Board Certified Ophthalmologist Retina and Vitreous Diseases Questions and Answers — Questions and Answers
Question 1: A 65-year-old patient with non-proliferative diabetic retinopathy and clinically significant macular edema (CSME) undergoes an OCT scan. Which finding is most characteristic of the conversion from dry age-related macular degeneration (AMD) to neovascular (wet) AMD?
- Large, soft, confluent drusen with pigmentary changes.
- Geographic atrophy of the retinal pigment epithelium (RPE).
- Subretinal or intraretinal fluid with a choroidal neovascular membrane. (Correct answer)
- Epiretinal membrane with macular pucker.
Correct answer: Subretinal or intraretinal fluid with a choroidal neovascular membrane.
The hallmark of conversion from dry to wet AMD is the development of choroidal neovascularization (CNV), which leads to leakage of fluid and blood. On OCT, this is visualized as the accumulation of subretinal and/or intraretinal fluid. Large drusen and geographic atrophy are features of dry AMD, while an epiretinal membrane is a separate condition.
Question 2: A 28-year-old male presents with a sudden, painless 'curtain' over the vision in his right eye, preceded by flashes of light and new floaters for two days. On examination, a bullous elevation of the neurosensory retina is noted in the superior temporal quadrant. What is the most likely diagnosis?
- Tractional retinal detachment
- Exudative retinal detachment
- Rhegmatogenous retinal detachment (Correct answer)
- Central serous chorioretinopathy
Correct answer: Rhegmatogenous retinal detachment
The classic presentation of flashes (photopsia), floaters, and a progressive visual field defect ('curtain') is highly suggestive of a rhegmatogenous retinal detachment (RRD). This type of detachment is caused by a full-thickness break in the retina that allows liquefied vitreous to pass into the subretinal space. Tractional detachments are typically more concave and seen in proliferative diseases, while exudative detachments are caused by underlying inflammation or tumors and often shift with patient position.
Question 3: A 58-year-old patient with a history of poorly controlled type 2 diabetes is diagnosed with high-risk proliferative diabetic retinopathy (PDR). According to the Diabetic Retinopathy Study (DRS), which of the following findings confers the highest risk for severe vision loss?
- Neovascularization of the iris (NVI).
- Four quadrants of intraretinal microvascular abnormalities (IRMA).
- Neovascularization of the disc (NVD) greater than 1/3 disc area with associated vitreous hemorrhage. (Correct answer)
- Hard exudates within the macula.
Correct answer: Neovascularization of the disc (NVD) greater than 1/3 disc area with associated vitreous hemorrhage.
The Diabetic Retinopathy Study (DRS) identified several high-risk characteristics for severe vision loss. The presence of neovascularization of the disc (NVD) greater than one-third of the disc area, especially when combined with pre-retinal or vitreous hemorrhage, is one of the most significant risk factors. While NVI is a severe complication, and extensive IRMA indicates severe non-proliferative disease, the specific high-risk criteria defined by the DRS point to NVD with hemorrhage as a critical finding requiring prompt treatment, typically panretinal photocoagulation (PRP).
Question 4: A 70-year-old male presents with acute, painless vision loss in his left eye. Fundus examination reveals diffuse retinal hemorrhages in all four quadrants, cotton-wool spots, venous tortuosity, and optic disc swelling. Fluorescein angiography shows delayed venous filling and capillary nonperfusion. What is the most appropriate initial treatment for associated macular edema?
- Panretinal photocoagulation (PRP)
- Intravitreal anti-VEGF injection (Correct answer)
- Pars plana vitrectomy
- Chorioretinal venous anastomosis
Correct answer: Intravitreal anti-VEGF injection
The clinical picture is classic for a central retinal vein occlusion (CRVO). The primary cause of vision loss in CRVO is macular edema. The current first-line, evidence-based treatment for macular edema secondary to CRVO is intravitreal injection of an anti-vascular endothelial growth factor (anti-VEGF) agent (e.g., aflibercept, ranibizumab, bevacizumab). PRP is used to treat neovascularization, not directly for macular edema. Vitrectomy and chorioretinal anastomosis are reserved for specific complications and are not initial treatments for macular edema.
Question 5: A young, otherwise healthy 22-year-old female presents with bilateral, rapidly progressive vision loss. Fundus examination reveals dramatic, widespread, circumferential perivascular sheathing of both arteries and veins, giving the appearance of 'frosted branches.' There is associated vitritis and mild disc edema. What is the most likely diagnosis?
- Eales disease
- Behçet's disease
- Frosted branch angiitis (Correct answer)
- Cytomegalovirus (CMV) retinitis
Correct answer: Frosted branch angiitis
The striking funduscopic appearance of severe, diffuse perivascular sheathing resembling frosted tree branches is pathognomonic for frosted branch angiitis. This is a rare form of retinal vasculitis that can be idiopathic or secondary to various systemic conditions. While other conditions like Behçet's, CMV retinitis, and Eales disease can cause retinal vasculitis, they do not typically present with this classic, diffuse 'frosted' appearance affecting both arteries and veins so extensively.
Question 6: Which of the following is the most characteristic initial symptom of typical retinitis pigmentosa (RP)?
- Acute onset of central scotoma
- Progressive loss of color vision
- Gradual difficulty with night vision (nyctalopia) (Correct answer)
- Metamorphopsia and photopsia
Correct answer: Gradual difficulty with night vision (nyctalopia)
Retinitis pigmentosa is a group of inherited retinal dystrophies that primarily affect the rod photoreceptors first. Since rods are responsible for vision in low-light conditions, the earliest and most common presenting symptom is nyctalopia, or night blindness. The disease then progresses to involve the peripheral visual field, leading to 'tunnel vision.' Central vision and color vision, which are mediated by cones, are typically affected later in the disease course.
Board Certified Ophthalmologist Retina and Vitreous Diseases Questions and Answers
A 65-year-old patient with non-proliferative diabetic retinopathy and clinically significant macular edema (CSME) undergoes an OCT scan.
Which finding is most characteristic of the conversion from dry age-related macular degeneration (AMD) to neovascular (wet) AMD?