Ocular Disease Final - Vitreous Flashcards

retinal detachment
Terms Definitions
T/F - It is rare to get a vitreous detachment from the vitreous base.
True - this is the strongest attachment of the vitreous (note this is different from a RETINAL detachment, which can occur at the vitreous base)
Where is the second strongest attachment of the vitreous?
ONH
Where does the vitreous attach at the ONH?
At the glial peripapillary ring (Gartner's or Vogt's ring)
T/F - The macular region has an area of vitreous attachment that gets stronger with age.
False - gets weaker with age
What kind of anomalous vitreo-retinal adhesion is a common site of retinal tears (horseshoe tears) particularly in PVD?
Lattice degeneration
What kind of anomalous vitreo-retinal adhesion involves significant inner retinal inflammation starting at the RNFL?
Toxoplasmosis scars (a chorioretinal scar)
T/F - Retinal vasculature is considered only a normal vitreo-retinal adhesion.
False - can be anomalous also
Name the various anomalous areas of vitreo-retinal adhesions.
Lattice degeneration, chorioretinal scars, retinal vasculature, meridional folds, granular tufts, tractional tufts, unusual posterior extensions of the vitreous base, rhegmatogenous RD
Where are the anomalous vitreo-retinal hemorrhages typically located?
Almost always in the equatorial region or further anteriorly
What is a rhegmatogenous RD associated with?
Related to retinal tears resulting from vitreoretinal traction
What is the most common symptom of vitreous disease?
Floaters
What causes white cells in the vitreous?
Uveal, vitreal, retinal, or ONH inflammation. Also iritis.
T/F - White cells in the vitreous typically go away after the associated inflammation has resolved.
False - remain for several months or years after inflammation has resolved
T/F - Pigment in the vitreous is pathognemonic for a PVD.
False - pathognemonic for a retinal tear; RPE is released into the vitreous (=Schafer's sign)
What is Schafer's sign?
Pigment in the vitreous
What can cause pigment in the vitreous?
Retinal tear, uveitis, intraocular surgery, trauma
You note pigment in the vitreous, but after careful examination using your BIO, you can't seem to find the cause. What is your course of action at that point?
Use scleral depression, if not found then 3-mirror lens, if not then consult with retinal specialist
RBCs in the vitreous is a likely sign of...
a retinal tear and/or RD
T/F - PVDs can cause floaters
True
What two types of floaters are typically associated with retinal tears?
Vitreous hemes, pigments in the vitreous
Flashes in both eyes suggest (neurovascular/ocular) origin.
Neurovascular (i.e. migraine, TIA)
Quick, bright sparks are characteristic of (vitreous traction/neurovascular) type flashes.
vitreous
Angular/zigzag flashes = vitreous traction or neurovascular?
neurovascular
Longer lasting flashes of light = vitreous traction or neurovascular?
neurovascular
Flashes while eyes closed = vitreous traction or neurovascular?
Can see flashes w/ eyes open or closed in both vitreous traction and neurovascular
Flashes more apparent in dark = vitreous traction or neurovascular?
vitreous traction
T/F - Neurovascular flashes are more obvious in the dark.
Neurovascular flashes are apparent in both dark and light
Head/eye movements elicit flashes = vitreous traction or neurovascular?
vitreous
T/F - Moore's lightning streak usually in temporal visual field.
True - nasal retina, temporal visual field
What percentage of pts w/ flashes and floaters involve retinal break?
10-34%
What percentage of sympomatic pts w/ retinal breaks progress to RD?
50% symptomatic pts (therefore 50% asymptomatic will lead to RD!)
T/F - Gartner's ring can result in a decrease in VA.
True - transient blur to clear
Can vitreal traction cause CME? How so?
CHRONIC vitreal traction on the macular region
What is Mittendorf's dot? How does it appear on retro view? On direct view?
Remnant of attachment of hyaloid artery to posterior lens capsule. Black dot on retro, white dot on direct.
What are the remnants of the hyaloid artery trapped within Cloquet's canal called?
Muscae volitantes.
T/F - Bergmeister's papilla is found on the anterior lens.
False - found on the posterior end of the hyaloid artery
What is a persistent hyaloid artery?
Persistent though nonfunctional hyaloid artery without fibrous components of primary vitreous; runs from ONH to lens at Mittendorf's dot
You see white fibrous projections jutting out of the ONH, and you suspect it is related to the hyaloid artery. What is this?
Posterior hyperplastic primary vitreous
You see a white fibrovascular mass just behind the pupil, and you suspect it is related to the hyaloid artery. It looks like as if the patient has leukocoria. What is this?
Anterior hyperplastic persistent hyperplastic primary vitreous
What characteristics are typically associated with anterior PHPV?
Microphthalmia, long ciliary processes, shallow AC, cataract, colobomas of uveal tract
How can anterior PHPV cause glaucoma?
1. Capsule rupture (angle closure, phacolytic glaucoma)2. Angle closure?
How do you Tx anterior PHPV?
Lensectomy
T/F - In X-linked retinoschisis, the retina split in two at the outer plexiform layer.
False - at the RNFL
You see spoke-wheel appearance at the macula with the retina split in two at the RNFL - this is characteristic of...
X-linked juvenile retinoschisis
Besides the retina split and the macular schisis, what characteristics are assoc w/ X-linked juvenile retinoschisis?
Peripheral retinal involvement, usually inferior temporal usually not extending to ora (50%), vitreous veils, viterous hemes, hyperopia, reduced B-wave, normal A-wave, slow progression, possible secondary RD
Depolymerization of hyaluronic acid, freely moving collagenous fibrils, and lacunae describe...
