Fundoscopic appearances of retinal pathologies

Question 1

Stages of diabetic retinopathy

Answer 1

1 = background diabetic retinopathy

2 = pre-proliferative diabetic retinopathy

3 = proliferative diabetic retinopathy

4 = advanced diabetic retinopathy

Question 2

What changes occur in background diabetic retinopathy?

Answer 2

Microaneurysms: These are localised outpouchings of capillaries. Appear as small red dots

Dot and blot haemorrhages: These arise from bleeding capillaries in middle layers of retina. Look like micro aneurysms if small enough

Question 3

What changes occur in pre-proliferative diabetic retinopathy?

Answer 3

Cotton wool spots: These are accumulations of dead nerve cells from ischaemic damage. Appear as small, fluffy, whitish superficial lesions.

Question 4

What changes occur in proliferative diabetic retinopathy?

Answer 4

New vessel growth (neovascularisation) on the retina: Occur due to retinal ischaemia that results in production of VEGF, leading to formation of new vessels on retina

New vessels may be either at the disc (NVD) or elsewhere (NVE)

Question 5

What changes and clinical signs occur in advanced diabetic retinopathy?

Answer 5

Vitreous haemorrhage - due to bleeding areas of neovascularisation

Retinal detachments - due to neovascularisation growing into vitreous

Rubeosis - neovascularisation occurring at the iris and drainage angle. This results in increased IOP and progressive glaucoma

Question 6

What is pan-retinal photocoagulation and how does it appear on fundoscopy?

Answer 6

Primary treatment for proliferative diabetic retinopathy

Appears as clusters of burn marks on retina - laser burns on peripheral retina reduces its oxygen demand, thus reducing production of VEGF and stopping new blood vessels from growing

Question 7

What changes occur in diabetic maculopathy?

Answer 7

Hard exudates at the macula: These are waxy yellow lesions arranged in clumps or rings, often surrounding leaking microaneurysm

Question 8

What changes occur in chronic hypertensive retinopathy?

Answer 8

Grade 1 disease: Early changes very subtle, with generalised arteriolar narrowing

Grade 2 disease: areas of focal narrowing and AV nipping (compression of venues at sites of arteriovenous crossing)

Grade 3 disease: Similar to diabetic retinopathy. You see blot haemorrhages, hard exudates around macula (macular star) and cotton wool spots

Question 9

What changes occur in malignant hypertensive retinopathy?

Answer 9

Features of grade 3 hypertensive (blot haemorrhages, hard exudates around macula, cotton wool spots) AND optic disc swelling (papilloedema)

Question 10

How does glaucoma appear on fundoscope?

Answer 10

Cupping or an increased cup to disc ratio (>0.3)

Question 11

How does papiloedema appear on fundoscope?

Answer 11

Blurred optic disc margins

Question 12

How does optic nerve atrophy appear on fundoscope?

Answer 12

Pale optic disc

Question 13

What changes occur in central retinal artery occlusion (CRAO)?

Answer 13

Cherry-red spot of fovea surrounded by pale, ischaemic retina

Question 14

What changes occur in central vein occlusion (CRVO)?

Answer 14

Tortuous veins, engorgement of retinal veins, deep haemorrhages, cotton wool spots and optic disc swelling

Question 15

What changes occur in dry age-related macular degeneration (AMD)?

Answer 15

Drusen (yellow-white deposits) in macula area (not fovea)

Question 16

What changes occur in wet age-related macular degeneration (ARMD)?

Answer 16

Severe blood and fluid leaking over macula area