil tamponade?

alternative to pneumatic retinopexy, uses silicone oil in vitreal space

When is silicone oil tamponade used?

in cases where facial positioning is not an option or if all other treatments failed

What can cause a macular hole?

vireo-retinal traction

How do you stage a macular hole?

OCT

What is vitreomacular adhesion (VMA)?

incomplete PVD where hyaloid is still attached at macula, but detached around macula

What can VMA cause?

decreased foveal depression and transient metamorphopsia, but usually does not cause a problem

What stage is vitreomacular adhesion (VMA)?

NOT a stage of macular hole, pre-VMT

What is the first stage of a macular hole?

vitreomacular traction (VMT)

What is vitreomacular traction (VMT)?

VMA with increased traction (Still an incomplete PVD with traction on macula)

What are the symptoms of vitreomacular traction (VMT)?

blurry/hazy vision, "foggy"

transient metamorphopsia and micropsia

visual distortion

decreased VAs

What does vitreomacular traction (VMT) cause?

decreased foveal depression, may split inner + outer retina+ form macular cysts, apparent xanthophyll @ base of fovea

What forces cause the inner + outer retina to split in vitreomacular traction (VMT)?

anterior-posterior forces

What are we worried about with vitreomacular traction (VMT)?

tangential forces may split the now thinned inner retina

What is stage 1b of macular hole?

lamellar hole

What is a lamellar hole?

partial thickness macular hole.

What is the difference in appearance in a lamellar hole compared to a full thickness hole?

lamellar holes are darker red

What is the main difference between vitreomacular traction (VMT) and a lamellar hole?

lamellar hole had the lateral tangential forces split the retina laterally, vitreomacular traction (VMT) only has ant-post forces that cause a separating of inner + outer retina

What is the most important diagnostic and staging tool for macular hole?

OCT

What is VMA?

posterior hyaloid detached around macula, (still attached at macula) therefore pulling on macula

the macula has is not split in any direction at this stage, may have slightly reduced foveal depression

Is VMA a complete or incomplete PVD?

incomplete

What is stage 1a of macular hole?

Vitremacular traction (VMT)

What is the number one symptom of VMT?

hazy or foggy vision

What are the direction of the forced in VMT?

anterior-posterior causing split

tangential/lateral forces (have not split)

What does VMT look like in OCT?

anterior posterior split (inner and outer retina split)

may have macular cysts

decreased foveal depression

more apparent yellow spot @ base of fovea (xanthophyll)

hyaloid still attached at macula

What is the acuity like for someone with VMT?

variable, 20/30-20/70

What is stage 1b of a macular hole?

lamellar hole

What is the main difference between a lamellar hole and VMT?

lamellar hole has a lateral split (inner retina has split, in addition to inner + outer retina split)

VMT just has inner/outer retinal split, no lateral split

What type of hole is a lamellar hole?

partial thickness hole

What is the management for a lamellar hole?

refer

What is the VAs with a lamellar hole?

20/40-20/60

What is a stage 2- hole?

lamellar hole but the outer retinal is split and the inner retina is still intact

What is more likely to progress a 1b hole or a 2- hole?

2- hole (outer retina split, inner retina intact)

What does a macular pseudohole look like?

no lateral splitting (not a hole)

straightening of foveal depression

macular cysts present

ERM present

What happens with a macular pseudohole?

can progress into lamella hole or full thickness hole, but is rare

Can lamellar hole progress?

Yes can progress into full thickness hole, not very common

What is the management for a macular pseudohole?

refer

Which is more likely to progress: VMT, lamellar hole, macular pseudohole?

VMT

What is stage 2 macular hole?

small (<400 microns) full thickness hole (both inner + outer retina split laterally)

What does a stage 2 macular hole look like?

full lateral split in inner + outer retina

may have macular cysts

inner retinal flap that may become operculum

can have edema (localized RD) at base of hole

posterior hyaloid is still attached

What is the main difference between a stage 2 and stage 3 macular hole?

size

What is a stage 3 macular hole?

large (>400 microns) full thickness hole

What does a stage 3 macular hole look like when looking at fundus?

very red + surrounded by edema cuff

What does a stage 3 macular hole look like on OCT?

full thickness lateral split

may have macular cysts

yellow drusen deposits at base of hole

hyaloid still attached at macula

What is the acuity like in a stage 3 macular hole?

20/200 or worse

What is the only difference between a stage 3 and stage 4 macular hole?

if the hyaloid is still attached

What is a stage 4 macular hole?

large full thickness hole with NO hyaloid attachment at macula

What is the only way to differentiate a stage 3 vs stage 4 macular hole?

OCT

What may a stage 4 macular hole have?

pseudooperculum

What is the management of macular hole?

refer at all stages except VMA

What is the management for VMA?

monitor 6 months + give amsler grid

What is the treatment for a macular hole?

vitrectomy + pneumatic retinopexy

What is a positive Watzke-allen sign? What does it mean?

positive= vertical slit lamp beam breaks when going across macular hole

means it is a full thickness hole

What is a negative Watzke-allen sign? What does it mean?

negative= vertical slit lamp beam bends/distorts over macular hole

means it is a pseudohole or partial thickness (lamellar) hole

When do you refer VMT?

patient has one of the following:

metamorphopsia

blind spot

20/60 or worse

What do you do to manage VMT if not referring?

monitor 6 months and give amsler grid

What is the RPE tightly adhered to?

Bruch's membrane

What is the RPE loosely adhered to?

photoreceptor layer of the retina

What parts of the retina receives blood from the choriocapillaris?

Outer plexiform layer

outer nuclear layer

photoreceptor layer

RPE

Where is the blood supply for the inner retina?

*one BV group in Inner nuclear layer

one BV group in superficial nerve fiber layer*

What is the most inner Layer of the retina and what does it face?

internal limiting membrane, faces the vitreous

What surrounds the vitreous?

hyaloid

Which method to view the retina is not a replacement for a routine dilation with BIO and fundo?

Optos Optomap/Ultra Wide Field Imaging

What dose optical coherence tomography (OCT) use to get an image?

reflections

How does fluid (vitreous) appear on OCT?

black

What does the fovea look like on OCT?

smooth-walled sloped foveal depression

What does the RPE look like on OCT?

deep red layer

What can you see on OCT that is not a true anatomical layer?

IS/OS, Ellipsoid, or PR integrity layer

What does the IS/OS, Ellipsoid, or PR integrity layer appear as on OCT?

red/yellow line above RPE that has no breaks in health