쉐도잉 연습: Retinal Vascular Disorders - CRASH! Medical Review Series - 영상으로 영어 말하기 배우기

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Retinovascular disorders is going to be the topic of this lecture

and by retinovascular disorders I'm referring to the central retinal artery occlusion

and the central retinal vein occlusion

so you have a central retinal artery the retinal artery is

is the first artery off of the internal carotid artery in most people

and that's going to branch into several branches smaller branches

that then go off to different parts of the retina now

if the entire retinal artery is blocked before it gives off tributaries branches then it's considered a central retinal artery occlusion.

If it's just a branch that's blocked, that can cause symptoms, but that would be considered just a branch retinal artery occlusion.

And it works the same way with the veins.

If the main vein that's leaving the eye is blocked, then it's a central retinal vein occlusion.

If it's just a tributary of that vein, then it's a branch retinal vein occlusion.

So hopefully that makes sense.

Okay, so the central retinal artery occlusion is an occlusion of the retinal artery, is mentioned.

It's the first artery coming off of the internal carotid

and it presents as a sudden profound monocular loss of vision without pain or redness.

So this is just like having a stroke to the eye.

And about one to two percent of patients will present with bilateral CRAO, but that's pretty unusual.

The incidence is one in 10 ,000 and the average age of onset is in the 60s.

So this is a disease of the elderly.

However, if you do see this in somebody who's in their 30s or 40s, you should be highly suspicious of something like a thrombophilia.

In many cases, the patient will have a history of giant cell arteritis, whether that's diagnosed or not diagnosed.

That's also called temporal arteritis.

And this is a big risk factor for central retinal artery occlusion

so that branch retinal artery occlusion as was mentioned I'm not going to spend a whole slide talking about it

but this is just a similar process due to similar causes

but it's a smaller clot and it affects a downstream vessel

and so it doesn't affect as much of the retina as a central retinal artery occlusion

so this is much further downstream and

so it affects a smaller part of the retina

and the symptoms will be similar

but it will only affect the part of the visual field that that obstructive segment supplied

okay so what are the risk factors hypercholesterolemia of course that's a risk factor for clotting obesity

Obesity, advanced age, diabetes mellitus, and all of these three things,

maybe not hypercholesterolemia, but obesity and advanced age, those certainly play into diabetes mellitus.

But just having diabetes mellitus by itself, even if you're not obese and you're not advanced age, that is a risk factor too

and then temporal arteritis is a big risk factor for artery occlusion

and so what is temporal arteritis again I address this in a different lecture in the medical section

but temporal arteritis happens to people 55 years of age

or older it involves a headache scalp tenderness and thickening

or tenderness of the superficial temporal artery you should be able to feel pulse over

that artery and it's right over the temple

if you feel your own superficial temporal artery you feel your temple you should be able to palpate

that artery patients with temporal arteritis they usually have this this inflamed firm cord

and you can't feel the pulse because the artery is

so inflamed so what does this lead to especially the hypercholesterolemia the obesity the diabetes

and the fact of being old those all can lead to

or increase your risk of carotid artery stenosis and of atrial fibrillation

because of small undetected heart attacks and those things carotid artery stenosis

because you're gathering plaque and atrial fibrillation because you can develop a clot

because of a lack of a lack of appropriate contraction both of those things you can develop a clot

or release a clot or release a plaque and

that can be the embolus that's needed that can go in to the into the retinal artery

and so this is how central retinal artery occlusion and

if it's a smaller plaque

or a smaller clot that's how a branch retinal artery occlusion can happen other risk factors include

congenital or acquired thrombophilia you can acquire thrombophilia by taking birth control pills

and so those would be something you would look for in younger patients who don't have these risk factors.

And there's other risk factors in addition to these, but these are some of the most common that you'll see.

So as mentioned, this is painless, sudden, and often this is a profound loss of vision.

98 to 99 % are monocular.

The symptoms are sudden loss of vision.

