Physical Diagnosis I Exam 3 (Part 3) - ABN Findings of the Inner Eye

Normally, the red eye reflex should be symmetrical and red, but if there is no red eye reflex in one eye, what could this indicate?

Retinal detachment

What is Leukocoria? What red flag does this indicate?

White-eye reflex

- Retinoblastoma!

NOTE: can also be caused by Retinopathy of Prematurity (ROP), Cataracts, strabismus

T/F: Certain angles in flash photography create a pseudo-leukocoria

TRUE

What condition is when the retinal tissue pulls away form the oxygenated blood vessel that supplies it, and is considered an emergency because if left untreated, it leads to vision loss, with symptoms such as absent red eye reflex, blurred vision, sudden floaters, flashes of light (photopsia), gradual reduced peripheral vision, curtain-like shadow across visual field??

Retinal Detachment

What are some risk factors for Retinal detachment?

Aging

Previous retinal detachment

Family history

Extreme myopia

Poor eye surgery/injury/disease

What type of Retinal Detachment is the MC, caused by a hole or tear in the retina and is most commonly seen in older populations as a complication of posterior vitreous detachment (POV) which causes the retinal tear?

Rhegmatogenous

What type of Retinal Detachment is scar tissue on the retina, seen in patients with uncontrolled diabetes?

Tractional

What type of Retinal Detachment is fluid accumulation beneath the retina, seen in patients with age-related macular degeneration or eye tumors/injuries/inflammation?

Exudative

What is an idiopathic, rare, mostly benign congenital anomaly where the retinal nerve fibers anterior to the lamina cribrosa have a myelin sheath, lading to white, sharply demarcated patches on the surface of the retina, obscuring underlying retinal vessels with rayed or feathered borders?

Myelinated Retinal Nerve Fibers

What condition is when the optic disc swells from increased intracranial pressure, with a distinct champagne cork appearance, and can be caused by inflammation of the brain/coverings, brain/spinal cord tumor, extremely high BP, brain bleed, blood clot/venous problem, pus from brain infection, cranial/cord fluid volume/flow problem, or taking/stopping some medications?

Papilledema

What condition is enlargement of the cup-to-disc ratio with blurred vision, reduced visual acuity, reduced peripheral vision, and reduced color vision/sharpness?

Optic Disc Cupping (ODC; Optic Nerve Cupping)

For the cup to disc ratio (C:D), which part is the cup (color and where), and which part is the disc? What should the ratio be?

Cup = yellow within disc

Disc = orange surrounding cup

C:D = 1:2

(Disc should be 2x as big as Cup)

What are 4 possible causes of Optic Disc Cupping (ODC; Optic Nerve Cupping)?

1) Glaucoma

2) Optic Neuritis

3) Optic Nerve Atrophy

4) Optic Nerve Head Drusen

If Optic Disc Cupping (ODC; Optic Nerve Cupping) is caused by Glaucoma, how is it treated? Optic Nerve Drusen? Optic Neuritis?

Glaucoma = eye drops, oral medication, surgical problems

Optic nerve drusen = intraocular pressure-lowering medication

Optic neuritis = prescription steroids (halt progress)

What is one form of Optic Disc Cupping (ODC; Optic Nerve Cupping) that is often the go-to diagnosis when discovered, is regularly misdiagnosed, and the leading cause of blindness?

Glaucomatous Cupping

What is the early warning sign of Glaucomatous Cupping?

Abnormally high intraocular pressure

How do you prevent glaucomatous cupping misdiagnosis? What is a hallmark sign of non-glaucomatous OCD?

Take a thorough history and look at the details surrounding the case

-- hallmark sign = Optic Disc Pallor

What condition is bleeding in the retina, commonly asymptomatic but can cause marked, rapid changes in vision, flashes/floaters, dark patches, or blind spots, is common unilaterally but possible bilaterally, and most common in those >40 years old?

Retinal Hemorrhage

What type of hemorrhage is a lesion of the retinal tissue?

