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Clinical skills year 2 > Normal Fundus I > Flashcards

Normal Fundus I Flashcards

1
Q

What is the fundus

A
  • The back portion of the interior of the eyeball, visible through the pupil by use of the ophthalmoscope.
  • Fundus is everything on the back of the eye, not just the retina
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2
Q

What is orra serrata:

A

Where retina meets ciliary body

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3
Q

What does fundus include

A

Includes retina, optic disc, vessels, choroid ( behind retina ) – everything you can see on ophthalmoscopy

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4
Q

What does direct ophthalmoscopy allow

A

Visualisation of about 65-70% of fundus

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5
Q

What is the limit of fundus

A

Ora serrata

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6
Q

What varies between people in terms of the fundus:

A
  • Fundus background varies between people

- Color seen not actually to do with colour of retina itself

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7
Q

What is colour of retina in healthy retina:

A

Clear

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8
Q

What gives orange/red colour of fundus:

A

Choroid

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9
Q

What is the choroidal capillaris:

A

Choroidal blood supply

Wall of blood behind retina

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10
Q

Where does the fundus orange red colour come from:

A
  • Retina is transparent so a lot of light is transmitted through retina and reflected back from choroid
  • Goes through sclera and reflected back through choroid
  • Light directly reflected from choroidal blood vessels
  • Light reflected from sclera and transmitted through choroidal blood vessels
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11
Q

What gives rise to bright orange glow in fundus:

A
  • Bright orange red = orange glow attenuated by pigment in RPE or choroid
  • Melanin which can be present in RPE and or choroid
  • These absorb light
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12
Q

Why are some fundus less orange:

A
  • Brown

- That bright orange glow is less bright

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13
Q

What does amount of light directly reflected from choroidal blood vessels and transmitted through choroidal blood vessels depends on

A
  • Degree of pigmentation of retina
  • Degree of pigmentation of choroid
    = This varies from eye to eye
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14
Q

Fundus layers in a healthy eye

A

Most of fundus layers are transparent and do not contribute to fundus appearance

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15
Q

What is the 1st layer to contribute to typical fundus appearance

A

The internal limiting membrane

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16
Q

What is the internal limiting membrane

A
  • Reflects ophthalmoscope beam
  • Can give shiny reflective appearance
    of retina
  • Shiny reflective layer esp in younger
    people
  • Can give appearance of “watered silk”
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17
Q

Types of fundus

A
  • Uniform Stippled:
    - Dark
    - Medium or causasian
    - Light or blonde
  • Tesselated (tigroid)
  • Albinotic
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18
Q

What is stipple

A

Stipple = to paint with individual dots

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19
Q

Describe uniform stippled fundus - DARK

A
  • Dark
  • Heavily pigmented RPE
    = Heavily pigmented choroid
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20
Q

Describe uniform stippled fundus - MEDIUM OR CAUCASIAN

A
  • Normally pigmented RPE
  • Normally pigmented
    choroid
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21
Q

Describe uniform stippled fundus - LIGHT OR BLONDE

A 
- Lightly pigmented
 RPE
- Lightly pigmented
 choroid
- Visibility underlying choroidal vessels
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22
Q

What are the fuzzy bright red vessels and what do they do:

A

Choroidal blood vessels which you can see through the retina CAUSE little pigmentation

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23
Q

Describe tessellated ( tigroid fundus )

A
  • Lightly pigmented RPE

- Normal to heavily pigmented choroid

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24
Q

Describe albinotic fundus

A
  • Virtually no pigment in RPE or choroid
  • Healthy variation
  • See completely through to choroidal pigmentation
  • Pale hair and skin maybe
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25
Q

What does degree of pigmentation of retina and choroid depends on

A
  • Age – lose pigment as get older
  • Race
  • Hereditary
  • Metabolic factors
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26
Q

Features of fundus background - pigmentation

A
  • The degree of pigmentation of the retina and choroid do not always run in parallel
  • Can have heavily pigmented retina and lightly pigmented choroid or vice versa
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27
Q

What is the optic disc

A

The ophthalmoscopic view of the optic nerve head

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28
Q

Features of the optic disc

A
  1. Size
  2. Shape
  3. Colour
  4. Margins
  5. Level
  6. Vessels
  7. Surroundings
  8. Other normal variations
29
Q

What does colour of optic disc depend on

A
  • The white lamina cribrosa and myelinated nerve fibres behind the lamina
  • The red blood in capillaries supplying the disc
30
Q

What is optic atrophy:

A
  • Pale disc

- All of capillaries which supply the disc with blood have died off so no blood supply

31
Q

What is Papilledema:

