Optic fundus in clinical medicine

1. 26/02/2008

2. 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

3. Direct ophthalmoscopy
Indirect opthalmoscopy
Sterioscopicalview possible

4. 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

5. Media-hazy, clear
Disc-size, shape, colour, margin, physiological
cup, neuroretinalrim
Blood vessels-caliber, tortousity, irregularities,
changes in the vessel wall, aneurism,
neovascularisation
Exudates
Haemorrhage

6. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

7. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

8. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

9. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

10. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

11. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

12. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

13. 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 neuroretinalrim
Macula temporally
Fovea 2.5mm-diameter, darker

14. Tygroidfundus
Deeply pigmented choroid
Choroidalvessels are seen
Polygonal pigmented areas
in between

16. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge, Retinal h‟ge

17. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge,Retinal h‟ge

18. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge,Retinal h‟ge

19. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge,Retinal h‟ge

20. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge,Retinal h‟ge

21. Dot haemorrhages
Deep within the retina
Leakage of capillaries, venules
Common in diabetes
Flame haemorrhages
Superficial nerve fibrelayer
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, Preretinalh‟ge,Retinal h‟ge

22. 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

23. 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

24. 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

25. White centered retinal haemorrhages
CWS surrounded by h‟mage
CWS-ischaemic axons
H‟maghe-precapillaryarterioles
Sub acute bacterial endocarditis
Leukaemia
Diabetes

26. 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

27. Crack like dehiscence in brusch‟ membrane
Degenerative process combined with calcium
deposition
Linear reddish brown lesion
Lies beneath normal blood vessels
“Pseud‟orange”
Salmon spots, optic nerve drusen
Pseudoxanthomaelasticum, EDS
Paget‟s, Hemoglobinopathies

28. Papillopheblitis(optic disc vasculitis)
Affects healthy individuals <50
Disc edema, cotton wool spots
Venous dilatation and tortousity
Retinal haemorrhages
Retinal vasculitis
Occurs in sarcoidosis, Behcet‟s disease,
Multiple sclerosis, idiopathic
Extremely rare in lupus
Perivenouslymphocytic infiltration
(sheathing)

29. Diffuse retinal dystrophy(rods)
Classic clinical triad
Arteriolar attenuation
Retinal bone-spiculepigmentation
Waxy disc pallor
Starts at mid periphery
Maculopathy
Associations
Bassen-Kornzwiegsyndrome,
Refsum‟sdisease, Kearn-sayre
syndrome , Usher‟s syndrome
Muchopolysaccharidoses, Lauren‟s
moon biedelsyndrome, Friederisch
ataxia

30. Attempt at vascularising ischaemic tissue
Lacks bifurcating pattern
Bleed spontaneously
Diabetic retinopathy
Retinal vein occlusion
Radiation
Sickle cell retinopathy
Retinopathy of prematurity

31. Separation of sensory retina from
pigment epithelium
RhegmatogenousRD
Non-rhegmatogenousRD
Tractional-PDR, ROP, sickle cell
retinopathy, penetrating posterior
segment trauma
Exudative-choroidaltumours,
exophytic retinoblastoma, harada
disease, posterior scleritis, subretinal
neovascularisation, severe
hypertension
Elevated sheath of retinal tissue
with folds

32. Separation of sensory retina from
pigment epithelium
RhegmatogenousRD
Non-rhegmatogenousRD
Tractional-PDR, ROP, sickle cell
retinopathy, penetrating posterior
segment trauma
Exudative-choroidaltumours,
exophytic retinoblastoma, harada
disease, posterior scleritis, subretinal
neovascularisation, severe
hypertension
Elevated sheath of retinal tissue
with folds

34. Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and
veins
Cherry red spot
Investigate for
Valvularheart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders

35. Cholesterol Fibrinoplatelet Calcific
(Hollenhorstplaques)

36. Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and
veins
Cherry red spot
Investigate for
Valvularheart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders

37. Atherosclerosis, embolism
Retina appears white
Attenuation of arteries and
veins
Cherry red spot
Investigate for
Valvularheart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders
Cattle-trucking

