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17/04/2017
Introduction
Examination of Fundus
Contents Ancillary Investigations
Conclusion
INTRODUCTION
Innermost layer of the eyeball
Optic disc to ora serrata
Vision – sole function
Form
Color
Scotopic (night vision)
Photopic (day vision)
Direct Ophthalmoscopy
Indirect Ophthalmoscopy
Media
Optic Disc
General Background
Vasculature
Exudates
Hemorrhages
Scar
Macula
Periphery
Detachment
Transparent – better visualization
Examination – direct
ophthalmoscope:
Distance of 20cm
Interposing plus lenses
Gradual reduction of distance
Causes for opaque media:
Corneal opacity
Lenticular opacity
Vitreous opacity
Normal – circular
Tilted Disc
Oblique entry of optic nerve
Oval or D-shaped
May be horizontal or nearly vertical
Situs inversus – nasal deviation of temporal
vessels before turning temporally
Myopia and/or astigmatism
Hypopigmentation of inferonasal fundus
Torsional Disc
Long axis is inclined at more than 15° from
vertical meridian
Often associated with tilting
Associated with myopia
Tilted Disc
Torsional Disc
Hypermetropia
Slightly elevated with small or absent
cup
Crowding of blood vessels
Absence of capillary dilatation
Hypoplasia
Small disc surrounded by halo of
pigmentary change (“double-ring”
sign)
Normal caliber of vessels; though
tortuous
Hypermetropia
Pathological Myopia
Papilledema
Condition Laterality Findings
• Initial: mild hyperemia,
indistinct margins
• Established: moderate disc
Papilledema Bilateral elevation, flame hemorrhage,
cotton-wool spots
• Chronic: optico-ciliary
shunts, drusen-like deposits
CRVO Unilateral • Mild hyperemic swelling
• Segmental, diffuse, edematous
AION Unilateral • Pale or hyperemic disc
• Splinter hemorrhage
• Disc hyperemia, blurred
margins
Optic Neuritis Unilateral • Splinter hemorrhages,
tortuous veins
Congenital
Bergmeister papilla – raised glial tissue
on the disc
Acquired
Collaterals
Veno-venular shunts
Develop in the framework of existing
vascular network
Bypass an area of closure
Distended, flat vessels that start and end
on the disc
Optico-ciliary shunt
Anastomoses between retinal and
choroidal circulations
Slightly tortuous vessels that disappear at
retina-disc junction
Cause – papilledema, optic nerve glioma
Neovascularization
Fine, lace-like vessels
Extend on to adjacent retina
Hemorrhage
Flame-shaped
Solitary or multiple
Causes
Acute papilledema
AION
Drusen of optic nerve
Chronic glaucoma
Optico-ciliary Shunt
Bergmeister Papilla
Retina – transparent membrane
Pink color – choroid shining
underneath
White color – separation,
inflammation, edema
Pale – CRAO, anemia, artery
attenuation due to toxins, edema,
retinitis, and detachment
Hyperemia – obstructive or
inflammatory venous congestion
Lesser amounts of pigment in
RPE
Streaks of underlying choroid
become visible
Dark individuals, advanced age,
myopia
Differentiated between choroidal
vessel sclerosis
Genetic, autosomal dominant
Diffuse atrophy of RPE and
choriocapillaris
Genetically determined
Heterogenous group of melanin
synthesis disorders
Three types:
Tyrosine-negative subcutaneous
Tyrosine-positive subcutaneous
Ocular
Types of Albinism Fundus Findings
• Lack of pigment
Tyrosine-Negative • Large choroidal vessels
Subcutaneous • Foveal hypoplasia
• Loss of foveal pit
Tyrosine-Positive
Variable hypopigmentation
Subcutaneous
• Females: Scattered areas of
depigmentation and
Ocular granularity
• Males: Hypopigmented
fundus
Tyrosine-Negative Subcutaneous Albinism Tyrosine-Positive Subcutaneous Albinism
Ocular Albinism
Tiny, yellow or white accumulations of
extracellular material with pigmented
margins
Broad range of constituents
Derived from immune-mediated and
metabolic processes in RPE
Builds up between Bruch’s membrane
and RPE
