Examination of the Optic Fundus
L. William WhitlatchWednesday Conference
Duke NeurosurgeryJanuary 19, 2005
http://www.eyeatlas.com/contents.htm
Unusual Disc Appearances:Medullated nerve fibers
Nerve fibers bare beyond lamina cribrosa: congenital field defect
Prepapillary arterial loops
5% of patients; embryological remnant
Persistent Hyloid Artery
Remnant of artery that supplied lens during development; ends blindly off of disc;Sometimes source of vitreous hemorrhage
Unusual Disc Appearances:Bergmeister’s Papilla
Glial membrane remnants; “ship’s sail”Normally disappears at 7 months
www.mrcophth.com
Unusual Disc Appearances:Retinitis pigmentosa
The brown pigment in the lower half of the eye is the finding that gives the condition its name. The sharp demarcation between the normal retina above and the abnormal retina below is characteristic of rhodopsin mutations.
www.ophth.uiowa.edu/ RP.html
Unusual Disc Appearances:Coloboma
Congenital malformation: flat, white cupped disc
The optic disc is vertically oval with excavation. The retinal vessels have abnormal origin. The choroid and the iris may be involved. The condition may be bilateral.
Patient may have enlargedblind spot, arcuate scotoma or altitudinal defect depending on the size of the coloboma.
Unusual Disc Appearances:
Drusen
Congenital abnormality, mass in optic nerve head;
Causes of Papilloedema
•Raised Intracranial pressure from:Mass lesionsCSF circulation block
•Cerebral edema •Increased CSF Protein (eg SAH)•Malignant hypertension•Metabolic (eg hypercapnia)•Disorders of Circulation (eg venous thrombosis)
Papilloedema
Papilloedema is a non-inflammatory congestion of the optic disc, invariably associated with raised intracranial pressure. It is most often bilateral.
Vision is rarely affected in acute papilloedema but peripheral vision may be lost in chronic cases where it is frequently accompanied by transient visual changes.
Papilloedema will not occur in the presence of optic atrophy as in the Foster-Kennedy syndrome where there is unilateral optic atrophyand contralateral papilloedema, or if the optic nerve sheath on that side is not patent.
Optic cup slightly pale
Earliest at upper and lower margins+/- cotton wool spots
Blind spot enlarges
Note the physiologic shape of the neuroretinalrim and the size of the optic cup in relation to the size of the optic disc. In normal eyes the areas of the optic disc and optic cup are correlated to each other (i.e., the larger the disc, the larger the cup). In most normal optic discs, the inferior neuroretinal rim is wider than the other quadrants. Note also the excellent visibility of the nerve fiber layer.
http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/pdself/fundus.ppt.
Chronic papilloedema
Macular star
Malignant hypertension, renal failure and benign intracranial hypertension
Deep optic cup
Simulates papilloedema
Secondary Optic Atrophy
Even after ICP decreases, scarring, reactive gliosis causes progressive loss of peripheral vision, starting nasally.
Close your right eye and and look directly at the number 3. Can you see the yellow spot in your peripheral vision? Now slowly move towards or away from the screen. At some point, the yellow spot will disappear.
Note how far you are from the screen when the yellow spot vanishes. Repeat the experiment looking at a larger and then again at a smaller number. Did you notice the difference in distance from the video screen when the spot disappeared?
http://www.yorku.ca/eye/blndspo1.htm
Blind Spot Explanation
Form a triangle using the distance between the optic disc and the fovea as one side. You can see that as the distance between the yellow spot and the retina changes the angle (a) changes. It gets larger as the distance gets shorter. Consequently, the closer you are to the screen the nearer you need to fixate to the spot in order to make it disappear. http://www.yorku.ca/eye/blndspo2.htm
Robert Foster Kennedy, 18841952, American neurologist), a neurological condition in which, at fundoscopic examination atrophy, of the papilla is seen on one side and elevation due to raised intracranial pressure on the other. This reflects an intracranial situation in which a tumour, usually a meningioma, compresses the atrophic optic nerve and simultaneously produces intracranial hypertension that can only be appreciated contralaterally.
Foster kennedy's syndrome