a physician who studies and treats diseases of the veins is called a This is a topic that many people are looking for. savegooglewave.com is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, savegooglewave.com would like to introduce to you Retinal Vascular Disorders – CRASH! Medical Review Series. Following along are instructions in the video below:
Vascular disorders is going to be the topic of this lecture and by retinal vascular vascular disorders. Im referring to the central retinal artery occlusion and the central retinal occlusion. So you have a central retinal artery.
The retinal artery is is the first artery off of the internal carotid artery in most people. And thats going to branch into several branches. Smaller branches.
That then go off to different parts of the retina now if the entire set of retinal artery is blocked before it gives off tributaries branches. Then its considered a central retinal artery occlusion. If its just a branch.
Thats blocked that can cause symptoms. But that would be considered just a branch retinal artery occlusion and it works the same way with the veins. If the main vein.
Thats leaving the eye is blocked then its a central retinal vein occlusion. If its just a tributary of that vein. Then its a branch retinal vein occlusion.
So hopefully. That makes sense okay so the central retinal artery. Occlusion is an occlusion of the retinal artery is mentioned.
Its the first is the first artery coming off of the internal carotid and it presents as a sudden. Profound monocular loss of vision without pain or redness. So this is just like having a stroke to the eye.
And about one to two percent of patients will present with bilateral. Crio but thats pretty. Unusual the incidence is one in 10000.
And the average age of onset is in the 60s. So this is a disease of the elderly. However if you do see this in somebody whos in their 30s or 40s.
You should be highly suspicious of something like a thrombophilia in many cases. The patient will have a history of giant cell arteritis whether thats diagnosed or not diagnosed thats also called temporal arteritis and this is a big risk factor for central retinal artery occlusion. So that branch retinal artery occlusion.
As was mentioned. Im not going to spend a whole slide. Talking about it this is just a similar process due to similar causes.
But its a smaller clot and it affects a downstream vessel. And so it doesnt affect as much of the retina as a central retinal artery occlusion. So this is much further downstream.
And so it affects a smaller part of the retina and the symptoms will be similar. But it will only affect the part of the visual field that that obstructive segment supplied okay. So what are the risk factors hypercholesterolemia of course thats a risk factor for clogging obesity advanced age diabetes.
Mellitus and all of the all these three things hyper well maybe not hypercholesterolemia. But obesity and advanced age those are certainly those certainly play into diabetes mellitus. But just having diabetes mellitus by itself even if youre not obese.
And youre not advanced age that is a risk factor. 2. And then temporal arteritis is a big risk factor for artery occlusion and so what is temporal arteritis again.
I address this in a different lecture in the medical section. But temporal arteritis happens to people 55 years of age or older. It involves a headache scalp tenderness and thickening or tenderness of the superficial temporal artery.
You should be able to feel pulse over that artery and its right over the tempo. If you feel your own superficial temporal artery. You feel your tempo.
You should be able to palpate that artery patients with temporal arteritis. They usually have this this inflamed firm cord. And you cant feel the pulse.
Because the artery is so informed so what does this lead to especially the hypercholesterolemia. The obesity.
The diabetes and the fact of being old. Those all can lead to or increase your risk of carotid artery. Stenosis and of atrial fibrillation.
Because of small undetected heart attacks and those things carotid arteries. Too because youre gathering plaque and atrial fibrillation. Because you can develop a clot.
Because of a lack of a lack of appropriate contraction. Both of those things you can develop a clot or release. A clot or release.
A plaque and that can be the embolus thats needed that can go in to the end of the retinal artery and so this is how central retinal artery occlusion and if its a smaller plaque or a smaller clot thats how a branch retinal artery occlusion. Other risk factors. Include congenital or acquired thrombophilia.
You can acquire thrombophilia by taking birth control. Pills. And so those would be something you would look for in younger.
Patients who dont have these risk factors. And theres other risk factors in addition to these. But these are some of the most common that well see so that as mentioned this is painless.
Sudden and often this is a profound loss of vision 98 to 99 are monocular the symptoms are sudden loss of vision acuity is typically worse than 22. Hundred which is the cutoff point for being legally blind and a lot of times. They wont even be able to tell you how many fingers youre putting up in front of their face.
Even if you get really close there may be some preservation in the temporal field. Im assuming thats because there may be some additional there may be some additional circulation coming from somewhere else im not exactly sure. But the literature does say that there may be some preservation and temporal fields.
And that is certainly the case so some of the things youre going to want to know from the patient or at least know on the question. Thats going to help you with the diagnosis is how long of the symptoms been present usually when somebody loses their vision. Theyre going to get to the er as quickly as possible you also want to know if they have any past medical history of ocular problems.
Youll want to know if the patient has a high cholesterol as it you ask the patient better if you look in their charts. Do they have a history of diabetes certainly both of those would increase the risk of this being a central retinal artery. Occlusion.
