Retinal Disorders

AMD (Age Related Macular Degeneration)

Clinical Pearls

Note

You will see Drusen in both forms of AMD
Drusen are yellow deposits of lipids and proteins and can be found all over the retina, not just in the macula
You can have Drusen in the absence of AMD, so it is the determination of the provider to say whether or not they have Dry AMD or not based on the presence of Drusen!

Dry AMD

The most common form of AMD (80% of people with AMD)
It occurs slowly and more gradual over many years
Must be monitored regularly as it can convert to Wet AMD!

Wet AMD (AKA: "Exudative" AMD)

Choroidal Neovascularization (CNV) is a hallmark here!
Abnormal vessels grow into the retina and leak fluid or hemorrhage (CNV)
Occurs very rapidly and will irreversibly damage your central vision
Treatment must be ASAP and will hopefully prevent any further progression, but will not reverse it!
Treatment is with VEGF inhibitor injections directly into the vitreous

Dry AMD

See the Drusen forming in the retina

Wet AMD

Notice the sub- retinal fluid accumulating beneath the macula due to active CNV!

Another example of Wet AMD

Wet AMD on Fluorescein Angiogram

We inject fluorescein dye into the patients bloodstream and look to see if it leaks out of the vessels
These blotches in the center of the image mean the dye has leaked out of the vessels, so is positive for Wet AMD!

Here is your vision with AMD!

This is an Amsler Grid
We give these to patients so they can monitor their Macular Degeneration at home, but they can also be done in the office

Retinal Detachment

Clinical Pearls

Patients will have a sudden loss of vision (partial or complete)
These are painless and can look like a "curtain" coming down over your vision
A patient with a detached retina can have 20/20 vision as long as the Macula is not affected!
Loss of vision is usually preceded by flashes and floaters
Loss of vision correlates opposite to what you see on the retina (see below)

Retinal Detachment as seen on an Optos

This is a detachment of the superior retina
Subsequently, the vision loss will be in the inferior visual field of OD as the light from here hits the superior part of the retina!

Where will the vision loss be here?????????

Where will the vision loss be here?????????

Macula on detachment

A Macula Off detachment!
This is the worst as the macula is involved
Central vision will be very poor with no improvement with the pinhole test!

Retinal Tears

Clinical Pearls

Retinal tears and retinal detachments go together like spaghetti and meatballs (or like R2D2 and C3PO)
If left untreated, retinal tears will almost certainly lead to a detachment!
Tears need to be sealed with an Argon laser immediately so as to not lead to a detachment

Horseshoe Retinal Tear with Detachment

Named because it looks like a horseshoe!

Posterior Vitreous Detachment (PVD) & Floaters

PVD occurs as part of the normal aging process
The vitreous can pull away from the back of the retina
It is possible to see some flashes & floaters with this

Here are examples of PVD

Vitreomacular Traction (VMT)

This occurs during PVD, where the vitreous does not completely separate from the retina
The part that is attached can pull on the retina and cause vision issues

ERM: Epiretinal Membrane ("Macular Pucker")

Clinical Pearls

An ERM is very thin membrane that can lay over the entire retina
It is usually caused by PVD. Sometimes when the vitreous pulls away from the retina, glial cells can migrate into the void and form this membrane
It can cause wrinkling on the retina and affect vision significantly
This membrane can be peeled off

Diabetic Retinopathy (NPDR & PDR)

NPDR

PDR (Neovascularization!)

Clinical Pearls

1) NPDR: Non- Proliferative Diabetic Retinopathy

This is the early stage of diabetic eye disease

You can see any of the following with NPDR:

Retinal microhemorrhage (AKA Flame hemorrhage)
Microaneurysms
Hard Exudates (fatty deposits in retina)
Cotton Wool Spots (nerve fiber layer damage)

2) PDR: Proliferative Diabetic Retinopathy

This is the more advanced stage of diabetic eye disease
The hallmark of this is seeing Neovascularization! This is similar to wet macular degeneration where new blood vessels grow into the retina and leak out fluid.
This can lead to retinal hemorrhage, diabetic macular edema, or also a detached retina!!

3) Hemoglobin A1c ("HbA1c" or "A1c")

This is one of the most important lab values in a diabetic patient. It is a measure of the percentage of glucose that is bound to hemoglobin in the blood over a 2-3 month period (the lifecycle of an Erythrocyte).
This essentially gives us a look at how well a patient's blood sugar has been controlled over this period.
Every person has a normal amount (less than 6.5%) but values above this are suspicious for type 2 Diabetes.

4) Fasting Blood Sugar (FBS)

This value is indicative of a person's blood glucose after an 8- 12 hour fast. This is usually done right in the morning before consuming anything.
Values above 100 mg/DL could indicate diabetes or pre- diabetes, but HbA1c is still the gold standard for monitoring a patient's diabetes.

