Study guide
19.2 Painless Vision Loss & Chronic Ophthalmic Disease
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
19.2 Painless Vision Loss & Chronic Ophthalmic Disease
Key Takeaways Explain This Topic AI
Macular degeneration, retinal detachment, diabetic retinopathy, amaurosis fugax, temporal arteritis and Roth spots are enumerated under retinal disease.
Central retinal artery occlusion is a stroke equivalent requiring urgent evaluation for a cardioembolic or carotid source.
Giant cell arteritis must be excluded in any patient over 50 with acute vision loss, and corticosteroids are started before biopsy.
Retinal detachment presents with flashes, floaters and a curtain-like field defect and requires urgent ophthalmology referral.
Annual dilated eye examination is recommended in diabetes because retinopathy is asymptomatic until advanced.
Last updated: August 2026
1. Painless Acute Vision Loss
Sudden, painless, monocular vision loss is a medical emergency requiring rapid diagnostic differentiation between arterial vascular occlusion, venous thrombosis, systemic inflammatory vasculitis, and mechanical retinal detachment.
Condition Pathophysiology & Etiology Funduscopic Hallmarks Key Diagnostic Workup Emergency Management
Central Retinal Artery Occlusion (CRAO) Embolic occlusion of central retinal artery (internal carotid artery atheroma, cardiogenic embolus, calcific valve plaque) Diffusely pale, ischemic white/edematous retina with a distinct "Cherry-Red Spot" at the fovea ; segmentation / "boxcarring" of retinal blood columns Emergency Stroke Protocol : Carotid duplex ultrasound, Echocardiogram (TTE/TEE), Continuous ECG telemetry, MRI brain/DWI, ESR/CRP Emergency stroke center admission; ocular massage, anterior chamber paracentesis (variable benefit); secondary stroke prevention (antiplatelet, statin, BP control)
Central Retinal Vein Occlusion (CRVO) Thrombotic occlusion of central retinal vein at lamina cribrosa; associated with HTN, DM, hyperlipidemia, glaucoma, hypercoagulability "Blood and thunder" fundus : Widespread flame-shaped and dot-blot hemorrhages across all 4 quadrants, engorged tortuous veins, disc edema, cotton-wool spots Screen for vascular risk factors, thrombophilia panel (if young/unprovoked: Factor V Leiden, APS, protein C/S deficiency), serum protein electrophoresis Ophthalmology referral; Intravitreal Anti-VEGF injections (Aflibercept, Ranibizumab) or Dexamethasone intravitreal implants for macular edema; PRP if neovascularization
Giant Cell Arteritis (GCA / A-AION) Immune-mediated granulomatous vasculitis of posterior ciliary arteries supplying optic nerve head; age ≥50 years Chalky-white, pale, edematous optic disc (Arteritic Anterior Ischemic Optic Neuropathy) with splinter hemorrhages; Relative Afferent Pupillary Defect (RAPD) Markedly elevated ESR (often >50–100 mm/hr) , elevated CRP, thrombocytosis; Temporal Artery Biopsy (≥2–3 cm specimen) IMMEDIATE High-Dose Systemic Corticosteroids: IV Methylprednisolone 500–1000 mg/day for 3 days , then Oral Prednisone 1 mg/kg/day. DO NOT DELAY STEROIDS FOR BIOPSY (protects contralateral eye); Tocilizumab (anti-IL-6R)
Rhegmatogenous Retinal Detachment Full-thickness retinal tear/hole allowing liquefied vitreous fluid to dissect into subretinal space, peeling neurosensory retina off RPE Elevated, billowing, folded, gray-white detached retina ; loss of normal red reflex; undulating with ocular movement; visible retinal tear/break Dilated funduscopic exam with indirect ophthalmoscopy; B-scan ocular ultrasonography if media opacified by vitreous hemorrhage Urgent vitreoretinal surgical intervention: Pneumatic retinopexy, Scleral buckle, or Pars plana vitrectomy; laser barrier photocoagulation for localized tears
- 2. Chronic Ophthalmic Diseases for the Internist
- Diabetic Retinopathy
Diabetic retinopathy is the leading cause of new blindness among working-age adults (aged 20–74 years) in developed nations.
Pathophysiology: Chronic hyperglycemia triggers retinal capillary pericyte apoptosis, basement membrane thickening, microvascular leakage, capillary non-perfusion, and tissue ischemia, upregulating Vascular Endothelial Growth Factor (VEGF) .
Clinical Staging & Manifestations:
Non-Proliferative Diabetic Retinopathy (NPDR):
Mild/Moderate: Microaneurysms (earliest sign), small dot-and-blot intraretinal hemorrhages, hard lipid exudates (circinate rings), and cotton-wool spots (microinfarctions of the retinal nerve fiber layer).
Severe NPDR (4-2-1 Rule): Intraretinal hemorrhages in all 4 quadrants , venous beading in ≥2 quadrants , or intraretinal microvascular abnormalities (IRMA) in ≥1 quadrant . High risk of rapid progression to proliferative disease.
