Aravind Kumar

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

Slit-Lamp Fundus Biomicroscopy

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

Optic Disc Hypoplasia

High myopia
Error >-6D, axial length >26mm
Disc – exaggerated by chorio-retinal
atrophy
Temporal crescent – thinning at optic disc
Optic Disc Pit
Isolated, unilateral, congenital condition
Mild enlargement of ONH
Round or oval depression of variable size
Involves temporal margin of disc
Look for – macular detachment; DD:
CSR
Coloboma
Unilateral or bilateral
Failure of fusion of fetal fissure
Partial excavation that has a glistening
appearance
DD – typical appearance (“splayed”)
of central blood vessel
Morning glory anomaly
Core of white tissue occupying the
central area
Blood vessels emerge in a spoke-like
manner
 Optic Disc Coloboma Optic Disc Pit

Pathological Myopia

Morning Glory Morning Glory Anomaly

Normal depression due to backward
bowing of lamina cribrosa
Lateral floor has slope toward center
Small bluish dots – holes in lamina
Visible holes – primary and
glaucomatous optic atrophy
Obscure – hypoplasia, papillitis,
papilledema, secondary optic atrophy
Physiological large cup
 Large cup with pink neuro-retinal rim
 Absence of notching and bayonetting
blood vessels
 Inferior neuro-retinal rim is broadest
followed by superior, nasal, and
temporal (ISNT rule)
 Glaucoma
 Notching and thinning of neuro-retinal
rim and bayonetting of blood vessels
 Disc pallor and peripapillary atrophy
 ISNT rule broken
 Normal Cup following ISNT rule Physiological Large Cup

Glaucomatous cup with bayonetting of vessel

Measured by direct ophthalmoscopy
Interposition of minus lenses until
bottom is visible
3D change in depth = 1mm
excavation
Causes for large cup
Chronic simple glaucoma
Myopia
Coloboma
Diameter of cup expressed as
fraction of diameter of disc
Normal – 0.3
Full cup – papilledema and papillitis
Normal – white (part of nerve)
Pink – presence of small capillaries
(10-15)
Hyperemia - >15
Pallor - <10
 Hyperemia Pallor
• Optic neuritis • Severe anemia
• Papilledema • Central retinal artery
• Venous obstruction occlusion
• Neovascularization • Ischemic optic
• Trace of blood on disc neuropathy
surface • Optic atrophy
• Splinter hemorrhage • Glaucoma
sometimes present • Coloboma
• Myopia
Primary optic atrophy – white and flat disc
Secondary optic atrophy – white or dirty grey disc
Consecutive optic atrophy – waxy yellow disc
Primary Optic Atrophy Secondary Optic Atrophy Consecutive Optic Atrophy

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

B-Scan USG of retinoblastoma Fundus appearance in retinoblastoma

Crack-like dehiscences in brittle, thickened
Bruch’s membrane
Associated with atrophy of overlying RPE
Grey or dark red linear lesions with
irregular serrated edges
Intercommunicate in a ring-like fashion
around the optic disc
Radiate outward from peripapillary area
‘Peau d’orange’ is common
Angioid Streaks

Peau d’Orange Appearance of the Fundus

 Artery Vein
Thin, rounded, and pale Broad, flat, and dark

More prone for hypertensive

More prone for sclerosis
changes
Attenuation
Thinning or weakening of vessels, esp.
arteries
Dilatation
Widening of blood vessels
Due to relaxation of smooth muscle
cells in the vessel walls
Tortuosity (twisted blood vessels)
 Change in Caliber Cause
• Diabetes
• Hypertension
Dilated, Tortuous Veins • Arteriosclerosis
• Collagen vascular disease
• Giant cell arteritis
Dilated, Non-tortuous • Behçet’s disease
Veins • Atherosclerosis

Dilated Arterioles • Retinal macro-aneurysm

• Possible association with systemic

Tortuous Arterioles vascular diseases
• Hypertension
• Retinitis Pigmentosa
Attenuation • Atherosclerosis
• Arterial occlusion
 Tortuous Vessels

Attenuated Vessels

Dilated and Tortuous Vessels

Increased light reflex from vessel wall
due to sclerosis
Types:
Silver-wire
Copper-wire
Sheathing
Changes in contents
 Type Features Causes
• Completely opaque vessel wall
Silver-wire • Invisible blood column
• Light reflex occupies entire width of arteriole • Arteriosclerosis
• Opacification of vessel wall • Hypertensive
Copper- • Blood column is seen perpendicularly retinopathy
wire • Acquires color of grey-yellow plaques in the
vessel wall
• Fibrous envelopes
• Ensheath arteries and their veins
• Retinal vasculitis
Sheathing • Collection of exudation consisting of
• Eale’s disease
inflammatory cells
• Appearance of white cuff around the vessels
Copper Wire Appearance

