Questions and Answers
What is the primary cause of Presumed Ocular Histoplasmosis Syndrome (POHS)?
Which symptom is commonly associated with maculopathy in POHS patients?
Which of the following are classic characteristics of POHS?
What age range is most commonly affected by macular involvement in POHS?
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How do Histo spots typically appear in patients with POHS?
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Which stage of maculopathy is characterized by a pigment nodule with overlying serous detachment?
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At what percentage do POHS patients develop Choroidal Neovascularization (CNVM) if one eye is affected?
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Which characteristic of peripapillary atrophy is true regarding its extension?
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What is the percentage increase in the rate of fetal infection during the third trimester compared to the first trimester?
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What is the most common cause of retinitis in otherwise healthy individuals?
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Which symptom is absent in Toxoplasma retinitis?
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In patients with compromised immune status, how do the presentations of Toxoplasma retinitis differ?
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What clinical feature would most likely appear adjacent to an old scar in Toxoplasma retinitis?
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What indicates that the retinitis has healed in an uncompromised host?
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Which sign is associated with Toxoplasma retinitis?
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What visual defect can results from indirect involvement in eyes affected by Toxoplasma?
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What does hyperpigmentation in the context of CNVM indicate?
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Which of the following genetic markers is linked to a predisposition for the ocular condition described?
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Which diagnostic test is least likely to provide value in typical cases?
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What is a significant risk factor for maculopathy in patients with atrophic scars?
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Which of the following routes is NOT a typical way of infection for Toxoplasma gondii?
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Which symptom is NOT typically associated with the clinical course of the ocular condition discussed?
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What kind of management is recommended for patients at risk of the ocular condition?
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Which test is used for measuring vision changes related to the ocular condition?
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Which of the following treatments is employed for ocular toxoplasmosis?
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What is the primary ocular sign of congenital rubella syndrome?
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Which condition is most likely to present with leukocoria and strabismus in young children?
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Which ocular feature is associated with sarcoidosis?
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What is a common manifestation of ocular toxocariasis?
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What is the test of choice for diagnosing toxocariasis?
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In tuberculosis, which ocular feature typically resembles sarcoidosis?
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What is a significant factor in the risk of ocular toxocariasis in young children?
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What ocular condition is characterized by the presence of candle-wax drippings?
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Which of the following is true about the systemic features of congenital rubella syndrome?
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What is the main etiology of syphilis?
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What is often observed in patients with sarcoidosis who present with uveitis?
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Which medication is specifically noted as useful in treating tuberculosis-related ocular issues?
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What is the common visual outcome associated with chronic endophthalmitis?
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What is a key educational point for expectant mothers to prevent toxoplasmosis?
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Which virus is most commonly associated with Acute Retinal Necrosis in younger patients?
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What is a common symptom of Multiple Evanescent White-Dot Syndrome (MEWDS)?
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What feature distinguishes Serpiginous Choroidopathy?
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What is a characteristic finding in Birdshot Retinochoroidopathy?
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Which finding is NOT associated with Acute Retinal Necrosis Syndrome?
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What is the typical demographic affected by Punctate Inner Choroidopathy (PIC)?
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What is the prognosis for patients with Acute Multifocal Placoid Pigment Epitheliopathy (AMPPE)?
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Which syndrome involves periphlebitis and can affect the retina acutely?
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How are herpetic retinopathies classified based on immune status?
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Which treatment is most commonly indicated for Acute Retinal Necrosis Syndrome?
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What is a typical course of vision recovery in Multiple Evanescent White-Dot Syndrome (MEWDS)?
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Which of the following is associated with a poor prognosis when untreated?
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What type of vision symptom is NOT typically reported in Punctate Inner Choroidopathy (PIC)?
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Study Notes
Traumatic Injury
- Fibrin membrane can result from traumatic ocular injury.
- Retinal dialysis involves separation of the retina from the underlying tissue.
Presumed Ocular Histoplasmosis Syndrome (POHS)
- Caused by Histoplasma capsulatum, a fungus typically inhaled via spores.
- Associated with exposure to chickens or pigeons; prevalent in the Histo Belt: Ohio & Mississippi River valleys.
- Maculopathy is six times more common in whites vs. blacks, typically manifests between ages 20-50, often asymptomatic unless severe.
- Classic triad of POHS: peripheral atrophic histo spots, peripapillary atrophy, and maculopathy, with at least two present for diagnosis.