And do they have any history of stroke or tiaa that would lead you to believe that perhaps theres by carotid artery. Stenosis and thats thats a big contributor to retinal artery occlusion. Now.
I just want to right now i differentiate central retinal artery occlusion from something else. Which is called amaurosis fugax and with amaurosis fugax. You get a temporary loss of vision.
It usually lasts. A few minutes and then your vision comes back with central retinal artery occlusion. You have a loss of vision.
And it stays at least until you get treated unphysical examination. You want to document their visual fields and then get their visual acuity. Even.
Though. Its probably going to be 20 200 or worse just to compare it to baseline and document it on the records look for signs of temporal arteritis especially in older patients. Because that contributes that strengthens your diagnosis.
You should also check their pupils for an afferent pupillary. Defect. Or the marcus gunn pupil auscultate for a carotid brewery and then oscillate to the heart for murmurs and especially in a regular beat.
Which can be consistent with atrial fibrillation for diagnosis. Youll want to get routine labs. And thats great.
But all patients with acute loss of vision. Should be referred to ophthalmology for a formal. Awful.
Mosca p. Highlighting the fact here that cr eo.
As in a lot of cases of vision loss cannot be diagnosed with a simple handheld ophthalmoscope. Youll need to do a dilated. A dilated exam.
And happy optometrist use their equipment. So findings consistent on indirect ophthalmoscope e. Consistent with cr eo includes.
No pallor. Which makes sense. Because its not getting enough blood.
A prominent cherry red macula and that is actually because the fovea. The macula gets its vascular ization elsewhere from the chorio capillaries and then attenuated arteries may be present as well as a boxcar appearance of veins. But what youre really going to notice is the the retinal pallor and the prominent cherry red macula.
So heres a normal posterior pole heres your optic disc and in the center. Here is your macula now the macula is red. But its a lot different in comparison than when we see the when we see the retinal artery occlusion.
So heres an example of a central retinal artery occlusion and as you can see theres pallor theater. This is much more pale. Now every ophthalmoscope uses slightly different lighting.
But you can see that theres a theres a much more contrast between the macula and the rest of the retina. Whereas here the macula. The retina werent as contrasted.
You also see that you dont have a whole lot of vasculature around the macula. Whereas on a normal visualization. You do have vasculature around macula.
So heres another one again. The macula is much more prominent that cherry ripe macula. See the same here.
Too. So this is a branch retinal artery occlusion. So you can see that its normal on the top here.
But its abnormal on the bottom. If there if the rest of the retina was like this on the bottom. Then youd have a central retinal artery occlusion.
You could youd be able to see this macula. Very distinguished from the rest of the retina. But its only distinguished from this retina here on the bottom.
Which is the diseased right now thats not getting enough blood. I think heres another one here above the above the macula. So the treatment.
The patient is going to need admission through opthamology. The treatment is going to be under the guidance of an ophthalmologist. So i dont expect ever youll be required to know how to do this or exactly how to treat them in the er or as an internist or even as a surgeon.
But you do need to know that they need to be admitted and its worth knowing some of the things that that ophthalmologists use so presently. Theres controversy in the exact management for patients with cr eo. But most ophthalmologists agree with some basic principles.
So high concentration inhaled 100. Percent. Oxygen.
Thats something you can start in the er. So thats something you should know iv acetazolamide. I think orrico steroids those are done the iv corticosteroids are done to reduce the inflammation and that is expected to help with maintaining vision reducing the inflammation and then treatment of the underlying costs as the internist.
This is going to be your concern finding and treating the underlying cause right some ophthalmologists use intra arterial thrombectomy lytx into the retinal artery system. Thats not a universal. But thats has been shown to be effective by the eagle study.
So you can look look more on that if you want. But high high concentration.
Inhaled oxygen acetazolamide corticosteroids and treatment of the underlying cause. So upon diagnosis. Its going to be your responsibility to work the patient up for underlying causes.
These dont just happen on their own. So. The patient will have something wrong with them that put them at predisposition all patients regardless of their age should get a carotid artery duplex ultrasound they should get an echocardiogram to look for atrial fibrillation or any other kind of abnormality valvular abnormalities that can gather clots and then and then release them they should get an ekg routine labs.
Thats usually done anyway when youre first investigating a patient a esr is useful and thats kind of to look more towards the temporal arteritis that would be elevated a fasting blood glucose is useful to work them up for diabetes. If they havent been diagnosed with diabetes and then coagulation studies. Younger patients or older patients who have normal results after this workup should get a workup for any kind of congenital or acquired thrombophilia.
So factor v. Leiden. Antithrombin.
3. Deficiency protein c. Deficiency.
Protein. S. Deficiency.
And so forth. Oh. And then elevated homocysteine.
That was another one. I like that up too. And thats another congenital thing.
