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26/02/2008
Only place in the body where blood vessels can be visualized directly
Mirror the status of the systemic circulation
Continuity of nerve fibers and meninges
Reflects specific changes in systemic diseases
Contribute to diagnosis
Direct ophthalmoscopy
Indirect opthalmoscopySterioscopical view possible
Ideally fundus should be examined in a darkened room
Patient should be asked to fix their gaze on a distant object
Examine with corresponding eyes
The ideal line of approach should bring the optic disc straight in to view
If only blood vessels on a pink background are seen they should be followed , the disk will eventually come in to view
Media- hazy, clear
Disc- size, shape, colour, margin, physiological cup, neuroretinal rim
Blood vessels- caliber, tortousity, irregularities, changes in the vessel wall, aneurism, neovascularisation
Exudates
Haemorrhage
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Uniform red to pink
Disc-pale pink
1.5 mm in diameter
Nasal margin slightly blurred
Vessels emanate from optic cup
Consist of central cup and
peripheral neuroretinal rim
Macula temporally
Fovea 2.5mm-diameter, darker
Tygroid fundus
Deeply pigmented choroid
Choroidal vessels are seen
Polygonal pigmented areas in between
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Dot haemorrhages Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages Superficial nerve fibre layer
Leakage of capillaries, venules
that are ischemic or, in the case of veins, under high pressure
Boat haemorrhages (pre-retinal) Interface between retina & vitreous
Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge
Hard exudate
Deep yellow with sharp margins
Often circinate
Leakage from pre-capillary arterioles
DM, HTN, VHL disease, radiation
„Macular star‟
Soft exudate(cotton wool spot)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
Hard exudate
Deep yellow with sharp margins
Often circinate
Leakage from pre-capillary arterioles
DM, HTN, VHL disease, radiation
„Macular star‟
Soft exudate(cotton wool spot)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
Hard exudate
Deep yellow with sharp margins
Often circinate
Leakage from pre-capillary arterioles
DM, HTN, VHL disease, radiation
„Macular fan‟
Soft exudate(cotton wool spot)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
White centered retinal haemorrhages
CWS surrounded by h‟mage
CWS- ischaemic axons
H‟maghe- precapillary arterioles
Sub acute bacterial endocarditis
Leukaemia
Diabetes
Deposition in ganglion cell layer
Thickening & loss of transparency of retina
Foveola-ganglion cells absent, thin, so contrast
Sphingolipidoses
Central retinal artery occlusion
Berlins edema
Crack like dehiscence in brusch‟ membrane
Degenerative process combined with calcium deposition
Linear reddish brown lesion
Lies beneath normal blood vessels
“Pseu d‟orange”
Salmon spots, optic nerve drusen
Pseudoxanthoma elasticum, EDS
Paget‟s, Hemoglobinopathies
Papillopheblitis (optic disc vasculitis)Affects healthy individuals <50
Disc edema, cotton wool spots
Venous dilatation and tortousity
Retinal haemorrhages
Retinal vasculitisOccurs in sarcoidosis, Behcet‟s disease,
Multiple sclerosis, idiopathic
Extremely rare in lupus
Perivenous lymphocytic infiltration (sheathing)
Diffuse retinal dystrophy(rods)
Classic clinical triadArteriolar attenuation
Retinal bone-spicule pigmentation
Waxy disc pallor
Starts at mid periphery
Maculopathy
Associations Bassen-Kornzwieg syndrome,
Refsum‟s disease, Kearn-sayresyndrome , Usher‟s syndrome Muchopolysaccharidoses, Lauren‟s moon biedel syndrome, Friederischataxia
Attempt at vascularising ischaemic tissue
Lacks bifurcating pattern
Bleed spontaneously
Diabetic retinopathy
Retinal vein occlusion
Radiation
Sickle cell retinopathy
Retinopathy of prematurity
Separation of sensory retina from pigment epithelium
Rhegmatogenous RD
Non-rhegmatogenous RD Tractional- PDR, ROP, sickle cell
retinopathy, penetrating posterior segment trauma
Exudative- choroidal tumours, exophytic retinoblastoma, haradadisease, posterior scleritis, subretinalneovascularisation, severe hypertension
Elevated sheath of retinal tissue with folds
Separation of sensory retina from pigment epithelium
Rhegmatogenous RD
Non-rhegmatogenous RD Tractional- PDR, ROP, sickle cell
retinopathy, penetrating posterior segment trauma
Exudative- choroidal tumours, exophytic retinoblastoma, haradadisease, posterior scleritis, subretinalneovascularisation, severe hypertension
Elevated sheath of retinal tissue with folds
Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and veins
Cherry red spot
Investigate for
Valvular heart disease, endocarditis, mural thrombi, Carotid artery disease, systemic vasculitis, hematological disorders