Intraretinal (dot-and-blot)

What type of hemorrhage is nerve cells connecting optic nerve to retina?

Retinal Nerve Fiber Layer (flame, disc, Drance)

What type of hemorrhage is a lesion of the membrane separating retina from vitreous cavity ?

Preretinal (boat shaped; D-shaped)

What type of hemorrhage is bleeding into the vitreous cavity & fluid?

Vitreous

What are 6 major trauma/vascular disease/autoimmune disease causes of Hemorrhage? (TQ)

1) Eye injuries

2) High cholesterol (hyperlipidemia)

3) High BP (HTN)

4) Atherosclerosis

5) Diabetes

6) Macular Degeneration

What are white/pale ischemic-infarct spots on the retina, that are asymptomatic unless large and/or near the fovea?

Soft Retinal Exudate (Cotton Wool Spots/bodies(

What are the top 2 risk factors for Cotton Wool Spots/bodies (Soft Exudate)?

1) HTN

2) Diabetes Mellitus

What are yellow spots composed of lipids and protein, located beneath the retina, generally benign and MC in patients >60 years old, and can be asymptomatic but with enough spots can cause dim/cloudy vision, difficulty transitioning form bright to dim light, or blank/blurry spot in central vision?

Drusen Bodies

Larger drusen bodies increase the risk for or can be a sign of what?

Age-related macular degeneration

(90% related to Dry Macular Degeneration)

What are some risk factors for Drusen Bodies?

Caucasian

>60

Family Hx

Smoking

High BP

Obesity

High cholesterol

What are smaller/yellow collection of lipids within the retina due to a leak from damaged retinal capillaries?

Retinal (Hard) Exudate

Hard Retinal Exudate is commonly seen with what condition?

Diabetic Retinopathy

How is Hard Retinal Exudate distinguished form Drusen Bodies?

Using OCT test (optical coherence tomography)

(NOTE: Retinal (Hard) Exudate = within retina; Drusen = beneath retina)

What is a crescent moon-shaped feature generally forming at the lateral margin of the optic disc, with grey or darker pigmented region and caused by weakening of the retinal tissue, exposing the pigmented choroid beneath?

Choroidal Crescent (Myopic Crescent)

What are benign, normal fundus with highly pigmented choroid epithelium, visualized between choroid vessels, and associated with better visual acuity and lower rate of myopic maculopathy, and described as leopard, tigroid, or mosaic?

Tessellated Retina

What is a benign, asymptomatic pigmented fundus abnormality that is generally detected as incidental findings of fundal exam on the periphery of the retina?

CHRPE (Congenital Hypertrophy of the Retinal Pigment Epitheliopathy)

What type of CHRPE (Congenital Hypertrophy of the Retinal Pigment Epitheliopathy) is single, flat, hyperpigmented region of the retina?

Solitary CHRPE

What type of CHRPE (Congenital Hypertrophy of the Retinal Pigment Epitheliopathy) are multiple (up to 30), grouped, flat, hyperpigmented regions of retina with a bear tracks appearance?

Grouped CHRPE

What type of CHRPE (Congenital Hypertrophy of the Retinal Pigment Epitheliopathy) is associated with familial adenomatous polyposis (FAP) as well as Gardner and Turcot Syndromes (autosomal dominant cancer syndromes)?

Atypical CHRPE

CHRPE (Congenital Hypertrophy of the Retinal Pigment Epitheliopathy) is sometimes mistaken for what condition?

Retinal Melanoma

What is cancer of the eye, with early stages asymptomatic and later stages causing visual deficit, sensation of flashes/floaters, growing dark spot in iris, change in pupil size, poor/blurry vision in one eye, or loss of peripheral vision/

Ocular Melanoma

What is the MC location for an ocular melanoma to occur in the eye?