Symptoms of POHS
- Blurred vision, painless.
- Metamorphopsia and micropsia may occur.
- Many patients may remain asymptomatic.
Peripapillary Atrophy
- Diffuse circumferential choroidal atrophy around the optic disc.
- Rarely focal; may extend beyond disc margin.
Histo Spots
- Appears as yellowish-white, punched-out lesions between 0.2 and 0.7 DD in size.
- May show pigment clumps at the margins; bilateral findings seen in approximately 60% of cases.
Maculopathy Stages
- Stage I: Active choroiditis near the macula presents as a fluffy yellow-white focus.
- Stage II: Features green/black pigment nodules with serous detachment.
- Stage III: Includes exudative detachment, severe vision reduction, and various hemorrhagic signs.
Choroidal Neovascularization (CNVM)
- Late manifestation of POHS; common in ages 20-45; more frequent in men.
- High chance of bilateral macular involvement if one eye is affected.
- CNVM may stem from old macular scars or histo spots.
Diagnosis of POHS
- Primarily clinical, based on characteristic signs.
- Genetics (linked to HLA-B7 and HLA-DRw2) may play a role.
- Imaging used to assess active maculopathy includes IVFA and OCT.
Management Strategies
- Education for at-risk patients.
- Regular vision monitoring, particularly for those with histo spots near the macula.
- Antifungals are ineffective, while oral steroids may be considered in early cases.
Signs of Recurrence
- New hypopigmentation near scar edges or subretinal fluid/blood.
Differentiating POHS From Other Conditions
- Differential diagnoses include age-related macular degeneration (ARMD), degenerative myopia, angioid streaks, and choroidal ruptures.
Toxoplasmosis
- Leading cause of posterior uveitis, accounting for 30-50% of cases in the USA.
- Caused by the protozoan Toxoplasma gondii, with cats as primary hosts.
- Infection routes include undercooked meat, contaminated soil, and transplacental transmission during pregnancy.
Diagnostic Testing for Toxoplasmosis
- Serology tests (IFA, ELISA, Sabin-Feldman dye test) and PCR of ocular fluids.
Congenital Toxoplasmosis
- Maternal infection can lead to severe fetal complications including retinochoroiditis and hydrocephalus.
- Usually subclinical; manifestations may include chorioretinal scars detectable later in life.
Toxo Retinitis in Healthy Individuals
- More likely to recur in ages 10-35 due to cyst ruptures in previous scars.
- Clinical signs include iridocyclitis and focal retinitis with vitritis.
Treatment for Toxoplasmosis
- Involves systemic medications like clindamycin and pyrimethamine; steroids used cautiously.
- Pregnant women advised to avoid exposure to contaminated sources.
Ocular Toxocariasis Canis
- Caused by ingestion of Toxocara canis ova, particularly affecting young children.
- Symptoms include unilateral floaters, blurred vision, and photophobia.
Ocular Signs of Toxocariasis
- Characterized by unilateral chronic endophthalmitis, granulomas, and potential retinal traction.
Congenital Rubella Syndrome
- Occurs from first trimester maternal infection, resulting in hearing, cardiac, and ocular defects.
- Ocular findings include pigmentary retinopathy, cataracts, and microphthalmos.
Sarcoidosis
- Granulomatous inflammatory disease affecting multiple systems, common among females and those of African descent.
- Uveitis is a frequent manifestation, possibly presenting as anterior or intermediate uveitis.
Tuberculosis
- Chronic granulomatous disease primarily affecting the lungs; caused by Mycobacterium tuberculosis.
- Ocular features include chronic iridocyclitis and choroidal tubercles.
Syphilis
- A multisystem bacterial infection caused by Treponema pallidum.
- Ocular signs include salt and pepper retinopathy and interstitial keratitis.
Management and Diagnostic Testing for Syphilis
- Lab tests such as FTA-ABS, VDRL, and lumbar puncture for confirmation.
- Treatment includes antibiotics like penicillin; alternative therapies exist for those allergic to penicillin.
Case Review Summary
- Patient with glaucoma evaluation showed normal visual acuity but with unusual pupil size and possible optic nerve involvement.
- Changes in visual field suggest broader systemic or ocular concerns, warranting further investigation and a tailored management plan.### Treat or Monitor?
- Important considerations in glaucoma evaluation include patient history, intraocular pressure, and optic nerve health.
- Distinguishing between disorders that mimic glaucoma symptoms is essential for accurate diagnosis.