Mainly involve posterior pole
Seen in: ARMD, Doyne’s honey-comb
dystrophy
Drusen Types
• Well-defined white-yellow –
“hard” drusen
Small • Measure <63 m m
• Vision loss – pigmentary
abnormalities
• Fairly-defined
• At level of RPE; b/w 63 and
125 m m
Intermediate • Pigmentary abnormalities –
risk of late AMD (10%) over 5
years
• Over 125 m m
• “Soft” drusen
Large • More numerous – coalesce
• Localized elevation of RPE –
“drusenoid RPE detachment”
Retinoblastoma
Melanoma
Astrocytoma
Leucocoria in a patient with retinoblastoma
Attenuated Vessels
Vessel Sheathing
Macro-aneurysm
Venous – present in 10-20% of
individuals
Absent in papilledema
Arterial – always pathological
Causes:
Diabetic retinopathy
Neovascular ARMD
Retrolental fibroplasia (retinopathy of
prematurity)
Neovascular glaucoma
Retinal venous occlusion
Incomplete vascularization of retina
Exposure to high ambient oxygen and
birth weight <1500g
Examined by indirect ophthalmoscopy
after 4-6 weeks chronological age
Hard Exudate
Hemorrhage Features Causes
• Flame-shaped or splinter • Hypertension
Intra-retinal: • Seen in RNFL • Diabetes
Superficial • Associated with exudates • Occlusions
• Blood dyscrasias
• Dot: small and round; located in middle retinal • Diabetic retinopathy
layers • Retinal venous
• Blot: full-thickness; larger, darker, and deeper than occlusion
Intra-retinal: Deep dot • Radiation
• Differentiate from micro-aneurysms on FFA: retinopathy
blockage in hemorrhage, visible in micro-aneurysm
• Trauma
• Dark, raised circular appearance
Sub-retinal • Sickle-cell anemia
• Between photoreceptors and RPE
• CNV
• Between ALM and vitreous • Eale’s disease
• Large; arise from unsupported new vessels • PDR
Pre-retinal • Settling down into “boat-shaped” crescentric • CRVO
configuration • Trauma
• May breach vitreous • Valsalva retinopathy
Dot-and-Blot and Flame-Shaped Hemorrhage
Age Above 50
Best Dystrophy
Separation of sensory retina from
RPE by sub-retinal fluid
Invariably caused by a tear or hole
Raised from its surroundings
White in color
Corrugations over surface
Blood vessels – traverse over
detached retina
Darker color of vessels
Occurs where hole or tear is located
Full-thickness defects in neuro-
retina
Vitreous percolation through breaks
– separation of neuroretina from
RPE
RD due to break – rhegmatogenous
RD due to tractional band –
tractional
Separation of all layers from
choroid – secondary detachment
Hole:
Circular
With or without operculum
Tear:
Triangular, irregular, arrow-head
shaped
May have operculum
Dialysis:
Separation of retina from periphery
Large with concave border
Rolled-up edge
Feature Rhegmatogenous Tractional Exudative
Incidence Common Less common
Present; cause for Not present initially;
Break detachment may develop later
None
May be small;
expands soon and Smaller, does not Small, never involves
Size may cover whole reach ora serrata whole retina
retina
Sub-retinal Fluid Does not shift Shifts
Corrugated b/c of
Surface inter-retinal edema
Smooth
Color of New
Absent May be present Seen at apex of tumor
Vessels
• Fundus Fluorescein
Angiography
• Indocyanine Green
Angiography
Some • B-scan USG
Ancillary • Optical Coherence
Investigations Tomography
Assesses the integrity of the retinal
and choroidal vasculature
Changes produced by fundus
disorders in flow of fluorescein
Indications:
Diabetic retinopathy
Vascular occlusions
Central Serous Retinopathy
Cystoid Macular Edema
FFA of Central Serous Retinopathy FFA of Cystoid Macular Edema
Retinoblastoma
Cross-sectional images of tissue using light
waves
Retina – easily accessible to light
Information akin to in-vivo histopathology of
structure
Allows study of macular and peripapillary
regions including RNFL and ONH region
Normal OCT of macula Normal OCT of Optic Nerve Head