Hemorrhages PDF

2. Vessel Occlusions (delayed or absent in a central, hemi, branch, or tributary artery, vein, arteriole, venule, capillary) 3. Ocular Ischemic Syndrome: delayed choroidal flush, prolonged arteriovenous transmit time 4. White dot syndrome: Acute...

2. Vessel Occlusions (delayed or absent in a central, hemi, branch, or tributary artery, vein, arteriole, venule, capillary) 3. Ocular Ischemic Syndrome: delayed choroidal flush, prolonged arteriovenous transmit time 4. White dot syndrome: Acute posterior multifocal placoid pigment epitheliopathy (AMPPE), Multiple evanescent white dot syndrome (MEWS), birdshot, multifocal choroiditis 5. Choroidal Melanoma: double circulation veins G should be starting to fill at 19-20 sec (max = 30 see Ocular Ischemic Syndrome White Dot Syndrome Choroidal Melanoma Lecture 3: Retina Vascular Retinopathy Posterior Segment Hemorrhages: -Sign of underlying vasculature/ systemic health issue -Happens spontaneously with blood vessel sealing shortly after (usually bleeding stops rapidly) -Hemorrhage blood reabsorbs over time Time depends on extent and varies person by person 6 weeks= average (can be anywhere from 4 weeks to 6 months) -Drance hemes touch the ON and can be difficult to see due to features of the ON Types of Hemorrhages -Look at the color, shape, and pattern of the hemorrhage to determine the layer of the retina it is present in Condition Pre-retinal Hemorrhage Superficial (Flame) Heme Intraretinal Hemorrhage Subretinal Hemorrhage Location Between the ILM and RNFL Within the RNFL In the INL but can extend Between PR and RPE (in front of retina) usually in outwards to OPL or ONL -Multiple layers usually will not go below ELM put the posterior pole due to involved · can extend up to the ILM robust vascular tissue Appearance Boat like shape that has Flame shaped since stains Dot is circular and small Lobular red or dark red elevation and dimension RNFL bundle while blot is slightly with a well demarcated -Can be isolated larger superior horizontal line -Can involve one quadrant -Can be isolated -Bright red (branch retinal vein) or -Bilateral=systemic; hemisphere (hemiretinal Unilateral= BRVO, vein) CRVO, blocked ICA Origin Retinal arteries and Superficial capillary From the deep capillary Choroidal neovascular superficial capillary network (between network (in the INL) or membrane (CNV) network in PP typically RNFL/GCL or within GCL) in venous stasis backup of > - blood radial circumpapillary zone Symptoms Can affect vision if No effect to vision usually Asymptomatic If sub macular, affects obscuring macula/fovea since there are no capillary vision -Larger than superficial and networks in the fovea so If posterior pole, may have intraretinal so can extend confined to RNFL VF defect into FAZ 2 -Central scotoma Etiology PVD (can damage fragile BV Ocular: BRVO, CRVO Diabetes** (most Choroidal neovascular or capillary vessels), (unilateral); Ischemic optic common in PP), venous membrane, Coat’s disease, Valsalva maneuver** neuropathy (inflammatory occlusive disease, HTN, leukemia, ROP, severe DM, (straining), DM, HTN, response), papilledema, juxta foveal trauma, RVO  trauma, blood dyscrasias, papillitis, low pressure telangiectasia, bacterial endocarditis, glaucoma (drance heme) tonne ipsilateral internal idiopathic Systemic: HTN, DM, blood carotid stenosis, -Order bloodwork if none of disorders, oral choroidal neovascular these are the cause contraceptives, smoking, membrane, emblood - usually bilateral disorders idiopathic hypercoagulability peripheral Resolution -May appear yellow and Varies; weeks to months Varies; weeks to months Treat underlying etiology then white as it resolves Scar tissue may result since the blood is losing hemoglobin -Takes weeks to months -VA and VF return to normal Notes OCT will have shadowing Also called splinter heme, Also called dot heme, -Know that the hemorrhage underneath due to drance heme, Roth spot blot heme, dot-blot is deeper since can see hyperreflective nature of -Suspect systemic disease heme overlying blood vessels blood if bilateral