Funduscopy of Retinal Pathologies

Jumat, 08 November 2019 08.04

Source : GeekyMedics
Retina is the inner most layer of the eye and is derived from neuroectoderm. Retina
is a thin membrane extending from the optic disc to the ora serrata in front. It
varies in thickness from 0.4 mm near the optic nerve to 0.15 mm anteriorly at the
ora serrata.

Ora Serrata It is the anterior termination of the retina where it is continuous with
the epithelium of the ciliary body.
Macula Lutea (Yellow Spot) It is an area 1.5 mm in diameter situated at the
posterior pole, about 3 mm to the temporal side of the optic disc. Fovea Centralis It
is a small depression in the centre of the macula. The cones predominate in this
area. The fovea is the most sensitive part of the retina.

Normal Appearance of the Retina

• The key parts of the retina to recognise are the optic nerve head (optic disc) and the macula.
• The optic nerve is found by tracing any of the blood vessels to the point of coalescence (branching vessels
form an arrow pointing towards the disc, as shown below).
• The macula is found lateral (temporal) to the optic nerve head. The central part of the macula, the “ fovea”
is about the same diameter as the optic disc and appears darker than the rest of the macula due to the
presence of an additional pigment.

Hypertensive Retinopathy
Chronic Hypertension
 Grade 1 disease – The changes of early hypertensive retinopathy are subtle, with generalised
arteriolar narrowing.
 Grade 2 disease – Development of areas of focal narrowing, and compression of venules at
sites of arteriovenous crossing (AV nipping).
 Grade 3 disease – Development of features similar to those of diabetic retinopathy, namely
retinal haemorrhages, hard exudates and cotton wool spots.

From <https://geekymedics.com/fundoscopic -appearances-of-retinal-pathologies/>

Clinical Signs of Diabetic Retinopathy

 The spectrum of diabetic retinopathy is shown below

 Many medical schools focus on the grading system below, though others do exist

Stages of Diabetic Retinopathy

Background Diabetic Retinopathy

Microaneurysms
 Microaneurysms are localised outpouchings of capillaries that leak plasma constituents into
the retina.
 May be clinically indistinguishable from small dot and blot haemorrhages (see below).

Arteriovenous Nipping (AV Nipping) 3

Malignant Hypertension
 Malignant hypertension typically presents with grade 4 hypertensive eye disease, which
includes all the features of grade 3, with the addition of optic disc swelling.
 Other features include headaches, eye pain, reduced visual acuity and focal
neurological deficits.
 Initial management typically involves antihypertensives and emergency hospital
admission.
 The image below on the right shows extensive haemorrhages, cotton wool spots, optic
disc swelling and a ring of exudates around the macula (macular star).

Microaneurysms in Diabetic Retinopathy 2

Dot and blot haemorrhages

 Dot and blot haemorrhages arise from bleeding capillaries in the middle layers of the retina.
 They may look like microaneurysms if small enough. It is not particularly important to be 
able to distinguish between small haemorrhages and microaneurysms as they are both
parts of pre-proliferative retinopathy.

Malignant Hypertension 7

Retina Page 1
 Malignant Hypertension 7

Dot and Blot Haemorrhages in Diabetic Retinopathy 2


Pre-proliferative diabetic retinopathy
The presence of retinal ischaemia represents a progression
from background diabetic retinopathy to the pre-proliferative stage.

Cotton wool spots

 Cotton wool spots appear as small, fluffy, whitish superficial lesions.
 They are accumulations of dead nerve cells from ischaemic damage.

Other signs
 Other signs of pre-proliferative retinopathy
include venous changes and intraretinal microvascular anomalies (IRMA) but you
would not be expected to know or recognise them at the undergraduate level.

Hypertensive Retinopathy Illustration 6

Optic Nerve Pathologies

Glaucomatous Disc Changes
 Glaucoma is defined as a progressive optic neuropathy that is associated with visual
field loss and usually raised intraocular pressure (IOP).
 Glaucoma results in irreversible loss of nerve fibres, leading to an appearance of
“cupping” or an increased vertical cup-to-disc ratio (C/D ratio).

Cotton Wool Spots in Pre-proliferative Diabetic Retinopathy 2

Proliferative diabetic retinopathy

 Insufficient retinal perfusion results in the production
of vascular endothelial growth factor (VEGF) which results in the development
of new vessels on the retina (neovascularisation).
 These new vessels may either be at the disc, termed “new vessels at the disc” (NVD), or
over the other areas of the retina “new vessels elsewhere” (NVE).

Cup to Disc Ratios (Normal vs Glaucoma) 2

Papilloedema / Optic Nerve Swelling

 Papilloedema refers to optic disc swelling secondary to raised intracranial pressure.
 “Optic disc swelling” is a general term referring to any cause of a swollen optic disc.