Vessel Sheathing

Silver Wire Appearance

Excessive localized enlargement of an
artery
Due to weakness of arterial wall
Risk for rupture and bleeding
Aneurysms in the retina
Micro-aneurysm
Macro-aneurysm
 Type Features Causes
• Localized outpouchings of capillary
wall
• Diabetic
• Formed by: focal dilatation of
retinopathy
capillary wall or fusion of two arms
Micro- of capillary loop
• Venous
aneurysm occlusions
• Tiny red dots, often temporal to
• Hypertensive
fovea
retinopathy
• FFA: hyper-fluorescence due to
leakage
• Localized dilatation of retinal
arteriole
• Occurs at a bifurcation or • Hypertensive
Macro- arteriovenous crossing retinopathy,
aneurysm • Enlarge to several times its size more in women
• Has predilection for older
hypertensive women (75%)
Micro-aneurysm

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

Grading of the fundus in retinopathy of prematurity

Stage I: Line of demarcation
separating immature avascular
retina from mature vascular retina
Stage II: Ridge of demarcation
Stage III: Extra fibro-vascular
growth
Stage IV: Retinal detachment
IV-A: Subtotal detachment with
spared macula
IV-B: Macular involvement
Stage V: Total retinal detachment
Stage I: Line of Demarcation Stage II: Ridge of Demarcation

Stage IV: Retinal Detachment

Stage III: Extra Fibro-vascular Growth

Stage V: Total Retinal Detachment

Leak of serum, protein, and fibrin
from a damaged vessel wall
Types
Soft
Hard
Level of development:
Superficial
Deep
Exudate Features Causes
• Cotton-wool spots
• Fluffy white patches
• Hypertension
• Anoxia and ischemia following occlusion of small
• Pre-proliferative DR
capillaries
• Coat’s disease
• Edema and proliferation of neural element
Soft • Represent axoplasmic residue
• CRVO
• Eale’s disease
• DD: myelinated nerve fibers – feathery-like streaks in
• HIV micro-
RNFL
angiopathy
• DD: retinitis – yellow-white cloudy lesions associated
with vitritis

• Chronic capillary leakage

• Develop at the junction of normal and edematous • Background diabetic
retina retinopathy
Hard • Composed of lipoprotein and lipid-filled macrophages • Wet ARMD
• Waxy yellow border • Coat’s disease
• Layers deeper to RNFL • Circinate retinopathy
• DD: drusen – not associated with changes
Soft Exudate

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

Pre-Retinal Hemorrhage Sub-retinal hemorrhage

Special type of superficial exudate
Seen in the center of a patch of
superficial hemorrhage
More than one spot visible on fundus
Causes:
 Severe anemia
 Leukemia
 Dysproteinemia
 HIV micro-angiopathy
Raised, diffuse, waxy pale areas
Obscure vessels and choroidal pattern
Healing – white with irregular pattern
Causes – rupture of choroid, diathermy,
laser

Scars induced by Laser Photocoagulation

 Responsible for central vision, color
vision, and stereopsis
 Disorders – either congenital or acquired
 Vision loss – congenital or hereditary
 May manifest in childhood or later
 Acquired lesions:
 Traumatic
 Vascular
 Inflammatory
 Dystrophies
 Degenerations
Edema – increased fluid collection
in sensory retina
Hole
Cherry-red Spot
Age-related Macular Degeneration
 Background Diabetic Retinopathy
Vascular Diseases
Venous Occlusion
Anterior and Intermediate Uveitis
Chronic Inflammation Birdshot Chorioretinopathy
Infectious Endophthalmitis

Secondary to Other Choroidal Neo-vascular Membrane

Maculopathies
Vitreomacular Traction
Cataract Surgery
Iatrogenic
Laser Photocoagulation
Retinitis Pigmentosa
Miscellaneous
Familial Dominant
Common cause of visual impairment in
diabetics, especially in type 2
Diffuse retinal edema – extensive
capillary leakage
Localized edema – focal leakage from
micro-aneurysms and dilated capillary
segments
Two types:
 Focal – well-circumscribed thickening
with complete or incomplete rings of
exudates
 Diffuse – diffuse thickening; sometime
association with cystoid changes
Satisfy one of the three criteria:
Thickening of retina at or within 500
microns of fovea
 Hard exudate at or within 500 microns
of fovea associated with retinal
thickening
 Zone of retinal thickening one disc
diameter in size
Three types:
 Focal – circinate pattern of hemorrhage,
aneurysm, and exudate
 Diffuse – retinal edema and thickening
throughout posterior pole
 Ischemic – microvascular blockage
Accumulation of fluid in the OPL
and INL
Causes – laser, vascular disease,
inflammation, dystrophies in retina
Signs:
Loss of foveal depression
Thickening of retina
Multiple cystoid areas
(“honeycomb” appearance)
Honey-comb appearance of macula