Cholesterol Fibrinoplatelet Calcific
(Hollenhorst plaques)
Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and veins
Cherry red spot
Investigate for
Valvular heart disease, endocarditis, mural thrombi, Carotid artery disease, systemic vasculitis, hematological disorders
Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and veins
Cherry red spot
Investigate for
Valvular heart disease, endocarditis, mural thrombi, Carotid artery disease, systemic vasculitis, hematological disorders
Cattle-trucking
Embolism, periarteritis
Retinal cloudiness corresponding to the areas of ischemia
Narrowing of arteries and veins
One or more emboli may be present
Present in 20% of population
It may be isolated, combined CRVO, combined AION
Localised cloudiness- macula and papillomacular bundle
Occlusion of short posterior ciliary arteries
Disc is pale
Diffuse or sectoral edema
Splinter shaped h‟mages
„Pseudo-Foster kennedy syndrome‟
Giant cell arteritis
Cotton wool spots are uncommon
Cilioretinal artery occlusion
Central artery occlusion
EtiologyArteriosclerosis
Increasing age
Hypertension
Diabetes mellitus
Blood dyscrasiasis
Periphlebitis
Raised intraocular tension
Dilatation & tortousity of all branches of CRV
Retinal h‟age- superficial & deep throughout
“Blood and thunder”
Cotton wool spots
Optic disc edema
Macular edema
Venous dilatation and tortousity peripheral to the site of occlusion
Hemorrhages
Retinal edema
Cotton wool spots
Neovascularisation
Most common cause of legal blindness in 20-65 yrs
Type 1>Type 2 (40% , 20%)
Risk factorsDuration of diabetes
Poor metabolic control
Pregnancy
Hypertension
Nephropathy
Smocking
Obesity
Hyperlipidaemia
Micro vascular occlusion Microvascular leakage
Eva kohner‟s classification
Non-proliferative diabetic retinopathy
Pre-proliferative diabetic retinopathy
Proliferative diabetic retinopathy
Micro aneurysms(earliest lesion)
Hard exudates
Retinal edema
Haemorrhages
Cotton wool spots
Intra retinal micro vascular abnormalities(IRMA)
Venous changes
Dilatation, looping
Beading, segmentation
Arterial changes
Narrowing, occlusion
Silver wiring
Dark blot haemorrhages
Involvement of fovea
Perifoveal hard exudates
Dark blot hemorrhages
Neovascularisation
Venous looping
Venous beading
NVD
NVE
NVD NVE
Primary response to HTN- vasoconstriction
Narrowing depend on pre-existing sclerosis
Narrowing seen in its pure form only in young individuals
Sustained HTN-inner BRB disrupted
Increased vascular permeability
Narrowing and sclerosis suggests duration of hypertension
GRADE 1
Generalised arteriolar narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes(Salus sign)
GRADE 1
Focal arteriolar narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes(Salus sign)
GRADE 3
Prominent AV changes (Bonnet, Gunn signs)
Retina edema, CWS
Flame h‟mages
GRADE 4
Features of grade 3
Papilloedema
Grade 0
Grade 1Grade 4
Grade 2Grade 3
Rare, occurs in hypertensive crisis
„Elschnig spots‟
„Siegrist streaks‟
Exudative retinal detachment
Creamy appearance of the vessels in the posterior pole and peripheral area
Triglycerides >2500mg/dl
Micro vascular occlusion and ischemia
Severe head trauma, chest compression injury, Embolism, a/c pancreatitis, carcinoma, connective tissue diseases,
Lymphoma, TTP, Bone marrow transplantation
Multiple superficial white retinal patches
Superficial pericapillaryhaemorrhages
Sickle cell anaemia & Sickle cell thalassemia are associated severe ocular manifestations
Proliferative changes
Seafan neovascularisation
Haemorrhages
STAGING
1. Peripheral arteriolar occlusion
2. Peripheral AV anastomosis
3. Sprouting new vessels
4. Vitreous haemorrhage
5. Retinal detachment
1
24
5
3
Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioid streaks
Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioid streaks
Rarely diagnostic importance
Duration &type don‟t influence
Pale fundus
Haemorrhages
Cotton wool spots
Roth spot
Venous tortousity-related severity of anemia
More common in a/c leukaemia
Primary- infiltration
Secondary- anemia, thrombocytopaenia, hyperviscosity, infection
Superficial haemorrhages
Roth spot
Cotton wool spot
Peripheral retinal vascularisation
Pigment epitheliopathy- ‛leopard spot‟
Venous dilatation
Segmentation
Venous tortousity
Retinal haemorrhages
Viral
CMV
HIV
Rubella
Bacterial
Tuberculosis
Syphilis
Parasitic
Toxoplasmosis
Fungal
Most common ocular infection in AIDS
Indolent retinitis
Starts in the periphery
Mild granular opacification
Fulminating retinitis
Dense white opacification
Vasculitis, mild vitritis
Hemorrhages
Extension along blood vessels
Involve optic nerve head
60% of AIDS patients
Retinal microangiopathy
Multiple cotton wool spots