Proliferative Diabetic Retinopathy (PDR):
Characterized by pathologic neovascularization originating from the optic disc (NVD) or retinal vessels elsewhere (NVE).
Complications: Preretinal and vitreous hemorrhage (sudden painless vision loss with dark floating streaks), fibrovascular traction causing tractional retinal detachment , and neovascular glaucoma.
Diabetic Macular Edema (DME): Fluid accumulation and retinal thickening involving the central macula/fovea; can occur at any stage of NPDR or PDR and is the leading cause of moderate visual impairment in diabetics.
Evidence-Based Management & Screening Guidelines:
Systemic Optimization: Intensive glycemic control (target HbA1c <7.0%), strict blood pressure control (<130/80 mmHg), and lipid management substantially reduce retinopathy onset and progression (DCCT and UKPDS landmark trials).
Intravitreal Anti-VEGF Therapy: First-line standard of care for center-involving diabetic macular edema and high-risk PDR ( Aflibercept , Ranibizumab , or Faricimab ).
Panretinal Photocoagulation (PRP): Argon laser ablation of ischemic peripheral retina to decrease angiogenic VEGF drive and stabilize proliferative vessels.
Screening Protocols:
Type 2 Diabetes: Comprehensive dilated eye examination at the time of initial diagnosis , then annually.
Type 1 Diabetes: Dilated eye examination within 5 years of diagnosis , then annually.
Pregnancy in Pre-existing Diabetes: Dilated exam prior to conception or in first trimester, with close trimester monitoring.
Hypertensive Retinopathy
Retinal vascular changes reflect systemic end-organ microvascular damage from acute or chronic hypertension. Staged using the Keith-Wagener-Barker (KWB) Classification :
KWB Grade Key Funduscopic Findings Pathophysiologic Mechanism Clinical Significance
Grade 1 Generalized and focal arteriolar narrowing; increased arteriolar light reflex ( "copper wiring" ) Diffuse arteriolar sclerosis and hypertonus Chronic mild-to-moderate hypertension
Grade 2 Grade 1 + Arteriovenous (AV) nicking / compression; "silver wiring" (opaque, whitish arteriolar wall) Thickened sclerotic arteriole wall compresses underlying venule at crossing points Longstanding sustained hypertension; marker of systemic atherosclerotic burden
Grade 3 Grade 2 + Flame-shaped retinal hemorrhages , cotton-wool spots , hard exudates forming a "macular star" Breakdown of blood-retinal barrier with focal retinal ischemia and lipid exudation Moderate-to-severe hypertension; high correlation with stroke and nephrosclerosis
Grade 4 Grade 3 + Papilledema (bilateral optic disc swelling with blurred margins, venous engorgement) Severe intracranial and microvascular hypertension with axoplasmic flow stasis Malignant / Hypertensive Emergency ; mandates urgent inpatient BP reduction
Age-Related Macular Degeneration (AMD)
Age-related macular degeneration is the leading cause of irreversible central visual loss in patients aged ≥65 years. Peripheral visual fields remain intact, but central visual acuity (reading, face recognition, driving) is severely impaired.
Dry (Non-Exudative / Atrophic) AMD (85–90% of cases):
Pathophysiology: Accumulation of acellular debris beneath the retinal pigment epithelium (RPE) forming focal extracellular yellow deposits known as drusen , progressing to geographic atrophy of the RPE and overlying photoreceptors.
Symptoms: Gradual, progressive loss of central vision, difficulty reading in low light, and visual distortion ( metamorphopsia , detected by wavy/distorted lines on an Amsler grid ).
Management: Smoking cessation is the most critical modifiable lifestyle intervention. Daily supplementation with the AREDS2 antioxidant formula ( Vitamin C 500 mg, Vitamin E 400 IU, Zinc oxide 80 mg, Cupric oxide 2 mg, Lutein 10 mg, Zeaxanthin 2 mg — replaces beta-carotene to eliminate lung cancer risk in current/former smokers) reduces the 5-year risk of progression to advanced AMD by 25–30% in patients with intermediate drusen or unilateral advanced AMD. Novel complement C3/C5 inhibitors ( Pegcetacoplan , Avacincaptad pegol ) slow the rate of geographic atrophy expansion.
Wet (Exudative / Neovascular) AMD (10–15% of cases, causes 90% of severe blindness):
Pathophysiology: Pathologic growth of abnormal choroidal neovascular membranes (CNVM) extending through breaks in Bruch's membrane into the sub-RPE or subretinal space. These fragile vessels leak fluid and blood, leading to subretinal hemorrhage, lipid exudation, and eventual disciform fibrovascular scarring.
Symptoms: Acute or subacute, rapid, painless distortion and severe drop in central vision with central dark blind spots (scotomas).
First-Line Treatment: Immediate Intravitreal Anti-VEGF Injections ( Aflibercept , Ranibizumab , Faricimab , or Bevacizumab ) administered on a monthly or treat-and-extend regimen to halt vascular permeability, regress neovascularization, and preserve central vision.