Acuity is typically worse than 2200, which is the cutoff point for being legally blind

and a lot of times they won't even be able to tell you how many fingers

you're putting up in front of their face even

if you get really close there may be some preservation in the temporal field I'm assuming that's

because there may be some additional there may be some additional circulation coming from somewhere else

but I'm not exactly sure but the literature does say

that there may be some preservation in temporal fields and

that is certainly the case

so some of the things you're going to want to know from the patient

or at least know on the question

that's going to help you with the diagnosis is how long have the symptoms been present usually

when somebody loses their vision they're going to get to the er as quickly as possible

you also want to know

if they have any past medical history of ocular problems you'll want to know if the patient has a high cholesterol,

if you ask the patient that or if you look in their charts, do they have a history of diabetes?

Certainly both of those would increase the risk of this being a central retinal artery occlusion.

And do they have any history of stroke or TIA?

That would lead you to believe that perhaps there's a carotid artery stenosis

and that's a big contributor to retinal artery occlusion

now I just want to right now differentiate central retinal artery occlusion from something else

which is called amaurosis fugax and with amaurosis fugax you get a temporary loss of vision

that usually lasts a few minutes

and then your vision comes back with central retinal artery occlusion you have a loss of vision

and it stays at least until you get treated on On physical examination,

you want to document their visual fields and then get their visual acuity, even though it's probably going to be 2200 or worse,

just to compare it to baseline and document it on the records.

Look for signs of temporal arteritis, especially in older patients, because that contributes, that strengthens your diagnosis.

You should also check their pupils for an afferent pupillary defect or the Marcus Gunn pupil.

Ocultate for a carotid brui, and then ocultate the heart for murmurs, and especially an irregular beat, which can be consistent with atrial fibrillation.

For diagnosis, you'll want to get routine labs,

and that's great, but all patients with acute loss of vision should be referred to ophthalmology for a formal ophthalmoscopy,

highlighting the fact here that CRAO, as in a lot of cases of vision loss,

cannot be diagnosed with a simple handheld ophthalmoscope.

You'll need to do a dilated exam and have the optometrist use their equipment.

So findings consistent on indirect ophthalmoscopy, consistent with CRAO, includes retinal pallor, which makes sense because it's not getting enough blood,

a prominent cherry red macula, and that is actually because the fovea,

the macula, gets its vascularization elsewhere from the choriocapularis.

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And then attenuated arteries may be present, as well as a boxcar appearance of veins.

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But what you're really going to notice is the retinal pallor and the prominent cherry red macula.

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So here's a normal posterior pole.

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Here's your optic disc and in the center here is your macula.

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Now the macula is red but it's a lot different in comparison than when we see the retinal artery occlusion.

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So here's an example of a central retinal artery occlusion and as you can see there's pallor here.

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This is much more pale.

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Now, every ophthalmoscope uses slightly different lighting,

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but you can see that there's a much more contrast between the macula and the rest of the retina,

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whereas here, the macula and the retina weren't as contrasted.

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You also see that you don't have a whole lot of vasculature around the macula,

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whereas on a normal visualization, you do have vasculature around the macula.

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So here's another one, again the macula is much more prominent, that cherry red macula.

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See the same here too.

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So this is a branch retinal artery occlusion.

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So you can see that it's normal on the top here, but it's abnormal on the bottom.

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If the rest of the retina was like this on the bottom, then you'd have a central retinal artery occlusion you'd be able

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to see this macula very distinguished from the rest of the retina

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but it's only distinguished from this retina here on the bottom

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which is the diseased retina that's not getting enough blood

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and then here's another one here above the above the macula

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so the treatment the patient is going to need admission through

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ophthalmology the treatment is going to be under the guidance of an ophthalmologist.

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So I don't expect ever you'll be required to know how to do this

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or exactly how to treat them in the ER or as an internist or even as a surgeon.

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But you do need to know that they need to be admitted and it's worth knowing some of the things that

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ophthalmologists use.

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So presently there's controversy in the exact management for patients with CRAO, but most ophthalmologists agree with some basic principles.

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So high concentration inhaled 100 % oxygen, that's something you can start in the ER.

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So that's something you should know.