Non infectious
Salt & pepper retinopathy, most marked at macula
Disc & vessels normal
Pigmentery disturbance at posterior pole
Optic neuritis
Intractable chronic uveitis
Focal/multi focal choroiditis
Choroidal granuloma
Periphlebits
Panuveitis
Quiscent Bilateral/unilateral healed chorio
retinal scars
Reactivation retinochoroiditis Adjacent to old scar
(satellite lesion)
Vasculitis,
Severe vitritis
(headlight in the fog‟ appearance)
Papillitis (secondary to juxtapapillary retinitis)
Atypical lesions
Quiscent Bilateral/unilateral healed chorio
retinal scars
Reactivation retinochoroiditis Adjacent to old scar
(satellite lesion)
Vasculitis,
Severe vitritis
(headlight in the fog‟ appearance)
Papillitis (secondary to juxtapapillary retinitis)
Atypical lesions
Quiscent Bilateral/unilateral healed chorio
retinal scars
Reactivation retinochoroiditis Adjacent to old scar
(satellite lesion)
Vasculitis,
Severe vitritis
(headlight in the fog‟ appearance)
Papillitis (secondary to juxtapapillary retinitis)
Atypical lesions
Retinal periphlebitis
„Candle wax drippings‟
Branch retinal vein occlusion
Cotton ball vitreous opacities
Haemorrhages,
Granulomas
Optic nerve edema and granuloma
Optic disc granuloma Retinal granuloma ‟Landers sign‟
Optic disc granuloma Retinal granuloma ‟Landers sign‟
A/c recurrent Hypopyon uveitis
Retinitis- superficial infiltrates
Retinal vasculitis
Periphlebitis & periarteritis
Vascular occlusion
Vascular leakage
Optic disc edema
Retinal exudation
Vitritis
Optic disc edema
Multifocal detachments of the sensory retina
Exudative retinal detachment
Numerous, residual, small, atrophic scars(‛sunset glow‟ fundus)
No typical features
Retinopathy
Haemorrhages
Cotton wool spots
Vascular occlusions
Hyaline like calcific material within optic disc
Often bilateral, 0.3%
Buried drusen
Elevated disc, scalloped margin
No physiological cup
No hyperaemia
Vessels not obscured
Venous pulsation present
Exposed drusen
Waxy pearl like irregularities
Hyaline like calcific material within optic disc
Often bilateral, 0.3%
Buried drusen
Elevated disc, scalloped margin
No physiological cup
No hyperaemia
Vessels not obscured
Venous pulsation present
Exposed drusen
Waxy pearl like irregularities
Hyaline like calcific material within optic disc
Often bilateral, 0.3%
Buried drusen
Elevated disc, scalloped margin
No physiological cup
No hyperaemia
Vessels not obscured
Venous pulsation present
Exposed drusen
Waxy pearl like irregularities
Incomplete closure of the choroid fissure
Discrete, focal, glistening, white,bowl shaped excavation
Disc may enlarged
Retinal vasculature normal
Complication- RD
Trisomy 13, 18, 22
CHARGE
Visual acuity very poor
Enlarged disc with funnel shaped excavation
Central core -whitish glial tissue
Spokes of wheel appearance
Complication- RD
Frontonasal dysplasia
Neurofibromatosis type-2
Myelination extend to retina
Don‟t interfere with vision
Larger & denser than CWS
Always connected to optic disc
No overlying vitreous haze
Normal vertical cup-disc ratio 0.3 or less
Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
Swelling of optic nerve head secondary to raised intracranial pressure
Early papilloedema
Optic disc- hyperemia & mild elevation
Disk margins indistinct
Loss of spontaneousvenous pulsation
Established papilloedema
Hyperaemia of optic disc
Blurred, elevated margin
Obliterated cup
Venous engorgement
Flame shaped hemorrhages
Cotton wool spots
Hard exudates-‛macular fan‟
Chronic papilloedema
Optic disc elevated and white ‛champagne cork appearance‟
Usual cause chronic elevated ICT
Corpora amylacea
Irreversible visual loss
Cotton wool spot & h‟mageabsent
Retro laminar portion of optic nerve to lateral geniculate body
Lesion anterior to optic chiasma-unilateral
RB neuritis, hereditary, compressive lesions, toxic& nutritional optic neuropathy
Without antecedent swelling of optic disc
Pale flat disc, clear margins
Reduction in no. of small BV on the disc- „Kestenbaum sign‟
Atrophy may be diffuse/sectoral
Retro laminar portion of optic nerve to lateral geniculate body
RB neuritis, hereditary, compressive lesions, toxic& nutritional optic neuropathy
Without antecedent swelling of optic disc
Lesion anterior to optic chiasma-unilateral
Pale flat disc, clear margins
Reduction in no. of small BV on the disc- „Kestenbaum sign‟
Atrophy may be diffuse/sectoral
Preceded by swelling
Papilloedema, AION, Optic neuritis
Dirty grey slightly raised disc
Ill defined margins –gliosis
Sheathed vessels
Reduction in small vessels
Clinical opthalmology- Jack J.Kanski 5th Ed.
“The Eyes Have It”-University of Michigan
Harrison‟s Principles of internal medicine 16th Ed.
Parsons‟ Diseases of the Eye 20th Ed.
New England Journal of Medicine