Questions Dr Fogt Said M2

Is a larger or smaller macular hole more likely to close spontaneously?

Smaller macular holes

The larger a macular hole is the more/less likely the hole is to close spontaneously

Larger = less likely to close on its own

Why do some doctors not refer VMTs?

At least 1/2 of VMTs will spontaneously resolve on their own

What is the test called that uses the slit lamp to distinguish between a full-thickness hole and a pseudo-hole?

Watzke-Allen sign

What do you do for the Watzke-Allen sign?

Place a vertical beam of light across the suspected or apparent macular hole with a fundus lens

Ask the patient what they see

What will a full-thickness hole look like during the Watzke-Allen sign?

the beam will look broke, middle is missing

What will a pseudo-hole or lamellar hole look like during the Watzke-Allen sign?

the beam will look distorted, curved in the middle

What do you expect of the patient's vision if they have asteroid hyalosis?

Pt will be able to see mostly normal (20/25ish)

What do you expect to see as the doctor if your patient has asteroid hyalosis?

It is very hard to view the retina and posterior structures in a patient that has asteroid hyalosis

What is the unique feature of asteroid hyalosis?

You expect that if the doctor cannot see into the eye that the pt cannot see out of the eye but their vision is relatively good (20/25ish)

What was Persistent Fetal Vasculature formerly known as?

Persistent Hyperplastic Primary Vitreous (PHPV)

What is Persistent Fetal Vasculature (PFV)?

failure of regression of the structures of the primary vitreous, rare condition

What are the differentials of a white pupil in an infant or a child?

Cataract, retinoblastoma, retinopathy of prematurity, persistent fetal vasculature

Cataract, retinoblastoma, retinopathy of prematurity, and persistent fetal vasculature all have a common presentation of..

white pupil (leukocoria)

What is anterior vitreous detachment commonly caused by?

Secondary to trauma or lens dislocation

What almost always causes an anterior vitreous detachment?

Trauma

What will an anterior vitreous detachment almost always lead to?

Retinal tear

What does the color black or brown mean in the retina?

extra pigmentation

sometimes hemorrhages can look brown

What does the color dull yellow mean in the retina?

Missing RPE pigmentation

or missing RPE altogether

What does the color orange mean in the retina?

missing RPE pigmentation and some of the outer retina

What does the color dark red mean in the retina?

Missing significant amounts of outer retina and maybe some inner retina

What is the management for CHRPE?

usually monitor in one year

What is the management for CHRPE if there is vascular leakage or feeder vessels?

Refer for potential RPE adenocarcinoma evaluation

What is the typical size of a choroidal nevus?

95% are under 2 disc diameters in size

Is it common for a choroidal nevus to be over 2 disc diameters in size?

No very uncommon

What is the Red free filter used for?

will filter out "red" from choriocapillaris (so makes it dark)

What happens when you use the Red free filter on a nevus?

Nevus is dark so it disappears

What do you use when you want to distinguish between a nevus and CHRPE?

Use the Red free filter

What is the results of using a Red free filter on a nevus/CHRPE?

Nevus - disappears

CHRPE - stays there, still able to see it

Is the Red free filter a reliable way to distinguish between a nevus and melanoma?

No

If you are looking at a lesion and use the Red free filter and the lesion disappears, what is the lesion?

A nevus

If you are looking at a lesion and use the Red free filter and the lesion does not disappear, what is the lesion?

CHRPE

What are the classifications based on size for a choroidal nevus?

0.5-2DD - Benign

2-5DD - Suspicious

5DD or larger - Refer, malignant

What is the classification for a choroidal nevus that is 0.5-2DD in size?

Benign

What is the classification for a choroidal nevus that is 2-5DD in size?

Suspicious

What is the classification for a choroidal nevus that is 5DD or larger in size?

Refer, malignant

What are some other criteria of choroidal nevi that should be considered when thinking about referring?

If it is blurry, has orange, or just looks weird

TFSOM-UHHD (what does it stand for)

To Find Small Ocular Melanoma Using Helpful Hints Daily

TFSOM-UHHD (list)

Thickness > 2mm

Subretinal fluid

Symptoms

Orange pigment present

Margin within 3mm of the optic disc

Ultrasonographic hollowness (versus solid/flat)

Absence of halo

Absence of drusen

What are the 4 most important TFSOM-UHHD?

Thickness > 2mm

Subretinal fluid

Symptoms

Orange pigment present

If there are no risk factors for a choroidal nevi..

3% chance of growth at 5 years and most likley nevi

If there is one risk factor for a choroidal nevi...

38% chance of growth, observation is okay

If there are 3 or more risk factors for a choroidal nevi...

50% chance of growth, probably small melanoma

What is important to know regarding a suspicious choroidal nevus?

Whether it is within 2DD of ON, if there is orange pigment, and how big the nevi is in DD

What is the halo made of in a halo choroidal nevus?

Halo consists of inflammatory cells

What are the different types of halos on a nevi?

Regulat halo, inverted halo

Describe an inverted halo?

Halo is on the inside, typical nevi color is on the outside?

Is a regular halo a good sign for a choroidal nevi?