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IV acetazolamide, IV corticosteroids, those are done,

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the IV corticosteroids are done to reduce the inflammation and

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that is expected to help with with maintaining vision reducing the inflammation

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and then treatment of the underlying cause as the internist this is going to be your concern finding

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and treating the underlying cause right some ophthalmologists use intra arterial thrombolytics

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and they inject those thrombolytics into the retinal artery system that's not universal

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but this has been shown to be effective by the EGLE study

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so you can look look up more on that if you want

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but high high concentration inhaled oxygen acetazolamide corticosteroids

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and treatment of the underlying cause

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so upon diagnosis it's going to be your responsibility to work

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the patient up for underlying causes these don't just happen on their own

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so the patient will have something wrong with them

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that put them at predisposition all patients regardless of their age should get a carotid artery duplex ultrasound

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they should get an echocardiogram to look for atrial fibrillation

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or any other kind of abnormality valvular abnormalities that can gather clots

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and then and then release them they should get an EKG routine labs that's usually done anyway

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when you're first investigating the patient an ESR is useful

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and that's kind of to look more towards the temporal arteritis

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that would be elevated a fasting blood glucose is useful to work them up for diabetes

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if they haven't been diagnosed with diabetes and then coagulation studies younger patients

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or older patients who have normal results after this workup should get a workup for any kind of congenital

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or acquired thrombophilia so factor V Leiden antithrombin 3 deficiency protein C deficiency protein S deficiency

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and so forth oh and then elevated homocysteine

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that was another one I wanted to add to and that's another congenital thing older

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Older patients should follow up regularly, patients with CRAO have a 56 % mortality rate within 9 years

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and that's compared to 27 % in aged match patients who have never had CRAO.

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So that's a big deal when you think about it.

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Somebody who's older and has the same,

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let's say you've got two twins and one twin develops a CRAO and the other twin doesn't,

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That twin that developed the CRAO is two times more likely to die within the next nine years.

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And that shows that it's likely due to the fact that there's some level of increased thrombosis.

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The plaque is not stabilized but it's important to remember that patients who have CRAO,

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really what this was, was a stroke that just happened to go the right way.

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Rather than go up to the brain, it went to the retinal artery.

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And so rather than having a debilitating or deadly stroke, you just got your eye taken out.

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And I mean, neither of those are good, but this is the same pathologic process that causes a stroke.

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So it's important that patients are aware that they are at imminent risk of stroke and that you take interventions as necessary,

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as if the patient had had a stroke.

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Okay, so central retinal vein occlusion is occlusion of the retinal vein.

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And this presents a little bit differently.

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So initially, the patient will present with sudden monocular loss of vision without pain or redness,

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but it's usually not as severe as the central retinal artery occlusion.

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But this is a more progressive disease, and the vision will worsen with time.

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And eventually, pain erythema and watering can develop.

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So this is less severe usually when it presents, but with time, when it's diagnosed with time, if it's not treated, it gets worse.

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The symptoms have a tendency to be noticed on wakening.

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I'm not sure why.

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The lifetime incidence is 2 to 5 per 1000

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and 90 % of cases are seen over the age of 50

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so again this has a preponderance in the elderly and there's a slight male preponderance.

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The equivalent branch retinal vein occlusion is a similar process

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but it affects a downstream vein and

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so it does not affect as much of the retina

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and the ophthalmoscopic findings will be localized so

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when we look at what the ophthalmoscopic findings of central retinal

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vein occlusion are you're only going to find them in one part of the retina with the BRVOs.

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BRVOs are thought to be most commonly caused by a mechanical compression on the branch vein by an artery

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but there are other possible causes systemic hypertension is considered the most significant major risk factor in BRVOs.

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So back on the CRVOs they're very similar as far as risk factors go

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but other risk factors with CRVO can include primary glaucoma probably because of the elevated pressure,

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alcohol consumption, head trauma, and excessive physical activity.

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Symptoms include as mentioned progressive visual impairment.

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The natural progression includes worsening of vision to the point of blindness, pain, photophobia, redness, and eye watering.

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All suspected cases of loss of vision, as mentioned, should be referred to an ophthalmologist for formal indirect ophthalmoscopy.

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And the findings on ophthalmoscopy depend on how progressed the CRVO is.

