® P R A C T I C I N G O P H T H A L M O L O G I S T S C U R R I C U L U M 2 0 1 4 - 2 0 1 6 Retina/ Vitreous *** Retina/Vitreous 2 © AAO 2014-2016 Practicing Ophthalmologists Curriculum Disclaimer and Limitation of Liability As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool for members to prepare for the Maintenance of Certification (MOC) -related examinations. The Academy provides this material for educational purposes only. The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all the circumstances presented by that patient. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any information contained herein. References to certain drugs, instruments, and other products in the POC are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. The Practicing Ophthalmologists Curriculum is intended to be the basis for MOC examinations in 2014, 2015 and 2016. However, the Academy specifically disclaims any and all liability for any damages of any kind, for any and all claims that may arise out of the use of any information contained herein for the purposes of preparing for the examinations for MOC. THE AMERICAN ACADEMY OF OPHTHALMOLOGY DOES NOT WARRANT OR GUARANTEE THAT USE OF THESE MATERIALS WILL LEAD TO ANY PARTICULAR RESULT FOR INDIVIDUALS TAKING THE MOC EXAMINATIONS. THE AMERICAN ACADEMY OF OPHTHALMOLOGY DISCLAIMS ALL DAMAGES, DIRECT, INDIRECT OR CONSEQUENTIAL RELATED TO THE POC. Any questions or concerns related to the relevance and validity of questions on the MOC examinations should be directed to the American Board of Ophthalmology. COPYRIGHT © 2014 AMERICAN ACADEMY OF OPHTHALMOLOGY ALL RIGHTS RESERVED Retina/Vitreous 3 © AAO 2014-2016 Practicing Ophthalmologists Curriculum Authors and Financial Disclosures The Practicing Ophthalmologists Curriculum was developed by a group of dedicated ophthalmologists reflecting a diversity of background, training, practice type and geographic distribution. Jeffrey A. Nerad, M.D., American Academy of Ophthalmology Secretary for Knowledge Base Development, serves as the overall project director for the acquisition and review of the topic outlines. The Academy gratefully acknowledges the contributions of the Vitreous Society, the Macula Society and the American Society of Retina Specialists. Practicing Ophthalmologists Curriculum Panel
 Timothy W. Olsen, M.D., Chair Brian D. Sippy, M.D. PhD, Vice Chair Neal H. Atebara, M.D. Justin L. Gottlieb, M.D. Sohail J. Hasan, M.D., Ph.D. Wayne A. Solley, M.D. Ivan J. Suner, M.D. Financial Disclosures The Academy’s Board of Trustees has determined that a financial relationship should not restrict expert scientific clinical or non-clinical presentation or publication, provided appropriate disclosure of such relationship is made. All contributors to Academy educational activities must disclose significant financial relationships (defined below) to the Academy annually. Contributors who have disclosed financial relationships: Timothy W. Olsen, M.D. Grant Support: Abraham J. and Phyllis Katz Foundation, National Eye Institute, Research to Prevent Blindness, The Fraser Parker Foundation, The R. Howard Dobbs Jr. Foundation Patent/Royalty: A Tissue Support Structure, Scleral Depressor Brian D. Sippy, M.D., Ph.D. Grant Support: Regeneron, Inc. Wayne A. Solley, M.D. Consultant/Advisor: Alcon Laboratories, Inc.; Regeneron Pharmaceuticals, Inc Lecture Fees: Alcon Laboratories, Inc. Equity Owner: ArcticDx, Inc. Ivan J. Suner, M.D. Consultant/Advisor: Bausch Lomb, GENENTECH, Optos, Inc., ThromboGenics Ltd Lecture Fees: Bausch Lomb, GENENTECH, Regeneron, ThromboGenics Ltd Grant Support: GENENTECH Contributors who state they have no significant financial relationships to disclose: Neal H. Atebara, M.D. Justin L. Gottlieb, M.D. Sohail J. Hasan, M.D., Ph.D. Retina/Vitreous 4 © AAO 2014-2016 Jeffrey A. Nerad, M.D. Retina/Vitreous 5 © AAO 2014-2016 Background on Maintenance of Certification (MOC) Developed according to standards established by the American Board of Medical Specialties (ABMS), the umbrella organization of 24 medical specialty boards, Maintenance of Certification (MOC) is designed as a series of requirements for practicing ophthalmologists to complete over a 10-year period. MOC is currently open to all Board Certified ophthalmologists on a voluntary basis; time-limited certificate holders (ophthalmologists who were Board Certified after July 1, 1992) are required to participate in this process. All medical specialties participate in a similar process. The roles of the American Board of Ophthalmology (ABO) and the American Academy of Ophthalmology relative to MOC follow their respective missions. The mission of the American Board of Ophthalmology is to serve the public by improving the quality of ophthalmic practice through a process of certification and maintenance of certification that fosters excellence and encourages continual learning. The mission of the American Academy of Ophthalmology is to advance the lifelong learning and professional interests of ophthalmologists to ensure that the public can obtain the best possible eye care. The role of the ABO in the MOC process is to evaluate and to certify. The role of the Academy in this process is to provide resources and to educate. Background on the Practicing Ophthalmologists Curriculum (POC) At the request of the ABO, the Academy developed the Practicing Ophthalmologists Curriculum (POC), a knowledge base that identifies and defines areas of knowledge important to the delivery of quality eye care as a basis for the content of examinations for the MOC process. The content in the POC is comprised of the information deemed as the most relevant clinical information for a practicing ophthalmologist. The ABO has agreed that their Periodic Ophthalmic Review Test (PORT) and closed-book Demonstration of Ophthalmic Cognitive Knowledge (DOCK) examinations will be based on the POC. The ABO is solely responsible for creating the PORT and DOCK exams and for certifying MOC candidates. The Academy has developed study tools based on the POC to assist doctors preparing to