PANCE Blueprint EENT (7%)

Vascular disorders (PEARLS)

The NCCPA™ PANCE EENT Content Blueprint => disorders of the eye => vascular disorders

Retinal vascular occlusion
Patient will present as → a 74-year-old man with sudden vision loss in his right eye. He has a medical history of hypertension, coronary artery disease, and new-onset atrial fibrillation. On physical exam, a carotid bruit is auscultated. His visual acuity is light perception. Confrontational visual fields reveal a dense scotoma, and a penlight examination shows an afferent pupillary defectDilated funduscopic examination shows retinal whitening with a cherry-red spot in the fovea.

Central retinal artery occlusion (cherry-red spot, ischemic retina)

  • Flow-through CRA occluded
  • Atherosclerotic thrombosis, embolism from the same side (ipsilateral) carotid artery, ophthalmic artery, and heart, or giant cell arteritis
  • Sudden, painless, unilateral, and usually severe vision loss (Amaurosis fugax)

DX: Fundoscopy

  • Look for perifoveal atrophy (cherry-red spot) and pale opaque fundus with red fovea and arterial attenuation
    • Arteriolar narrowing, separation of arterial flow, retinal edema, and ganglionic death lead to optic atrophy and pale retina
  • Rule out carotid artery stenosis by carotid ultrasound

TX: Emergent ophthalmologic consult - Immediate treatment is indicated if occlusion occurs within 24 hours of presentation

  • Reduction of intraocular pressure with ocular hypotensive drugs (e.g., topical timolol 0.5%, acetazolamide 500 mg IV or PO)
  • Intermittent digital message over the closed eyelid or anterior chamber paracentesis
  • If patients present within the first few hours of occlusion, some centers catheterize the carotid/ophthalmic artery and selectively inject thrombolytic drugs
  • Workup and management of atherosclerotic disease
  • Irreversible damage to the retina after 90 min; Poor prognosis

Patient will present as → a 65-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department complaining of unilateral sudden, painless vision loss in his right eye that started 2 hours ago. On examination, his visual acuity in the right eye is 20/200, and fundoscopy reveals retinal hemorrhages, dilated and tortuous retinal veins, and cotton-wool spots. There is no evidence of neovascularization.

Central retinal vein occlusion (blood and thunder fundus)

  • Sudden, painless, unilateral vision loss. Blurred vision or complete visual loss
  • Most common in ages 50+, associated with HTN, primary open-angle glaucoma (POAG), diabetes, hyperlipidemia, hyperviscosity states (polycythemia, leukemia)
  • Usually occurs secondary to a thrombotic event

DX: Funduscopy: retinal hemorrhages in all quadrants, optic disc swelling; blood and thunder retina (dilated veins, hemorrhages, edema, exudates)

TX: vision resolves with time (partially); workup for thrombosis

  • Neovascularization treated with intravitreal injection of VEGF inhibitors

Hyphema (ReelDx + Lecture) (Prev Lesson)
(Next Lesson) Retinal vascular occlusion (Lecture)
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