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So typically with CRVO, we see a certain degree of optic disc swelling there's going to be a certain amount of hemorrhages

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and you may see some tortuous veins

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but as it progresses you're going to see a more swelled optic disc you're going to see more

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and more and larger hemorrhages

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and a lot of times the hemorrhages get in the way to where you can't see the veins even

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if they are tortuous so i'll show you some examples

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further tests to evaluate the CRVO include fluorescein angiography

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when to do this test is at the discretion of the ophthalmologist

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so here is a case of what would be considered early CRVO

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so the you can see there's some hemorrhaging here on these early veins

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and then you also have this tortuosity this would be probably a little bit later

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so you've got more hemorrhages here and this is much later too

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because the hemorrhages are much further out okay

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so this is a branch retinal vein occlusion so you can see here

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that the veins and arteries are normal but here you have this localized area of hemorrhage

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So this was found to be a branch retinal vein occlusion.

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Here's another one.

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Now just looking at the results of an ophthalmoscope, it isn't going to tell you what the disease is.

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You always have to include it in the clinical picture of the patient.

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Any radiologist would tell you that.

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But with a patient with consistent symptoms, this is certainly a branch retinal vein occlusion, as is this.

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So patients with central retinal vein occlusions should be worked up for diabetes, hyperlipidemia.

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So both of those are easy.

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You can get them in the morning, get a fasting blood glucose level, get a lipid panel.

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They should also be worked up for thrombophilia markers such as factor V Leiden, protein C, etc. and then be worked up for an elevated homocysteine.

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For treatment, unfortunately there is no available effective medical treatment for CRVO.

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Various treatment modalities are under investigation, however, and they may be performed by the ophthalmologist.

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Some patients can get enrolled in studies, but you won't be responsible for knowing any of this on the USMLE

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but some of those modalities include intravitreal administration of anti -VEGF inhibitors

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so remember that VEGF is a protein that stimulates angiogenesis and

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so this will reduce the development of more arteries

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which is the classic response

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when there's ischemia there's also intravitreal administration of corticosteroids to reduce some of the inflammation

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that invariably happens with this the use of locally injected tpa and then plasmapheresis

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complications include neovascular glaucoma panretinal photocoagulation can be performed either prophylactically in crvo

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or as soon as there's signs of neovascularization

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and macular edema is another complication for that laser photocoagulation can be effective but only if it's due from BRVO.

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It has not been shown to be effective in CRVO.

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So if you have any questions, feel free to leave a message below.

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이 레슨의 어휘와 말하기 포인트

이 말하기 레슨은 영상 “Retinal Vascular Disorders - CRASH! Medical Review Series”을(를) 바탕으로 합니다. 가장 자주 반복되는 단어는 다음과 같습니다: artery, retinal, occlusion, patient, vein. 이 영상에는 섀도잉할 문장 234개와 단어 3050개가 있습니다. 말하는 구간의 길이는 22:30입니다. 화자는 분당 약 136단어의 일정한 속도로 말해서 섀도잉하기에 편한 속도입니다. 영어에서 가장 많이 쓰이는 3,000단어에 속하는 단어가 75%뿐이라 어휘가 어려운 편입니다.

이 영상의 핵심 어휘

영상에 나오는 익혀 둘 만한 단어 15개를 발음, 뜻과 함께 정리했습니다.

단어	발음	뜻
artery 명사	/ˈɑɹ.təɹ.i/	동맥
vein 명사	/veɪn/	정맥
diabetes 명사	/ˌdaɪəˈbiːtiːz/	당뇨병
symptom 명사	/ˈsɪm(p)təm/	증상, 증후
sudden 형용사	/ˈsʌd.ən/	급격한
twin 명사	/twɪn/	쌍둥이, 갈오기
diagnosis 명사	/daɪəɡˈnəʊsɪs/	진단
obesity 명사	/ə(ʊ)ˈbiːsɪti/	비만
prominent 형용사	/ˈpɹɑmɪnənt/	돌출(突出)되다
cherry 명사	/ˈt͡ʃɛɹi/	버찌, 체리
acquire 동사	/əˈkwaɪɚ/	획득하다
disk 명사	/dɪsk/	디스크, 원반
inflammation 명사	/ɪnfləˈmeɪ̯ʃən/	염증
formal 형용사	/ˈfɔɹməl/	형식적
temple 명사	/ˈtɛm.pl̩/	절, 사찰

이 영상의 문법

화자가 가장 많이 쓰는 문형을 영상 속 실제 표현과 함께 정리했습니다.