Vitreous Hemorrhage

This is commonly seen in PDR it can progress to the point where it starts to bleed into the vitreous humor
Patients will have a sudden loss of vision
This usually completely blocks any light from reaching the retina, so vision will likely be very poor (CF, HM, or even LP)
It also makes getting a clear diagnostic image difficult to impossible

This is a patient with PDR. Notice the laser burns from a prior Pan Retinal Photocoagulation (PRP)
You can see how the fundus is visible for examination here

Here is the same patient 6 months later when he came in for an emergency exam due to sudden loss of vision in OS
He has suffered a vitreous hemorrhage!!
Vision in OS was very poor, and now looking at the fundus is near impossible due to the blood in the vitreous

Retinal Artery Occlusions (Think Stroke!)

CRAO: Central Retinal Artery Occlusion

Clinical Pearls of CRAO & BRAO

Essentially, the patient will have a sudden loss of vision in the affected eye with either partial loss of vision (BRAO) or the entire visual field (CRAO)
A patient suffering a retinal artery occlusion has literally suffered from an ischemic stroke, only that the blood clot has made its way to the eye, instead of the brain!
The ischemic area will look pale/white on a fundus photo
These patients needs to be sent to the emergency room IMMEDIATELY!

BRAO: Branch Retinal Artery Occlusion

Retinal Vein Occlusions

With any vein occlusion, you will see blood pooling in the retina
Think of it as clogging a drain. If the vein can't drain blood out of the retina, where does it go?

CRVO: Central Retinal Vein Occlusion

BRVO: Branch Retinal Vein Occlusion

BRVO on an OCT

BRVO

BRVO on AF setting

Macular Edema

There are two main types of Macular Edema

1) Diabetic Macular Edema (DME)

2) Cystoid Macular Edema (CME)

3) Other Causes: AMD, vein occlusions, medications such as Tamoxifen and Pioglitazone for type 2 diabetes

CME

DME

Myopic Degeneration

Clinical Pearls

In patients with higher degrees of Myopia (-6 diopters or more) , you will notice the retina is almost U- shaped as seen in the OCTs because remember, Myopic eyes have an elongated axial length
The retina can stretch in patients with these degrees of myopia, which can lead to degeneration and/or tears/detachment of the retina itself!!

Endophthalmitis

Clinical Pearls

Endophthalmitis is infection inside the eye
This almost exclusively occurs after a surgical procedure or intravitreal injection as there was a direct opening made to the inside of the eye
This is very serious and requires direct injection of antibiotics into the vitreous ASAP
It is imperative that a patient take their post- operative drops and proper disinfection protocols are followed before and after eye injection and/or surgeries to help prevent this!

Puss in the anterior chamber!

Plaquenil Retinopathy

Clinical Pearls

Plaquenil (Hydroxychloroquine) is an anti- inflammatory medication originally used for treating Malaria, but now is primarily used to treat many autoimmune diseases, but commonly Rheumatoid Arthritis and Systemic Lupus Erythematosus
Although retinopathy is rare, there is still a risk and should have a screening exam once per year
Initially, there will be subtle changes to the retinal pigmentary epithelium
If toxicity is present you will see a "bullseye maculopathy" in the retina

Bullseye Maculopathy

Plaquenil Workup

The areas circles in red are the responsibility of the technician

Tips

Plaquenil only comes in 200mg pills. If the patient says they are taking 50mg, they are wrong!
To simplify this, ask the patient how many pills they are taking per day

Choroidal Nevus/Melanoma

Remember, cancer can form in any living tissue, including the eye

Choroidal Nevus

Although benign, we keep an eye on these annually

Choroidal Melanoma

Treatments include laser and radiation therapy, but definitive treatment is removal of the entire eye (Enucleation)

Self Test

What is AMD?
What are the two types of AMD and the major differences between them?
A patient tells you that they heard Wet AMD is reversible if they use a certain type of eye drop. What do you think?
What are the symptoms of a retinal detachment?
What is an Epiretinal Membrane?
Explain what HbA1C is
Explain what FBS is
What are NPDR and PDR?
What is the main feature seen in PDR?
What is Hydroxychloroquine? What is another name for it?
A patient comes in for loss of vision in OD 2 days after receiving an injection for AMD. What is the most likely diagnosis?

11) What eye is this?

12) What is going on in the image?

13) Where will the vision loss be here?

14) What is this person glasses Rx most likely?

15) What is going on here?

**Expert Level Question**

A patient comes in to see BTK or SBD and you see this on the Optos.

16) What is the diagnosis?

17) After we finish the exam, what is the most appropriate next course of action for this patient?

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