Older patients should follow up regularly patients with cr eo have a 56 mortality rate. Within nine years and thats compared to 97 for sorry to 27 in aged matched. Patients who have never had cra o.
So thats thats a big deal when you think about it somebody whos older and has the same lets say you got two twins and one twin develops. A cra. Oh and the other twin doesnt that twin that develop the cre o.
Is two times more like to die. Within the next nine years and that shows that its likely due to the fact that theres some level of increased thrombosis. The plaque is not stabilized.
But its important to remember that patients who have cra. Oh really what this was was a stroke that just happened to go the right way rather than go up to the brain. It went to the retinal artery and so rather than having a debilitating or deadly stroke.
You just got your eye taken out. And i mean. Thats neither of those are good.
But this is the same pathologic process that causes a stroke. So its important the patients are aware that they are at imminent risk of stroke. And that you take interventions as necessary as if the patient had had a stroke.
Okay so central retinal vein occlusion is occlusion of the retinal vein. And this presents a little bit differently. So initially the patient will present with sudden monocular loss of vision without pain or redness.
But its usually not as severe as the central retinal artery occlusion. But this is a more progressive disease and the vision will worsen with time and eventually pain erythema and watering can develop so this is less severe usually when it presents but with time and when its diagnosed with time if its not treated it gets worse the symptoms have a tendency to be noticed on wakening. Im not sure why the lifetime incidence is 2 to 5 per 1000.
And 90 of cases are seen over the age of 50. So again. This has a preponderance in the elderly.
And theres a slight male preponderance. Oh. The equivalent branch retinal vein occlusion is a similar process.
But it affects a downstream vein. And so it does not affect as much of the retina and the ophthalmoscope findings will be local.
So when we look at what the phallus copic findings of central retinal vein occlusion are youre only going to find them in one part of the retina with the vr vos brb o.s are thought to be most commonly caused by a mechanical compression on the branch vein by an artery. But there are other possible causes systemic hypertension is considered the most significant major risk factor in vr videos.
So back on the crb os. Theyre very similar as far as risk factors go. But other risk factors with cr vo can include primary glaucoma probably because of the elevated pressure alcohol consumption head trauma and excessive physical activity symptoms include as mentioned progressive visual impairment the natural progression includes worsening of vision to the point of blindness pain photophobia redness and i watering all suspected cases of loss of vision as mentioned should be referred to an ophthalmologist or formal door indirect ophthalmoscope ii.
And the findings on ophthalmoscopy depend on how progressed. The cr vo is so typically with cr vo. We see a certain degree of optic disc swelling.
Theres going to be a certain amount of hemorrhages and you may see some tortuous veins but as it progresses youre going to see a more swelled. Optic disc youre going to see more and more and larger hemorrhages and a lot of times. The hemorrhages get in the way to where you cant see the veins.
It even if they are tortuous so ill show you some examples further tests to evaluate the cr vo include fluorescing and geography. When to do this test is at the discretion of the ophthalmologist. So here is a case of what would be considered early cr vo.
So the you can see theres some hemorrhaging here on these early veins and then you also have this tortuosity. This would be probably a little bit later. So youve got more hemorrhages here.
And this is much later. Too because the hemorrhages are much further out okay. So this is a branch retinal vein occlusion.
So you can see here that the veins and arteries are normal. But here you have this localized area of of hemorrhage. So this was found to be a branch retinal vein occlusion heres another one now just looking at the results of an ophthalmoscope isnt going to tell you what the disease is you always have to include it in the clinical picture of the patient.
Any radiologists would tell you that but with a patient with consistent symptoms. This is certainly. A branch retinal vein occlusion as is this so.
Patients with central retinal vein occlusions should be worked up for diabetes hyperlipidemia. So both of those are easy you can get them in the morning. Get a fasting blood glucose level get.
A lipid panel. They should also be worked up for thrombophilia markers. Such as factor v.
Leiden. Protein c. Etc and then be worked up for an elevated homocysteine for treatment.
Unfortunately. There is no available effective medical treatment for cr vo. Various treatment modalities are under investigation.
However and they may be performed by the ophthalmologists. Some patients can get enrolled in studies. But you wont be responsible for knowing any of this on the usmle.
Some of those modalities include introverted ministration of anti vegf inhibitors. So remember that vgf is a protein that stimulates angiogenesis and so this will reduce the development of more arteries. Which is the classic response when theres ischemia.
Theres also interval administration of corticosteroids to reduce some of the inflammation that invariably happens with this the use of locally injected. Tpa and then plasmapheresis complications. Include neovascular glaucoma.
Pan. Retinal photocoagulation can be performed either prophylactically in cr vo or as soon as theres signs of neovascularization and macular edema is another complication for that laser photocoagulation can be effective. But only if its due from b r.
Vo. It has not been shown to be effective cr. So.
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