Yes

Is an inverted halo a good sign for a choroidal nevi?

Yes

Is drusen a good sign for a choroidal nevi?

Yes

When might a doctor do something about a choroidal nevus lesion?

If there is serous fluid in the lesion

What is used to look for serous fluid in a lesion/choroidal nevus?

Use an OCT

If you are suspicious that there is serous fluid within a choroidal nevus/lesion, what should be your next step?

Run an OCT

What is a MUST refer with a choroidal nevus?

>5DD in diameter OR

2-5DD and one or more features from TFSOM-UHHD

What is a could refer with a choroidal nevus?

2-5DD with no other features from TFSOM-UHHD

What should you do if you decide to monitor a choroidal nevus?

Photo-document it and follow up

When do you follow up with a choroidal nevus if it is <2DD?

One year

When do you follow up with a choroidal nevus if it is 2-5DD?

Six months

What is the requirement if you are going to monitor a choroidal nevus in one year?

Nevus must be <2DD

What is the requirement if you are going to monitor a choroidal nevus in six months?

Nevus must be 2-5DD

What is the management for a choroidal nevus that is >5DD?

MUST refer

What is the management for a choroidal nevus 2-5DD in size and one or more features from TFSOM-UHHD?

MUST refer

What is the management for a choroidal nevus 2-5DD in size with no other features from TFSOM-UHHD?

Could refer

What are the differentials for an amelanotic choroidal nevus?

Amelanotic melanoma

Malignant melanoma (choroidal melanoma)

Choroidal metastasis

What is the most common choroidal metastasis in women?

Breast cancer

What is the most common choroidal metastasis in men?

Lung cancer

What is the most common choroidal metastasis in women and men?

Women - breast cancer

Men - lung cancer

What is the median survival time after finding a choroidal metastasis that indicates lung cancer?

8 months

What is the median survival time after finding a choroidal metastasis that indicates breast cancer?

18 months

After finding a choroidal melanoma that indicates breast cancer, what is the mean survival time?

18 months

After finding a choroidal melanoma that indicates lung cancer, what is the mean survival time?

8 months

What tests can be done to distinguish an amelanonitic nevus versus a choroidal metastasis or malignant melanoma?

B Scan and OCT

What are 3 differentials that B Scan and OCT can be used for?

Amelanotic Nevus (or Inverted Halo Nevi)

Choroidal metastasis

Malignant melanoma

What are some things you want to watch out for in a malignant melanoma?

Larger lesions, changes in color (mottling), changes in border shape or size, elevation

What is mottling?

Mixture of colors

What colors might you see in a malignant melanoma?

Dark pigment (black), white pigment, green, orange, yellow

What is dark pigment in a malignant melanoma called?

RPE Hyperplasia called melanoma bodies, black/pepper-like

Where does the green color come from in a malignant melanoma?

everything below the RPE that is pigmented will look green

When can yellow coloring (drusen) be a bad thing that indicates a malignant melanoma?

When drusen covers 1/2 or more of the lesion

What is an OCT good for in distinguishing melanomas?

Thickness and presence/absence of serous fluids

Is the Red free filter a reliable way to tell the difference between a nevus and a melanoma?

No, not a definitive way since both can grow into the RPE/retina

What study do we need to know about malignant melanomas?

Collaborative Ocular Melanoma Study (COMS)

What does the COMS study stand for?

Collaborative Ocular Melanoma Study

What percent of small melanomas grew in the COMS study?

25% grew over 2 year period

What percent of tumor-related mortality occurred in the COMS study for small melanomas?

6% total mortality

1% tumor-related mortality

What do the results of the small melanomas portion of the COMS study indicate?

That observing/watching a melanoma could be okay

Did the COMS study use an OCT for measurement of tumors?

No

What did the COMS study use to measure tumors?

Ophthalmoscopy, ultrasound, fluorescein angiography

What was the question being asked in the COMS study regarding medium melanomas?

Is irriadiation with iodine plaque (called brachytherapy) the same as enucleation?

What were the results of the COMS study regarding medium melanomas?

No significant difference in survival at 5 year follow up

What percent of tumor-related mortality occurred in the COMS study for medium melanomas?

20% all-cause mortality

10% tumor-related mortality after 5 years

What was the question being asked in the COMS study regarding large melanomas?

Would radiation before enucleation prevent metastasis?

What were the results of the COMS study regarding large melanomas?

No advantage to radiation prior to enucleation

What percent of tumor-related mortality occurred in the COMS study for large melanomas?

40% all-cause mortality

27% tumor-related mortality after 5 years

What is the prognosis of a melanoma if it is larger when discovered?

Larger it is, worse the prognosis is

How do the numbers change if you do not do any treatment with a melanoma?

The numbers for growth and mortality will hardly change

What is the most common cause of an isolated scar in the retina?

Toxoplasmosis

What is the #1 reason for an infectious chorioretinal scar?

Toxoplasmosis

What is toxoplasmosis?

Caused by an obligate intracellular protozoan parasite

What are the modes of transmission for toxoplasmosis?

Congenital, ingestion of feces or undercooked meat (unwashed vegetables, water-borne)