38. Embolism, periarteritis
Retinal cloudiness
corresponding to the areas of
ischemia
Narrowing of arteries and
veins
One or more emboli may be
present

39. Present in 20% of population
It may be isolated, combined
CRVO, combined AION
Localised cloudiness-macula
and papillomacularbundle

40. Occlusion of short posterior ciliaryarteries
Disc is pale
Diffuse or sectoraledema
Splinter shaped h‟mages
„Pseudo-Foster kennedysyndrome‟

41. Giant cell arteritis
Cotton wool spots are uncommon
Cilioretinalartery occlusion
Central artery occlusion

42. Etiology
Arteriosclerosis
Increasing age
Hypertension
Diabetes mellitus
Blood dyscrasiasis
Periphlebitis
Raised intraocular tension

43. Dilatation & tortousity
of all branches of CRV
Retinal h‟age-superficial
& deep throughout
“Blood and thunder”
Cotton wool spots
Optic disc edema
Macular edema

44. Venous dilatation and
tortousity peripheral to
the site of occlusion
Hemorrhages
Retinal edema
Cotton wool spots
Neovascularisation

45. Most common cause of legal blindness in 20-65 yrs
Type 1>Type 2 (40% , 20%)
Risk factors
Duration of diabetes
Poor metabolic control
Pregnancy
Hypertension
Nephropathy
Smocking
Obesity
Hyperlipidaemia

46. Micro vascular occlusionMicrovascularleakage

47. Eva kohner‟sclassification
Non-proliferative diabetic retinopathy
Pre-proliferative diabetic retinopathy
Proliferative diabetic retinopathy

48. Micro aneurysms
(earliest lesion)
Hard exudates
Retinal edema
Haemorrhages

49. Cotton wool spots
Intra retinal micro vascular abnormalities(IRMA)
Venous changes
Dilatation, looping
Beading, segmentation
Arterial changes
Narrowing, occlusion
Silver wiring
Dark blot haemorrhages

50. Involvement of fovea
Perifovealhard exudates
Dark blot hemorrhages

51. Neovascularisation
Venous looping
Venous beading
NVD
NVE

52. NVD NVE

53. 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

54. GRADE 1
Generalisedarteriolar
narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes
(Salussign)

55. GRADE 1
Focal arteriolar
narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes
(Salussign)

56. GRADE 3
Prominent AV changes
(Bonnet, Gunn signs)
Retina edema, CWS
Flame h‟mages
GRADE 4
Features of grade 3
Papilloedema

57. Grade 0
Grade 1Grade 4
Grade 2Grade 3

58. Rare, occurs in hypertensive crisis
„Elschnigspots‟
„Siegriststreaks‟
Exudative retinal detachment

59. Creamy appearance of the
vessels in the posterior
pole and peripheral area
Triglycerides >2500mg/dl

60. 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 pericapillary
haemorrhages

62. Sickle cell anaemia& Sickle cell thalassemia
are associated severe ocular manifestations
Proliferative changes
Seafanneovascularisation
Haemorrhages

63. STAGING
1.Peripheral arteriolar
occlusion
2.Peripheral AV
anastomosis
3.Sprouting new vessels
4.Vitreous haemorrhage
5.Retinal detachment
1
24
5
3

64. Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioidstreaks

65. Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioidstreaks

66. Rarely diagnostic importance
Duration &type don‟t influence
Pale fundus
Haemorrhages
Cotton wool spots
Roth spot
Venous tortousity-related severity of anemia

67. More common in a/c leukaemia
Primary-infiltration
Secondary-anemia, thrombocytopaenia,
hyperviscosity, infection
Superficial haemorrhages
Roth spot
Cotton wool spot

68. Peripheral retinal vascularisation
Pigment epitheliopathy-‛leopard spot‟

69. Venous dilatation
Segmentation
Venous tortousity
Retinal haemorrhages

70. Viral
CMV
HIV
Rubella
Bacterial
Tuberculosis
Syphilis
Parasitic
Toxoplasmosis
Fungal

71. 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

72. 60% of AIDS patients
Retinal microangiopathy
Multiple cotton wool spots
Non infectious