문형	영상 속 표현
수동태 be + 과거분사 — 누가 하는지보다 무슨 일이 일어나는지에 초점	is blocked · would be considered · is mentioned
현재완료 have/has + 과거분사 — 과거의 일이 지금도 관련이 있을 때	has been shown · haven't been diagnosed · have never had
관계절 who / which + 절 — 사람이나 사물에 대한 추가 정보	beat, which can · pallor, which makes

주의할 발음

화자는 you're, I'm, you'll 같은 축약형과 약화된 형태를 40번 사용합니다. 들리는 대로 짧게 발음하세요.

“th” 소리: gather /ˈɡæðɚ/, ophthalmologist /ˌɔf.θə(l)ˈmɑ.lə.d͡ʒɪst/, ophthalmology /ˌɒfθə(l)ˈmɒləd͡ʒi/, antithrombin /ˌæntɪˈθɹɒmbɪn/
“sh”와 “zh” 소리: inflammation /ɪnfləˈmeɪ̯ʃən/, deficiency /dɪˈfɪʃənsi/, concentration /ˌkɑn.sənˈtɹeɪ.ʃən/, examination /ɪɡˌzæm.ɪˈneɪ.ʃən/, preservation /ˌpɹɛz.əˈveɪ.ʃən/
긴 단어 — 강세 위치에 주의: obesity /ə(ʊ)ˈbiːsɪti/, inflammation /ɪnfləˈmeɪ̯ʃən/, deficiency /dɪˈfɪʃənsi/, concentration /ˌkɑn.sənˈtɹeɪ.ʃən/, examination /ɪɡˌzæm.ɪˈneɪ.ʃən/

한국어 화자가 어려워하는 소리:

/f/ — ㅍ(/p/)으로 바꾸지 말고 윗니를 아랫입술에 대기: inflammation /ɪnfləˈmeɪ̯ʃən/, deficiency /dɪˈfɪʃənsi/, formal /ˈfɔɹməl/, profound /pɹəˈfaʊnd/, superficial /ˌsupɚˈfɪʃəl/
/v/ — ㅂ(/b/)과 구별하기: vein /veɪn/, progressive /pɹəˈɡɹɛsɪv/, preservation /ˌpɹɛz.əˈveɪ.ʃən/, universal /ˌjunəˈvɜɹs(ə)l/, investigate /ɪnˈvɛs.tə.ɡeɪt/
/z/ — ㅈ이 아니라 성대를 울리는 /s/: diabetes /ˌdaɪəˈbiːtiːz/, whereas /(h)wɛɹˈæz/, examination /ɪɡˌzæm.ɪˈneɪ.ʃən/, preservation /ˌpɹɛz.əˈveɪ.ʃən/, glucose /ˈɡluː.kəʊz/

이 영상으로 연습하는 방법

먼저 말하지 않고 영상을 끝까지 듣고 모르는 단어를 적어 둡니다.
보통 속도로 한 문장씩 섀도잉하고, 화자의 리듬과 맞을 때까지 반복합니다.
자신의 목소리를 녹음해 원본과 비교하고, artery, vein, diabetes 같은 단어에 특히 주의합니다.

쉐도잉이란? 영어 실력을 빠르게 키우는 과학적 방법

쉐도잉(Shadowing)은 원래 전문 통역사 훈련을 위해 개발된 언어 학습 기법으로, 다언어 학자인 Dr. Alexander Arguelles에 의해 대중화된 방법입니다. 핵심 원리는 간단하지만 매우 강력합니다: 원어민의 영어를 들으면서 1~2초의 짧은 지연으로 즉시 소리 내어 따라 말하는 것——마치 '그림자(shadow)'처럼 화자를 따라가는 것입니다. 문법 공부나 수동적인 청취와 달리, 쉐도잉은 뇌와 입 근육이 동시에 실시간으로 영어를 처리하고 재현하도록 훈련합니다. 연구에 따르면 이 방법은 발음 정확도, 억양, 리듬, 연음, 청취력, 말하기 유창성을 크게 향상시킵니다. IELTS 스피킹 준비와 자연스러운 영어 소통을 원하는 분들에게 특히 효과적입니다.

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