Posterior Uvea/Choroid

NOTE: MC affect the middle layer of the eye (uvea, iris, ciliary body, choroid)

What are risk factors for Ocular melanoma?What a

Light eyes

Caucasian

Increased age

UV radiation

Genetic mutations

Certain Skin Disorder

What is the autosomal recessive disorder in which the genetic defects cause cell death predominantly in the rod photoreceptors, with early symptoms such as night blindness/tunnel vision, late symptoms such as vision loss/blindness, and also photosensitivity and reduced color vision?

Retinitis Pigmentosa

What is a distinctive feature of Retinitis Pigmentosa?

Optic atrophy w/ waxy pallor, narrowed arterioles, and peripheral black "bone spicule" pigmentation

What two conditions is Retinitis Pigmentosa associated with?

1) Usher syndrome (deafness)

2) Kearns-Sayre Syndrome (mitochondrial cardiac conduction defect)

NOTE: also extraocular muscle dysfunction

T/F: The blue filter is used to visualize Retinitis Pigmentosa

FALSE

Red-free (Green) filter

What condition appears as creamy white retinal vessels in the presence of excessively high serum TG levels and in hyperlipidemic states, with symptoms such as elevated serum TG but normal vision?

Lipidemia Retinalis

At what TG level does Lipidemia Retinalis occur?

When TG exceeds 2000 mg/dL

In Grade I of Lipidemia Retinalis, its a white/creamy appearance of _____________- retinal vessels.

In Grade II of Lipidemia Retinalis, its white/creamy appearance extending towards __________.

In Grade III of Lipidemia Retinalis, the retina appears ___________ with the milky vessel appearance

Peripheral

Optic Disc

Light (Salmon-colored)

T/F: In Lipidemia Retinalis, the vessel appearance will improve once TGs are lowered

TRUE

What is an inflammatory process involving the choroid and retina with pain, worsening vision, floaters, photophobia, sharply defined lesion with demarcated boarders, strippled whitish-yellow with darkened edges and a scar appearance, and a visual field deficit when large?

Chorioretinal Inflammation (Chorioretinitis)

NOTE: do NOT confuse with the feathery margins of the retinal nerve myelination

What is the MC cause of Chorioretinal Inflammation (Chorioretinitis)? What are some other distinctive causes?

Diabetic retinopathy laser therapy

Other = Histoplasmosis, CMV, Toxoplasmosis (cat litter box)

What are some risks of Chorioretinitis?

Laser surgery

Cleaning cat litter box

What condition is when high BP damages the layer of tissue at the back of the eyeball (Retina)?

Hypertensive Retinopathy

What are the 2 major symptoms of Grade 1 Hypertensive Retinopathy?

1) Subtle changes

2) Arteriole narrowing

What are the 2 major symptoms of Grade 2 Hypertensive Retinopathy, in addition to Grade 1 symptoms?

1) Focal narrowing

2) Compressed venules at arteriovenous crossing (AV nipping)

What are the 3 major symptoms of Grade 3 Hypertensive Retinopathy, in addition to Grade 1 & 2 symptoms?

1) Hemorrhage

2) Hard Exudate

3) Cotton wool

NOTE: similar to diabetic neuropathy (except chronic HTN)

What are the 5 major symptoms of Grade 4 Hypertensive Retinopathy, in addition to Grades 1-3 symptoms?

1) Optic Disc Swelling

2) Headache

3) eye pain

4) Reduced visual acuity

5) Neurological focal deficits

What condition has dot hemorrhages, microaneurysms and/or the presence of hard or soft exudates in someone with diabetes, often asymptomatic in initial stages, eventually leads to blurred vision, distortion, and/or loss of visual acuity?

Non-Proliferative Diabetic Retinopathy

What condition has the characteristic of growth/developing of new/erratic blood vessels as a result of anoxic stimulation (rat nest appearance) in someone with diabetes, asymptomatic in early stages but eventually leads to blurred vision, floaters, and/or loss of visual acuity with seen obstruction of the retina by vitreous hemorrhage?

Proliferative Diabetic Retinopathy

What are the 4 hallmark signs of Non-Proliferative Diabetic Retinopathy?