meet these MOC requirements. Organization of the POC The Practicing Ophthalmologists Curriculum comprises 10 practice emphasis areas (PEA), plus Core Ophthalmic Knowledge. The ABO has designated the following as practice emphasis areas: • Comprehensive Ophthalmology • Cataract/Anterior Segment • Cornea/External Disease • Glaucoma • Neuro-Ophthalmology and Orbit • Oculoplastics and Orbit • Pediatric Ophthalmology/Strabismus • Refractive Management/Intervention • Retina/Vitreous • Uveitis Retina/Vitreous 6 © AAO 2014-2016 In addition to two practice emphasis areas of choice, every diplomate sitting for the DOCK examination will be tested on Core Ophthalmic Knowledge. Core Ophthalmic Knowledge is defined as the fundamental knowledge every practicing ophthalmologist must have whatever their area of practice. Each PEA is categorized into topics presented in an outline format for easier reading and understanding of the relevant information points by the reader. These outlines are based on a standard clinical diagnosis and treatment approach found in the Academy’s Preferred Practice Patterns. For each topic, there are Additional Resources that may contain journal citations and reference to textbooks. These resources are supplemental to the topic outline, and should not be necessary for MOC exam preparation purposes. Creation of the POC The POC was developed by panels of practicing ophthalmologists in each of the ten practice emphasis areas. The panels reflect a diversity of background, training, practice type and geographic distribution, with more than 90 percent of the panel members being time-limited certificate holders. The panels ranked clinical topics (diseases and procedures) in terms of clinical relevance to the subspecialist or comprehensive ophthalmologist. The panelists created outlines for the topics deemed Most Relevant, based on what an ophthalmologist in a specific practice emphasis area needs to know to provide competent, quality eye care (i.e., directly related to patient care). These outlines were reviewed by subspecialty societies and the American Board of Ophthalmology. Revision Process The POC is intended to be revised every three years. The POC panels will consider new evidence in the peer-reviewed literature, as well as input from the subspecialty societies, the American Board of Ophthalmology and the Academy’s Self-Assessment Committee, in revising and updating the POC. Prior to a scheduled review the POC may be changed only under the following circumstances: • A Level I (highest level of scientific evidence) randomized controlled trial indicates a major new therapeutic strategy • The FDA issues a drug/device warning • Industry issues a warning Retina/Vitreous 7 © AAO 2014-2016 Retina/Vitreous Anatomy 1. Anatomy of the retina .................................................................................................................... 12 Diagnostic Tests 2. Fluorescein angiography ................................................................................................................ 15 3. Optical coherence tomography ..................................................................................................... 19 4. Echography (ultrasound) ................................................................................................................ 23 Macular Diseases 5. Age-related macular degeneration ................................................................................................ 27 6. Ocular histoplasmosis syndrome ................................................................................................... 38 7. Angioid streaks ............................................................................................................................... 41 8. Pathologic myopia (myopic degeneration) .................................................................................... 45 9. Central serous chorioretinopathy .................................................................................................. 49 10. Epiretinal membrane ................................................................................................................... 54 11. Vitreomacular traction syndrome ................................................................................................ 57 12. Macular hole ................................................................................................................................ 60 Retinal Vascular Diseases 13. Hypertensive retinopathy ............................................................................................................ 65 14. Diabetic retinopathy .................................................................................................................... 68 15. Branch retinal vein occlusion ....................................................................................................... 76 16. Central retinal vein occlusion (CRVO) .......................................................................................... 82 17. Branch retinal artery occlusion .................................................................................................... 88 18. Central retinal artery occlusion.................................................................................................... 93 19. Sickle cell retinopathy .................................................................................................................. 98 20. Retinopathy of prematurity ......................................................................................................... 104 Retina/Vitreous 8 © AAO 2014-2016 21. Retinal telangiectasis ................................................................................................................... 110 22. Acquired retinal macroaneurysm ................................................................................................ 117 23. Cystoid macular edema................................................................................................................ 