PANCE Blueprint EENT (7%)

Retinal disorders (PEARLS)

NCCPA™ PANCE EENT Content Blueprint eye disorders ⇒ retinal disorders

osmosis Osmosis
Macular degeneration
Patient will present as → a 62-year-old male who arrives for his follow-up visit for chronic central visual loss. He describes a phenomenon of wavy or distorted vision that has deteriorated rather quickly. The patient is frustrated because he “just can’t drive anymore” and he is “having difficulty seeing words when he reads.” When looking at a specific region of the Amsler grid, he reports a dark “spot” in the center, with bent lines. On the fundoscopic exam, you note areas of retinal depigmentation along with the presence of yellow retinal deposits

Gradual painless loss of central vision. The macula is responsible for central visual acuity which is why macular degeneration causes gradual central field loss.

  • Metamorphopsia (distortion on Amsler grid)
  • Dry macular degeneration (85% of cases): atrophic changes with age – a slow gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY) = yellow retinal deposits.
  • Wet macular degeneration: an advanced form of dry age-related macular degeneration. New blood vessels growing beneath the retina (neovascularization) leak blood and fluid, damaging the retinal cells. These small hemorrhages usually result in rapid and severe vision loss

DX: funduscopic findings are diagnostic; color photographs, fluorescein angiography, and optical coherence tomography assist in confirming the diagnosis and in directing treatment.

TX:

Wet age-related macular degeneration

  • VEGF inhibitors (e.g., bevacizumab)
  • Photodynamic therapy
  • Zinc and antioxidant vitamins

Dry age-related macular degeneration

  • Zinc and antioxidant vitamin
Retinal detachment
Patient will present as → a 65-year-old man complaining of a sudden unilateral vision loss which he describes as “a curtain or dark cloud lowering over my eye.” This was preceded by small moving flashing lights, and floaters. The fundoscopic exam reveals a detached superior retina.

Separation of the retina from the pigmented epithelial layer causing the detached tissue to appear as a flap in the vitreous humor

  • Can occur spontaneously or secondary to trauma or extreme myopia
  • Vertical curtain coming down (curtain of darkness) across the field of vision may sense floaters or flashes at the onset, loss of vision over several hours (acute and painless)
  • Myopia (nearsightedness) is a risk factor for the development of retinal detachment
  • Retinal detachment usually presents with defects in the peripheral visual field

DX: is by fundoscopy

  • Retinal detachment is visualized on fundoscopy as crinkling of retinal tissue and changes in vessel direction
  • Ultrasonography may help determine the presence and type of retinal detachment if it cannot be seen with funduscopy

TX: Retinal detachment is an ophthalmologic emergency

  • Stay supine (lying face upward) with head turned towards the side of the detached retina
  • Consult ophthalmologist
  • Pneumatic retinopexy is a procedure for the management of retinal detachment that involves cryoretinopexy followed by injection of an air bubble in the vitreous
Retinopathy
Patient will present as → a 64-year-old diabetic patient who is being seen for a routine health screening. On fundoscopic exam, you see cotton wool spotshard exudatesblot and dot hemorrhagesneovascularizationflame hemorrhages, A/V nicking

Caused by systemic disorders, including diabetes, hypertension, preeclampsia-eclampsia, blood dyscrasias, and HIV disease -may affect the retina

  • Diabetic retinopathy falls into two main classes: nonproliferative (early) and proliferative (late, advanced)
  • Prolonged hyperglycemia causes basement membrane thickening, decreased pericytes (hyperproliferation), microaneurysms, and neovascularization
  • Leading cause of blindness in adults

Nonproliferative type (an early form of the disease)

Proliferative type (most severe, abnormal blood vessel growth)

  • Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease
  • At this stage, circulation problems deprive the retina of oxygen. As a result new, fragile blood vessels can begin to grow in the retina and into the vitreous. The new blood vessels may leak blood into the vitreous, clouding vision
  • Fundoscopic exam (abnormal growth of vessels) neovascularization

TX:  control of blood glucose and BP

  • Ocular treatments: retinal laser photocoagulation, intravitreal injection of antivascular endothelial growth factor drugs (eg, ranibizumab, bevacizumab), intraocular corticosteroids, vitrectomy, or a combination
  • If diabetic get yearly dilated ophthalmoscopic examination
Orbital cellulitis (ReelDx) (Prev Lesson)
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