1) Hard exudate

2) Cotton Wool Spots (soft exudates)

3) Dot hemorrhages

4) Microaneurysms

What is the Hallmark sign of Proliferative Diabetic Retinopathy?

Development of NEW VESSELS that grow out of retina toward vitreous humor due to ANOXIC STIMULATION

The new vessels in proliferative diabetic retinopathy lack supporting structures and are weak, so they are prone to ____________, with this leading to the major cause of blindness in patients with ___________.

Hemorrhage

Diabetes

T/F: In Proliferative Diabetic Neuropathy new vessels may occur in the peripheral retina, but avoid the optic nerve

FALSE

may occur in peripheral retina or on optic nerve

What is a rare, inherited or genetic mutation based embryonal malignant tumor arising form the retina with signs such as white eye reflex, ill defined mass rising from retina w/ chalky white calcification, eyes appearing to look in different directions, poor vision, and eye redness/swelling?

Retinoblastoma

What is the MC age that Retinoblastoma affects?

Children w/in first 2 years of life

What is a disruption of normal progression of retinal vascular development in preterm infants, with the abnormal straight proliferation of blood vessels laterally/temporally, with anemia, poor weight gain, blood transfusion, respiratory distress/breathing difficulties, failure to thrive, refractive error, amblyopia, or progressive retinal detachment/blindness?

Retinopathy of prematurity

Who is MC affected by Retinopathy of prematurity?

Younger and smaller pre-term infants

What is abnormal bleeding of the retinal blood vessels, occurring MC in infant victims of shaken baby syndrome, with altered responsiveness without good explanation (suspicion of physical abuse) and many retinal hemorrhages?

Retinal hemorrhages in infancy

NOTE: other causes may be HTN, bleeding issues/leukemia, meningitis/sepsis/endocarditis, vasculitis, retinal disease, anemia, hypoxia/hypotension

In the older population, ________ production naturally decreases over time. When lacrimal gland begin to involute, the eyelashes will turn in and has _________ effect on tear production. When the lacrimal gland evolutes, it will have ___________ effect on tear production.

Tear production

No effect (normal; but has rubbing of eyelashes leading to corneal abraisions)

Decreased effect (leading to dry eye)

What are the 3 most common causes of decreased visual function in the elderly?

1) Glaucoma

2) Cataracts

3) Macular Degeneration

What is disease of the optic nerve resulting form increased intraocular pressure, where nerve cell die, producing characteristic cupped appearance of the optic nerve (increased cupping), making the inner disc disproportionally larger than normal when compared to the outer disc?

Glaucoma

What type of Glaucoma is slow and progressive, initially asymptomatic and progressing slowly, but in advanced cases can lead to reduced peripheral vision (tunnelling), with risk factors such as family history, sleep apnea, BP meds, diabetes, chronic anemia, systemic meds, carotid disease, phosphodiesterase inhibitor, low CSF pressure?

Open Angle Glaucoma

What type of Glaucoma is rapid and severe with painful, blurry vision, and very high intraocular pressure that damages the optic nerve?

Acute Angle Glaucoma

What is opacities in the lens, with cloudy lens/blurred vision, faded color, light appears too bright, halo around lights, poor night vision, double vision, and frequent eye reaction changes?

Cataracts

What type of Cataracts is commonly advanced age-related, from denatured lens protein?

Central Opacity

What age-related condition is degeneration of macular tissue?

Macular Degeneration (Age-Related Macular Degeneration; AMD; ARMD)

What type of Macular Degeneration (Age-Related Macular Degeneration; AMD; ARMD) causes slow progression, blurry vision/vision loss, and is due to thinning of the macula?

Dry (Atrophic)

What type of Macular Degeneration (Age-Related Macular Degeneration; AMD; ARMD) causes rapid development of blurry vision or "blind spot" in field of vision, due to blood vessels breaking, bleeding, or leaking into macula?

Wet (exudative)

What is the leading cause of legal blindness in people older than 55 years old in the United States?

Macular Degeneration