73. Salt & pepper retinopathy,
most marked at macula
Disc & vessels normal
Pigmenterydisturbance at
posterior pole
Optic neuritis

74. Intractable chronic uveitis
Focal/multi focal choroiditis
Choroidalgranuloma
Periphlebits
Panuveitis

75. 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
juxtapapillaryretinitis)
Atypical lesions

76. 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
juxtapapillaryretinitis)
Atypical lesions

77. 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
juxtapapillaryretinitis)
Atypical lesions

79. Retinal periphlebitis
„Candle wax drippings‟
Branch retinal vein occlusion
Cotton ball vitreous opacities
Haemorrhages,
Granulomas
Optic nerve edema and
granuloma

80. Optic disc granuloma Retinal granuloma
‟Landers sign‟

81. Optic disc granuloma Retinal granuloma
‟Landers sign‟

82. A/c recurrent Hypopyonuveitis
Retinitis-superficial infiltrates
Retinal vasculitis
Periphlebitis & periarteritis
Vascular occlusion
Vascular leakage
Optic disc edema
Retinal exudation
Vitritis

83. Optic disc edema
Multifocal detachments of
the sensory retina
Exudative retinal
detachment
Numerous, residual, small,
atrophic scars
(‛sunset glow‟ fundus)

84. No typical features
Retinopathy
Haemorrhages
Cotton wool spots
Vascular occlusions

86. 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

87. 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

88. 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

89. Incomplete closure of the choroid fissure
Discrete, focal, glistening, white,
bowl shaped excavation
Disc may enlarged
Retinal vasculature normal
Complication-RD
Trisomy13, 18, 22
CHARGE

90. Visual acuity very poor
Enlarged disc with funnel shaped excavation
Central core -whitish glialtissue
Spokes of wheel appearance
Complication-RD
Frontonasaldysplasia
Neurofibromatosis type-2

91. Myelinationextend to retina
Don‟t interfere with vision
Larger & denser than CWS
Always connected to optic disc
No overlying vitreous haze

92. Normal vertical cup-disc ratio 0.3 or less

93. Inflammatory, infective or demyelinatingprocess
Retrobulbarneuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltiswith retinal nerve fibrelayer inflammation
Macular star
Viral infection , cat scratch fever, syphilis

94. Inflammatory, infective or demyelinatingprocess
Retrobulbarneuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltiswith retinal nerve fibrelayer inflammation
Macular star
Viral infection , cat scratch fever, syphilis

95. Inflammatory, infective or demyelinatingprocess
Retrobulbarneuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltiswith retinal nerve fibrelayer inflammation
Macular star
Viral infection , cat scratch fever, syphilis

96. Swelling of optic nerve head secondary to
raised intracranial pressure
Early papilloedema
Optic disc-hyperemia
& mild elevation
Disk margins indistinct
Loss of spontaneous
venous pulsation

97. Established papilloedema
Hyperaemia of optic disc
Blurred, elevated margin
Obliterated cup
Venous engorgement
Flame shaped hemorrhages
Cotton wool spots
Hard exudates-‛macular fan‟

98. Chronic papilloedema
Optic disc elevated and white
‛champagne cork appearance‟
Usual cause chronic elevated ICT
Corpora amylacea
Irreversible visual loss
Cotton wool spot & h‟mage
absent

99. 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-„Kestenbaumsign‟
Atrophy may be diffuse/sectoral

100. 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-„Kestenbaumsign‟
Atrophy may be diffuse/sectoral

101. Preceded by swelling
Papilloedema, AION, Optic neuritis
Dirty grey slightly raised disc
Ill defined margins –gliosis
Sheathed vessels
Reduction in small vessels

103. Clinical opthalmology-Jack J.Kanski5
th
Ed.
“The Eyes Have It”-University of Michigan
Harrison‟s Principles of internal medicine 16
th
Ed.
Parsons‟ Diseases of the Eye 20
th
Ed.
New England Journal of Medicine