 Causes of optic disc swelling include intracranial space-occupying lesions, optic

neuritis (multiple sclerosis), malignant hypertension and uveitis (tuberculosis,
 sarcoidosis etc.).
 Optic disc margins appear blurred and small haemorrhages may be noted.

Neo-vascularisation at the optic disc 2

Papilloedema 2

Optic Nerve Atrophy

  Optic nerve atrophy involves the death of nerve fibres within the optic nerve. This results
in a pale optic disc as opposed to the usual pink appearance.
 Primary optic nerve atrophy is caused by inflammation (optic neuritis), glaucoma or
general retinal ischaemia.
 Secondary optic nerve atrophy is caused by longstanding papilloedema.
 Investigation of this condition often requires neuroimaging to rule out life-threatening
intracranial causes

Neo-vascularisation elsewhere 2

Retina Page 2
 Neo-vascularisation elsewhere 2

Advanced diabetic retinopathy

Advanced diabetic retinopathy results in:

 Recurrent vitreous haemorrhage from bleeding areas of neovascularisation

 Tractional retinal detachments as areas of neovascularisation grow into the vitreous and
form fibrous bands suspending the retina
 Rubeosis as neovascularisation occurs at the iris and drainage angle resulting in increased
intraocular pressure and progressive glaucoma

Pan-Retinal Photocoagulation (PRP)

 Pan-retinal photocoagulation is the primary treatment for proliferative diabetic retinopathy.
 The rationale behind the treatment is to reduce the production of VEGF by reducing the
oxygen demand from the peripheral retina

 Clinically it is seen as clusters of burn marks on the retina which have been created by the
laser used in the treatment process.

Optic Nerve Atrophy (Pale Optic Disc) 2

Vascular Occlusive Diseases

Central Retinal Artery Occlusion (CRAO)
 Central retinal artery occlusion presents with sudden, profound loss of vision.
 It is most frequently caused by emboli obstructing the retinal artery (e.g. stroke).
 Occasionally it can be caused by vasculitis (e.g. giant cell arteritis)

 Classical appearance is of a “cherry red spot”. This occurs due to the intact reflex of the
fovea standing out against a pale, ischaemic retina.

Pan-retinal Photocoagulation (PRP) 2

Diabetic Maculopathy
 Diabetic maculopathy refers to the presence of exudates and/or macular oedema at the
macula’
 You are unlikely to be asked to identify oedema as it is hard to visualise using a direct
ophthalmoscope.

Hard exudates
 Hard exudates are waxy yellow lesions with relatively distinct margins arranged
in clumps or rings, often surrounding leaking microaneurysms.
 NB: They are called “hard exudates” to distinguish them from “soft exudates”, an older term
for cotton wool spots (see below). Central Retinal Artery Occlusion (CRAO) 4

Central Retinal Vein Occlusion (CRVO)

 Central retinal vein occlusion occurs secondary to atherosclerotic thickening of
the central retinal artery compressing the central retinal vein at a common crossing
point.
 Occlusion of the vein results in retinal hypoxia, and the resultant endothelial cell damage
leads to extravasation of blood.
 Fundoscopy typically reveals severe tortuosity, engorgement of retinal
veins, deep haemorrhages, cotton wool spots and optic disc swelling.

Central Retinal Vein Occlusion 2

Hard exudates in Diabetic Maculopathy 2

Macular Pathology
Age-related Macular Degeneration (AMD)
 Age-related macular degeneration is a degenerative disorder of the macula and
the most common cause of irreversible blindness in the elderly population.
The most common form of AMD (90% of cases) is the “dry” variant, termed so as it

Retina Page 3
  The most common form of AMD (90% of cases) is the “dry” variant, termed so as it
produces no exudation or neovascularisation.
 Early signs of AMD include the presence of yellow-white deposits which are termed
“drusen”.

Drusen in Age-related Macular Degeneration 5

References
Reference Images
1. Normal fundus photograph provided courtesy of Yandle on Flickr for re -use under CC BY
2.0.
2. All diabetic retinopathy, optic nerve pathologies, and CRVO photographs provided by
Community Eye Health on Flickr for non-commercial reuse under CC BY-NC 2.0.
3. Photograph of AV nipping originally provided by Frank Wood for re -use under CC BY 3.0.
4. Photograph of a cherry red spot originally provided by Fieß et al. and BioMed Central Ltd.
Under CC BY 2.0.
5. Photograph of AMD provided by National Eye Institute on Flickr for re -use under CC BY 2.0.
6. Ophthalmic Atlas Images by EyeRounds.org, The University of Iowa are licensed under
a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
7. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of
Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 ]. Modified by Dr
Lewis Potter.

Reference Texts
 Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. Edinburgh,
Elsevier/Saunders; 2015
 Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000; 356:411–417

Retina Page 4