Normal liquefaction of the vitreous due to aging
Clumping of collagenous fibers in the mid-vitreous describes...
Syneresis
T/F - Lacunae contain collagenous fibers
False
T/F - You can observe the Tyndall effect in lacunae
False - no collagenase fibers therefore no effect
What is fibrillary degeneration?
Clinical appearance of frayed fragmented vitreous fibers due to liquefaction and syneresis
Where does the vitreous typically collapse first?
At the macula
Where does liquefaction have its greatest effect?
at the macula
Where does the break of the post-hyaloid membrane typically occur?
at the macula
What is a rhegmatogenous PVD?
Liquid vitreous moves behind the post-hyaloid face through the break; PVD is the primary cause of this in the elderly.
Over time, the vitreous fibers tend to...
contract towards the central vitreous
Where is the Ring of Gartner located?
ON the posterior hyaloid face, avulsed from ONH on PVD
What factors contribute to more rapid "aging" of the vitreous and earlier PVD?
Myopia, intraocular inflammation (e.g. uveitis), diabetes, vitreous heme, ocular trauma, surgery
What defines a PVD?
A detachment of the posterior hyaloid membrane from the retina
T/F - A PVD is normal and most people end up getting one.
True - it is a normal age-related change
Clinical PVD in __% in pts older than 50 y/o in phakic eyes; about __% with patients older than 60 y/o in phakic eyes.
50%, 66%
PVD in __% of aphakes.
93%
PVD in __% at age 50 in phakic eyes
53%
Photopsias in ___ to ___ of acute PVDs
1/3 to 1/2
Photopsias tend to be (unilateral/bilateral)?
Unilateral
T/F - Coalesced vitreous fibers, Gartner's ring, and vitreous hemes/pigments are the types of floaters associated with retinal tears.
False - Vitreous hemes and vireous pigments are associated with retinal tears - but all three are associated with PVD
Syneresis = gradual or acute
gradual
Your patient complains of a single floater that looks like a cobweb, and is very annoying - what do you suspect is the cause?
Gartner's ring
What is an important difference in the patient's complaints when DDx between Gartner's ring and vitreous hemes/pigment?
Vitreous hemes/pigment = numerous floaters
Vitreous hemes can occur in up to __% of acute PVD, some (__ to ___%) of these do not have retinal tears.
20, 10, 30
T/F - Visual fields cannot detect retinal tears.
True
If you see the posterior hyaloid membrane, you can pretty much say that your patient has...
a PVD
Where is the most common location of a retinal tear due to PVD?
Posterior edge of vitreous base
What are the types of retinal tears?
Operculated, Horseshoe
T/F - If operculum free of retina, you have a small chance of RD
True
Horseshoe tears are more common in what part of the retina?
Superior
What proportion of PVDs with a retinal tear will have a vitreous heme? What proportion will have Schafer's sign?
2/3, all
When does an RD occur after onset of Sx from a PVD?
6 months
What proportion of vitreous hemes occur without a retinal break?
1/3
Equatorial and oral dot and/or blot hemes suggest...
Continued vitreal traction
If you see equatorial and oral and/or blot hemes related to PVD, what course of action should you take?
Watch closely every month for subsequent retinal break until resolution of heme and symptoms of traction
T/F - Peripapillary hemes due to acute trauma of PVD is benign.
True, but must DDx vs other causes of intraretinal hemes
How soon do you re-evaluate a PVD patient with flashes?
1-3 months, until flashes have subsided; if many photopsias then 1-2 wk intervals until photopsias subsided and clear vitreous, no traction, tears, RD and acertain complete PVD
If your patient sees a shower of floaters but no break or cell apparent in vitreous, how often should your patient visit?
Weekly for 6 weeks
If you see a gross vitreous heme obscuring your view of a possible PVD/RD, what is indicated?
B-scan, bedrest w/ no exertion to allow settling for 2 days, then re-evaluate
If you see a horseshoe tear, what is the next step?
Retinal consult
If you see significant rim edema around an operculated tear with free operculum, what do you do next?
Retinal consult
T/F - PVD is likely to occur in the other eye if it happens to one eye.
True - must make patient aware of this
T/F - Asteroid hyalosis is mostly in middle aged individuals.
False - more in elderly
Asteroid hyalosis = unilateral or bilateral?
Usually unilateral (90%)
T/F - Intravitreal hemes tend to float around the vitreous.
False - tend to clot quickly and fixed in location
What happens after an intravitreal heme clots?
Dense fibrotic membranes form
How long does an intravitreal heme take to resolve?
Months to years
T/F - Retrovitreal posterior hemes tend to take months to resolve.
False - quicker resolution vs intravitreal hemes (retrovitreal = months)
What is characteristic of retrovitreal posterior hemes?
Behind posterior hyaloid membrane, bright red, boat shaped, shifts with shift in head position, quicker resolution
What are the causes of vitreous hemorrhages?
Tear in normal retinal vessel, rupture of neovascular BVs, increased BV pressure (arterial or venous), retinal angiomas
How can you get a good view of the fundus when you have a heme in the way?
Bedrest 24-48 hrs with slight head elevation to allow settling of hemorrhage
T/F - Preretinal membrane = Glial cell proliferation in the NFL at the macula.
False - at the ILM
T/F - Preretinal membrane can affect VA.
True - can distort macular architecture, can also have metamorphopsia (rare)
You see a glistening, irregular reflection off the ILM in the macular region with your DO. You also see retinal striae. What do you suspect?
Epiretinal membrane
Don't forget about the review questions at the end of the vitreous section!
Just a reminder
Most common location of a retinal tear due to PVD?
Posterior edge of vitreous base
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