and CRVO or -Usually deeper hemes -Flayed edges called a Blood collecting carotid disease if unilateral associated with DM thumbprint heme between nerve fibers Picture Roth spots: superficial hemorrhage surrounding a white center White center is usually WBC, CWS (ischemia), or fibrin Etiology: subacute bacterial endocarditis, HTN, DM, blood disorder, leukemia, myeloma, anemia, Condition SubRPE Hemorrhage Choroidal Hemorrhage Vitreous Hemorrhage Location Between RPE and Bruch’s or in In the choroid Between detached vitreous hyaloid - choroid membrane and ILM or within the vitreous Appearance Gray-green lobular since RPE Gray-green Variations of red breaks down some of the Can be hazy wavelengths of light Will block retina/vessels -Can see overlying vasculature Origin Choroidal - Symptoms Affects vision if submacular Floaters or blurry vision if in front macula VF defect if in PP Etiology Choroidal neovascular Hemorrhagic choroidal effusion Pre-retinal neovascularization** (from membrane, choroidal rupture, (abnormal accumulation of fluid in DM, BRVO, CRVO, SC retinopathy), PVD choroidal tumor suprachoroidal space) (retrovitreal), retinal tear, trauma, Eale’s -Typically from intraocular sx but can disease, nearby pathology (tumor, retinal be from inflammatory, infectious, macroaneursym) neoplastic, drug related disease Resolution Underlying etiology treated, Turns yellow then whitish before scar tissue can result disappearing in 2-3 months -May need B scan if cannot view retina  not still may caused g resolve if by new -May need vitrectomy if not clearing Picture Condition Edema Exudate Cotton wool spot Location Serous fluid within/between Lipid and lipoprotein deposits leaking Within RNFL INL and OPL but can extend due to breakdown in blood-retina barrier through whole retina (ILM to in the OPL; can extend to the ONL to ILM RPE) if diffuse when extensive Appearance Clear bubble/elevation if Bright light-yellow/white that can be Moderately sized; white fluffy cotton extensive isolated, localized, or in an arc/circinate ball appearance pattern Origin Outer/deep capillary network Outer/deep capillary network C (venous Minor infarct of superficial capillary (local) or both inner and outer based disease) network or retinal arterioles due to capillary networks (diffuse) artery based retinal disease and C ischemia of RNFL Symptoms Asymptomatic, n/a none metamorphopsia, blur/refractive shift if PR involved Etiology DM, Retinal vein occlusion, DM, HTN, Coat’s disease, CRVO or HTN, DM, lupus, anemia, leukemia, vitreomacular traction, BRVO, retinal tumor, Leber’s disease, high altitude retinopathy internal carorid · stenosis ansproteinemia reneous occlusive inflammatory disease, genetic papillitis, papilledema, VHL disease , , , pablilitis is chemic optic papilledema , , disease, intraocular sx and Neuropathy HIV/AIDS retinopathy purtsches retinopathy , , tumors, injury/trauma Resolution/Tx Depends on underlying etiology Serous fluid clears first in 6-12 weeks 6-12 weeks, longer for diabetics but untreated can lead to (longer for DM); tx depends on -Transient, no permanent damage ischemia underlying etiology Notes On OCT, inside is hypo Remains even once edema goes away RNFL hypoxia leads to swelling of the reflective and total retinal -Usually a microaneurysm at the center RNFL thickness will be seen as when in a circinate pattern; deemed -OCT would show thickened RNFL thicker on a color scale macular star when around fovea Picture 4 Retinal Blood Vessel Anomalies Optical Coherence Tomography Angiography: looking at blood vessels and perfusion to help with decision making in the diagnosis & and treatment o Noninvasive imaging of microvasculature of retina and choroid o Uses laser light reflectance of MOVING RBCs to depict vessels of the eye o Blood that is NOT moving like a hemorrhage or blood vessel damage/ischemia will not show up and will cause a shadow over the blood vessel surrounding o Macular scars are segmented into superficial retinal plexus, deep retinal plexus, outer retina, choriocapillaris zones o Artifacts are common