- Multiple follow-up visits provide valuable insights for determining treatment or monitoring strategies.
Acute Retinal Necrosis vs. Progressive Outer Retinal Necrosis
- Necrotizing herpetic retinopathies are linked to herpes family viruses, managed by immune status.
- Patients with intact immunity are more likely to present with acute retinal necrosis.
- Severely immunocompromised patients typically face progressive outer retinal necrosis.
- Diagnostic tests such as PCR of aqueous and vitreous biopsy offer high sensitivity and specificity.
Acute Retinal Necrosis Syndrome
- This rare condition affects healthy individuals, primarily males aged 20-50.
- Causes of retinal necrosis include herpes simplex in younger patients and herpes zoster in older patients.
- Symptoms involve blurred vision, ocular pain, and photophobia, with a classic triad including:
- Arteritis and periphlebitis.
- Confluent necrotizing retinitis primarily in the peripheral retina.
- Moderate to severe vitritis, anterior uveitis, and potential optic disc edema.
- Resolution of symptoms occurs in 4-12 weeks; however, 30-50% may experience involvement of the second eye within two months.
- Visual loss commonly results from retinal detachments and ischemic optic neuropathy, leading to poor prognoses.
- Prompt referral to a retinal specialist is essential for treatment, which includes IV and systemic Acyclovir, systemic steroids, and possible surgery.
Idiopathic Multifocal White-Dot Syndromes
- These rare inflammatory disorders affect the retina, retinal pigment epithelium (RPE), and choroid.
White Dot Syndromes
- Key conditions include AMPPE, Serpiginous Choroiditis, MEWDS, Multifocal Choroiditis with Panuveitis, PIC, and Birdshot Retinochoroidopathy.
Multiple Evanescent White-Dot Syndrome (MEWDS)
- Characterized by a good prognosis with no treatment required.
- Typically affects one eye of young, healthy females, presenting with acute unilateral vision impairment and photopsia.
- Features small white dots at the RPE level, with mild vitritis and optic nerve swelling.
- Vision often recovers to 20/20 or 20/30 within 6-12 weeks.
Acute Multifocal Placoid Pigment Epitheliopathy (AMPPE)
- A rare bilateral disorder affecting young adults following flu-like symptoms, generally with good visual prognosis.
- Symptoms include subacute unilateral vision impairment and paracentral scotomas.
- Fundus lesions yield cream-colored lesions confined to the posterior pole, identifiable through IVFA.
Serpiginous or Geographic Choroidopathy
- This uncommon, idiopathic condition progresses bilaterally in older patients, typically with poor prognosis.
- Features chorioretinal lesions with hazy borders and a jigsaw-puzzle appearance expanding outward from the optic nerve.
- Associated with mild anterior uveitis and vitritis, and can involve choroidal neovascular membranes (CNVMs) in 25% of cases.
- Management often requires systemic and intravitreal steroids.
Birdshot Retinochoroidopathy
- Primarily affects healthy middle-aged white women presenting with floaters and decreased vision.
- Notable for bilateral, flat, creamy-yellow lesions in the midperiphery and posterior pole.
- Strong association with HLA-A29; treatment outcome is poor without immunosuppressive therapy or steroids.
Multifocal Choroiditis with Panuveitis Syndrome
- Common among middle-aged females post-flu-like syndrome with a fair prognosis.
- Characterized by bilateral anterior uveitis and multifocal choroidal lesions.
- Management includes steroids and anti-VEGF treatments.
Punctate Inner Choroidopathy (PIC)
- Predominantly affects young, healthy women aged 16-40, often myopic with no prior health issues.
- Presents with bilateral blurred vision, scotomas, and clusters of yellow spots at the RPE.
- Typically has a favorable prognosis unless CNV develops, with 75% retaining vision of 20/25 or better.
Other Conditions to Be Aware Of
- Systemic Lupus Erythematosus: Affects the retina with cotton-wool spots and potential retinal vascular lesions.
- Scleroderma and Relapsing Polychondritis: Associated with ocular manifestations.
- Diffuse Unilateral Subacute Neuroretinitis (DUSN): Recognized as a separate entity in this context.
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Description
Test your knowledge on Presumed Ocular Histoplasmosis Syndrome (POHS), its key characteristics, and related conditions. This quiz covers aspects such as histoplasma capsulatum exposure, demographics affected, and maculopathy prevalence. Perfect for students or professionals in the medical field.
