PANCE Blueprint EENT (7%)

Retinopathy (Lecture)

Patient will present as → a 64-year-old diabetic patient who is being seen for a routine health screening. On fundocopic exam, you see cotton wool spotshard exudatesblot and dot hemorrhagesneovascularizationflame hemorrhages, A/V nicking

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What lesions are characteristic of nonproliferative retinopathy?
Microaneurysms, dot and blot hemorrhages, hard exudates, and “cotton-wool” spots

Most common cause of new, permanent vision loss and/or blindness in 25-74-year-olds

Most common is diabetic retinopathy: damage to retinal blood vessels leads to retinal ischemia and edema. Excess sugar attaching to proteins such as the collagen of blood vessels (glycosylation) causes capillary wall breakdown.

  • Other types of retinopathy are divided by cause – Inflammatory or Infectious.
    • Inflammatory: Bechet's, Sarcoidosis, SLE, Giant cell arteritis, Polyarteritis nodosa
    • Infectious: Syphilis, Herpes simplex, Varicella Zoster, Toxo and CMV = HIV
Diabetic-Retinopathy-compare-internal

Cotton wool spots, hard exudates, blot and dot hemorrhages, neovascularization, flame hemorrhages

Diagnosis is by funduscopy

Treatment includes control of blood glucose and BP

  • Ocular treatments included retinal laser photocoagulation, intravitreal injection of antivascular endothelial growth factor drugs (eg, ranibizumabbevacizumab), intraocular corticosteroids, vitrectomy, or a combination.

Question 1
Which of the following is the most common cause of adult blindness in the USA?
A
Hypertension
B
Diabetes mellitus
C
Macular degeneration
Hint:
See B for explanation.
D
Retinal artery occlusion
Hint:
See B for explanation.
Question 1 Explanation: 
Diabetes is the leading cause of blindness in the US, and is usually due to diabetic retinopathy. Up to 15% of type 1 diabetics and up to 7% of type 2 diabetics become legally blind.
Question 2
Which of the following is considered a risk factor for retinopathy of prematurity?
A
maternal rubella infection
Hint:
While maternal rubella infection is a risk factor for ocular disease in the newborn, it is not a specific risk for retinopathy of prematurity.
B
maternal alcohol abuse
Hint:
Maternal alcohol abuse is associated with the development of fetal alcohol syndrome, which includes craniofacial abnormalities, but does not include increased risk for retinopathy of prematurity.
C
perinatal oxygen therapy
D
family history of retinal detachment
Hint:
If retinopathy of prematurity is not treated, retinal detachment may occur causing blindness. A family history of retinal detachment is not considered a risk factor for the development of retinopathy of prematurity.
Question 2 Explanation: 
Risk factors for retinopathy of prematurity include perinatal oxygen therapy, low birth weight, prematurity, and sepsis.
Question 3
In patients with diabetic retinopathy, what clinical intervention is most successful in preserving vision?
A
Panretinal laser photocoagulation
B
Iridectomy
Hint:
Iridectomy is of no value in preserving the retina and iridectomy is harmful in this situation due to the trauma it causes to the eye.
C
Radial keratotomy
Hint:
Radial keratotomy is indicated to correct myopia. This surgery destroys normal eye architecture and has no benefit in diabetic retinopathy.
D
Vitrectomy
Hint:
Vitrectomy is indicated for treatment of retinal tears and not to preserve an intact retina.
Question 3 Explanation: 
Panretinal laser photocoagulation is indicated for preservation of vision in patients with diabetic retinopathy.
Question 4
A patient with history of hypertension and dyslipidemia presents for routine follow up. On funduscopic examination you note moderate sized fluffy white lesions with irregular borders. This is most consistent with which of the following?
A
Drusen
Hint:
Drusen are tiny to small yellowish round spots with hard or soft edges that are often seen in age-related macular degeneration.
B
Cotton-wool patches
C
Hard exudates
Hint:
Hard exudates are yellowish bright lesions with well-defined borders. They are often small and round.
D
Preretinal hemorrhages
Hint:
Preretinal hemorrhages obscure the underlying retinal vessels and are seen as a horizontal line of demarcation with plasma above and cells below.
Question 4 Explanation: 
Cotton-wool patches are fluffy white or grayish ovoid lesions with irregular borders. They are typically moderate in size and seen in patients with hypertension.
Question 5
A 67 year-old African American male presents for a new patient evaluation. History reveals an aphasic CVA which limits his history. Funduscopic examination reveals an abnormal vessel light reflex described as a silver or copper- wire appearance. Where the vessels intersect, there appears to be some nicking. He has no carotid bruits, and his cardiac exam is normal. What is the most likely cause of his ocular findings?
A
Cytomegalovirus retinitis
Hint:
See C for explanation.
B
Diabetic retinopathy
Hint:
See C for explanation.
C
Hypertensive retinopathy
D
Sickle cell retinopathy
Hint:
See C for explanation.
Question 5 Explanation: 
Chronic hypertension accelerates the development of atherosclerosis. The retinal arterioles become more tortuous and narrow and develop abnormal light reflexes (silver-wiring and copper-wiring). There is increased venous compression at the retinal arteriovenous crossings (arterio-venous nicking), an important factor predisposing to branch retinal vein occlusion.
Question 6
You are counseling a newly diagnosed type 2 diabetic about the need for referral to ophthalmology for a dilated funduscopic exam. Which of the following best describes the rationale for referral?
A
He can wait until next year when he goes to get his refraction
Hint:
In type 2 diabetes, retinopathy is present in up to 20% of patients at diagnosis and may be the presenting feature. Eye examination for vision usually does not require a dilated eye exam, and refraction is not calculated with ophthalmoscope or direct visualization but by refractometer which does not examine the retina where retinopathy occurs.
B
He does not need to see an ophthalmologist if his Hemoglobin A1C is < 6.0
Hint:
See C for explanation.
C
Retinopathy is present in 20% of patient with type 2 Diabetes Mellitus at time of diagnosis
D
Your non-dilated exam can substitute for this referral
Hint:
See C for the explanation.
Question 6 Explanation: 
In type 2 diabetes, retinopathy is present in up to 20% of patients at diagnosis and may be the presenting feature.
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