Flower-petal appearance on FFA

 Cause Features

• Central foveal defect

Age-related
• Yellow deposits within crater
(Idiopathic) • Cuff of sub-retinal fluid
• Very small
Micro-hole • Red, well demarcated
• Foveal or juxta-foveal

• Retinal detachment; confined to

Myopia posterior pole

Traumatic • Outer lamellar or full-thickness

(Berlin’s edema) hole
Inner lamellar hole caused by
cystoid macular edema
Round discontinuity at epiretinal
membrane overlying macula
Rhegmatogenous RD involving
posterior pole
Thinness of retina at fovea
Thickening and loss of transparency
of the retina at the posterior pole
Persistent transmission of choroidal
hue when rest of retina becomes
opaque
Causes:
Metabolic storage diseases (sphingo-
lipidoses)
 Normal appearance of fovea – devoid
of ganglion cells
Central Retinal Artery Occlusion
 Orange reflex from intact choroid
stands out at foveola – intracellular
edema
 Attenuated arteries with segmentation
of blood column (“cattle-tracking”)
in veins and arteries
Commotio retinae (Berlin’s edema)
 Cherry-red Spot

CRAO: “Cattle-Track” Appearance

CRAO: Cherry-red Spot

Criteria Dry Wet

Age Above 50

Vision Rapid and

Gradual
Loss Progressive
• Dull or absent • RPE
foveal reflex detachment
• RPE atrophy • SNRVM
Fundus
• Mottling of • Disciform
Changes pigment scar
• “Geographic
atrophy” of macula
Degenerations
Dystrophies
 • Lattice
• Snail-Track
Degenerations
• Paving Stone
• Retinoschisis
 Common degeneration of peripheral
retina
 Important one associated with RD
 Signs:
 Spindle-shaped areas of retinal thinning
 Sclerosed vessels arranged in an
arborizing pattern of white lines
 Hyperplasia of the RPE
 Some lesions associated with
“snowflakes” – remnants of Muller cells
 Retinal holes
Sharply demarcated areas of
“snowflakes”
White, frost-like appearance to the
retina
Viewed by some as precursor to
lattice degeneration
Discrete, yellowish areas of chorio-
retinal thinning and atrophy
Does not predispose to RD
Split between the areas of sensory
retina
Generally seen in inferotemporal
part
Symptoms
Absence of photopsia and floaters –
no retinal traction
Rarely visual field defect
Symptoms from vitreous
hemorrhage or progressive RD
Layer Features
• Bulges toward vitreous
• Beaten metal shine
Inner • Thin
• Transparent with
snowflake deposits
• Larger holes
• Hazy
Deeper • Details of choroid
unseen through it
Retinitis Pigmentosa
Other Hereditary Dystrophies
Diffuse group of inherited retinal
degenerative diseases
Affect photoreceptors, with rods as
dominant
Signs:
Diffuse bony corpuscles
Vessel attenuation
Waxy pallor of optic disc with
consecutive atrophy in advanced
cases
Associated changes in macula –
CME, macular hole, epiretinal
membrane
Dystrophy Fundus Changes
• Initial: mottling of macula
Stargardt • Later stages: beaten bronze
maculopathy appearance
• Advanced: Geographic atrophy
Best dystrophy • Yolk-like lesion on the macula

North Carolina • Confluent macular deposits

dystrophy progressing to atrophic changes

Butterfly-shaped • Yellowish pigment arranged in

dystrophy triradiate manner in macula
• Pigmentary changes leading to
Cone dystrophy geographic atrophy
• Few cases – “Bull’s eye” maculopathy
Stargardt Maculopathy Butterfly Dystrophy

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

Convex surface with Concave surface with

Shape convex border concave border
Convex

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

FFA of Microaneurysms and Hard Exudates

Demonstrates fluorescence in infra-
red range
Enhances choroidal vessels and
choroidal neovascularization
Indications:
Choroidal disorders
Retinal disorders in patients allergic
to fluorescein
Normal ICG angiogram

ICG angiogram of choroidal hemorrhage

USG in ophthalmology – pulse-echo
technique
Rapidly repeating bursts beamed into
structures
Portion of this is returned to transducer
Echoes transformed into display form
B-scan: 2D, dotted section
Uses:
 Assessment of posterior segment in
presence of opacity
 Localization of foreign bodies
 Study of intraocular tumors
 Retinal Detachment

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

OCT of macular hole OCT of cystoid macular edema

Disorders of retina and fundus –
potentially blinding
Careful examination, accuracy of
diagnosis, and timely management
Direct examination using
ophthalmoscopy aided by ancillary
investigations