120 Chorioretinal Inflammations 24. Selected white dot syndromes..................................................................................................... 123 25. Multiple evanescent white dot syndrome ................................................................................... 137 26. Multifocal choroiditis with panuveitis ......................................................................................... 140 27. Sarcoidosis ................................................................................................................................... 143 28. Intermediate uveitis/pars planitis ................................................................................................ 146 29. Endophthalmitis associated with filtering or inadvertent blebs .................................................. 150 30. Acute onset postoperative endophthalmitis ............................................................................... 153 31. Endogenous endophthalmitis ...................................................................................................... 158 32. Chronic or delayed onset endophthalmitis following cataract surgery ....................................... 166 33. Necrotizing herpetic retinitis: acute retinal necrosis (ARN) and progressive outer retinal necrosis (PORN) ................................................................................................................................................ 170 34. Toxoplasmosis .............................................................................................................................. 174 35. Syphilitic panuveitis ..................................................................................................................... 179 36. Toxocariasis posterior uveitis ...................................................................................................... 183 37. Cytomegalovirus retinitis ............................................................................................................. 186 Retinal/Choroidal Dystrophies 38. Retinitis pigmentosa .................................................................................................................... 192 39. Stargardt disease/fundus flavimaculatus .................................................................................... 198 40. Best disease (Vitelliform dystrophy) ............................................................................................ 202 41. Juvenile retinoschisis ................................................................................................................... 205 Diseases of the Vitreous 42. Spontaneous vitreous hemorrhage ............................................................................................. 208 Retina/Vitreous 9 © AAO 2014-2016 43. Posterior vitreous detachment .................................................................................................... 212 Peripheral Retinal Abnormalities 44. Traumatic breaks ......................................................................................................................... 216 45. Horseshoe tears ........................................................................................................................... 220 46. Giant retinal tear .......................................................................................................................... 224 47. Atrophic holes .............................................................................................................................. 227 48. Lattice degeneration .................................................................................................................... 230 49. Rhegmatogenous retinal detachment ......................................................................................... 233 50. Traction retinal detachment ........................................................................................................ 237 51. Exudative retinal detachment ...................................................................................................... 240 52. Degenerative retinoschisis ........................................................................................................... 243 Posterior Segment Trauma 53. Commotio retinae ........................................................................................................................ 246 54. Choroidal rupture ......................................................................................................................... 249 55. Sclopetaria ................................................................................................................................... 252 56. Scleral ruptures and lacerations .................................................................................................. 254 57. Ocular penetrating and perforating injury ................................................................................... 257 58. Intraocular foreign body .............................................................................................................. 261 59. Hemorrhagic choroidal detachment ............................................................................................ 265 60. Serous choroidal detachment ...................................................................................................... 269 61. Post-traumatic endophthalmitis .................................................................................................. 273 62. Sympathetic ophthalmia .............................................................................................................. 277 63. Shaken baby syndrome ................................................................................................................ 280 Retinal Toxicity 64. Drug Toxicity (posterior segment) ............................................................................................... 283 Retina/Vitreous 10 © AAO 2014-2016