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

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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