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Slide 1
There Will Be Blood
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The Differential Diagnosis of Retinal Hemorrhage Salil Shukla MD March 8, 2015
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Slide 2
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Why Will There Be Blood?
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Slide 3
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Arterial Retinal Circulation
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Retinal Circulation Inner Retinal Circulation
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Outer retinal Circulation
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Blood Retinal Barrier
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Venous Retinal Circulation
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Venous Retinal Circulation
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Guiding Principles “Common things occur commonly.”
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– Unknown
"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
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– A. Maslow, The Psychology of Science, 1966
“If it bleeds, we can kill it.”
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– Arnold Schwarzenegger, Predator, 1987
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Slide 11
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Characteristics • Size/Shape
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– Aneurysm, flame shaped, dot‐blot, scaphoid
• Frequency – Single, numerous, discreet, clustered
• Location/Distribution
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– Macula, mid periphery, far periphery – Along a vessel, respecting raphe, diffuse
• Depth – Preretinal, intraretinal, subretinal, choroidal
• Associated anatomy
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Roth spot, exudate, NV, emboli
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Slide 12
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Pathology Type • Vascular
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– arterial, venous, systemic disease
• Degenerative – choroidal, vitreoretinal
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Inflammatory Infectious Neoplastic Traumatic
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Ocular Ischemic Syndrome • Ischemia of inner retina from ICA stenosis. • Unilateral or Bilateral. • Men (2:1) age 50‐80. • History of decreased vision, pain, possible amaurosis fugax. • Ask about cholesterol, HTN, stroke, heart Dz.
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Ocular Ischemic Syndrome • Large peripheral blot hemorrhages not corresponding to particular venous perfusion. • Scattered hemorrhages simulate CRVO, but there no retinal venous tortuosity/ON swelling. • Patients require carotid U/S.
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Sickle Cell Retinopathy • Ocular manifestations of sickle cell disease result from vascular occlusion. • Constellation of findings: – – – – –
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Sclerotic vasculature Venous tortusoity Salmon patch/sunburst Neovascularization (sea fan) VH/TRD
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• Order sickle cell prep and Hgb electrophoresis.
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Blood Dyscrasias • Pathologic conditions of • Frequently ocular manifestations. the blood marked by abnormal levels of • Broad range of over‐ cellular components lapping retinal – RBC presentation. – WBC • Order complete blood – Platelets count (CBC) with • Often multiple systemic differential & peripheral manifestations. blood smear for screening.
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Blood Dyscrasias • • • • • •
Retinal Hemorrhage: dbh and flame shape Microaneurysms: typically peripheral Hard Exudates Retinal Edema Cotton Wool Spots Vascular Changes: Venous dilation and tortuosity, sheathing, neovascularization.
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Purtscher’s Retinopathy • LOV associated with head/chest trauma, long bone trauma, pancreatitis, child birth. • Peri‐papillary retinal whitening with retinal and/or preretinal hemorrhage, edema, dilated veins. • History is essential. • Prognosis is variable.
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Anemia • Reduction in the concentration of hemoglobin or red blood cells in the blood. • Retinal hemorrhages are common findings. • In profound anemia, CWS and white‐centered hemorrhages may be observed. • Can present with other dyscrasias.
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Polycythemia Vera • chronic disorder of bone marrow with increase in the number of RBC and total blood volume. • Fundus findings include retinal venous dilatation tortuosity, intraretinal hemorrhages.
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Leukemia • Ocular findings include • Cancer typically intraretinal originating in the bone hemorrhages (flame‐ marrow with high levels shaped, dot‐blot, white‐ of abnormal white centered), micro‐ blood cells in the blood. aneurysms, hard • Acute and chronic exudates, retinal subtypes. edema, CWS, venous stasis retinopathy, NV.
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Leukemia
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Platelet/Clotting Disorders
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Blood Dyscrasia Workup • Complete blood count (CBC) with differential. • Peripheral blood smear. • Prothrombin time (PT) and partial prothrombin time (PTT).
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Retinal Vein Occlusion • Glaucoma • DM, HTN, cholesterolemia • Coagulopathy:
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Homocystenemia, Protein C/S, Factor V Leiden, Antiphospholipid Ab, Cryoglobulinemia, leukemia, PCV, multiple myeloma
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• Drugs: OCP, diuretics • Vasculitis: TB,
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sarcoidosis, SLE, syphyllis
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Choroidal Neovascularization
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Choroidal Neovascularization AMD High myopia Angioid streaks POHS Choroidal rupture CRS Inflammatory CR spots • Choroidal tumor
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Purtscher’s Retinopathy • LOV associated with head/chest trauma, long bone trauma, pancreatitis, child birth. • Peri‐papillary retinal whitening with retinal and/or preretinal hemorrhage, edema, dilated veins. • History is essential. • Prognosis is variable.
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Valsalva Retinopathy • Abrupt vision loss associated with valsalva maneuver. • Small/large, uni/bilateral, preretinal heme in macular area. • History is essential. • Prognosis is excellent.
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Terson Syndrome • Classic preretinal hemorrhage associated with subarachnoid hemorrhage. • ± sub/intraretinal hemorrhage, vitreous hemorrhage. • History is essential. • Prognosis is good.
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Retinal Artery Macroaneurysm (RAMA)
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Slide 37 RAMA • Saccular dilation of artery, often ST macular, ± exudate. • Sub/intra/preretinal hemorrahge. • Painless LOV. • Classically women aged 57‐71 years. • Treat CME with anti‐ VEGF, focal laser is curative.
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Macular Telangiectasia • Idiopathic juxtafoveal telangiectasia Type II. • Prevalence as high as 0.1% of population. • Mean age onset 55, no gender/race predilection. • Bilateral but asymmetric. • Presents with decreased VA, c/o metamorphopsia, paracentral scotoma, often more aware while reading.
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Macular Telangiectasia • Fundus findings include parafoveal graying of retina, superficial crystalline deposits, subfoveal cystoid cavities, parafoveal telangiectasias, and right‐angle vessels.
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Macular Telangiectasia
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Macular Telangiectasia
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Radiation Retinopathy
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Infectious
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Auto‐Immune
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Coming Attractions
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