A

Optic disc is swollen

32
Q

Feature of optic disc - margins

A
  • Distribution of nerve fibres i.e a lot of them on healthy disc leads to relative blurring and elevation of margins on nasal 2/3rds of disc
  • Very sharp clear margins, especially on nasal side, can indicate optic atrophy
  • Most healthy eyes – clear margins all the way around the disc
  • However, blurred margins, especially on temporal side, can indicate oedema (swelling of the disc – may be a sign of raised intracranial pressure)
33
Q

Margins in heathy eyes of optic disc

A

Clear margins all the way around the disc

34
Q

What is indication of oedema - optic disc margins

A

Blurred margins, especially on temporal side,

35
Q

What can papilledema/ swollen disc / oedema be sign off

A

Raised intracranial pressure)

36
Q

Symptoms associated with Papilloedema:

A

Bad headaches and nausea

37
Q

What does level of optic disc feature

A
  • Cupping

- Cup depth

38
Q

Feature of optic disc - cupping

A
  • No detectable cup in 15% of eyes - in some people cup is so small and shallow that its undetectable
  • Can be measured by recording vertical C/D ratio
  • > 0.6 is suspicious of glaucoma (primary/chronic open angle) – normal for some people
  • > 0.1 difference between eyes is suspicious
  • Change over time e.g 0.4 to 0.6 after 2 years suspicious
39
Q

How can you measure cupping

A

Vertical C/D ratio

40
Q

What does lamina cribrosa look like:

A

Grains of rice at bottom of optic cup

41
Q

Feature of optic disc - cup depth

A
  • Physiological differences between people

- Lamina cribrosa may be visible in deep cups.

42
Q

How to determine C:D ratio:

A
  • Change in color – looking at pallor of disc – cup is paler than rest of disk
  • Look at where blood vessels curve – cup starts
43
Q

What is the neural retinal rim

A

Bit of optic disk that’s not optic cup i.e bit around outside

44
Q

What does deeper cup mean

A
  • Paler
  • Increased pallor
  • Due to increased visibility of lamina cribrosa and myelinated nerve fibers
45
Q

What are way of detecting changes in level – depth of cup:

A
  1. Difference in lens required for focussing on neural retinal rim compared to what you need to focus on bottom of cup = how deep cup is
  2. Parallax
  3. Increased pallor with increasing depth due to visibility of lamina cribrosa and underlying myelinated fibres.
46
Q

What are way of detecting changes in level – depth of cup - difference in lens required for focussing on neural retinal rim compared to what you need to focus on bottom of cup

A
  • For example, edge of disc clear with plano, but bottom of cup first clear with –3D
  • Focus on neural retinal rim using the direct ophthalmoscope then move across to centre of cup itself and note difference in power you need to focus on bottom of cup i.e see if change lens power in ophthalmoscope to focus on bottom of cup
47
Q

What are way of detecting changes in level – depth of cup - parallax

A
  • When moving ophthalmoscope beam, areas at different levels move at different speeds
  • Focus slit lamp when using px forehead = assess depth of optic cup
  • When looking at optic depth, if you move your light from side to side, if the bottom of the cup looks like its moving a lot relative to the neural retinal rim, theres a lot of motion parallax, which means the bottom of the cup is relatively far from the neural retinal rim meaning the cup is deep.
  • If theres less relative movement, you have a shallow cup
  • Place ophthalmoscope beam on optic cup or NRR and move from side to side and see if theres a lot of movement between the 2
  • If not = shallow cup
  • If there is = deeper cup
48
Q

What are way of detecting changes in level - pallor

A
  • Deeper the cup = paler = increased pallor = due to increased visibility of lamina cribrosa and myelinated nerve fibers
  • Change in color – looking at pallor of disc – cup is paler than rest of disk
49
Q

Features of optic disc - neural retinal rim

A
  • The part around the cup
  • Pinky/yellow colour
  • Usually follows ISNT rule in healthy eyes i.e. thickest inferiorly, then superiorly, then nasally, then temporally.
50
Q

Features of optic disc - vessels

A

CRA and CRV:

  • Branch out from optic nerve head
  • Soon after branching become arterioles / venules across retina (small diameter vessels which link to capillaries)

Spontaneous pulsation of CRV – central retinal vein:
- CRV pressure is usually constant, about 2mmHg higher than mean IOP
- During cycle of variation of IOP it is quite likely that IOP will become greater than CRV pressure
= This leads to partial collapse of the vein, which will not recover until IOP falls back to below that in the

Cilio retinal arteries:

  • Not branches of CRA but are derived from blood vessels supplying the choroid
  • Vary in size but can be as large as a principal retinal arteriole and supply a significant area of retina
51
Q

Where do you see spontaneous pulsation of CRV

A
  • See it at optic disk

- Can see the pulsation of the CRV pulsating with the cardiac cycle

52
Q

What causes spontaneous pulsation of CRV

A
  • Happens because of fluctuations in IOP
  • As IOP changes, IOP might be higher than pressure in the CRV itself
  • If IOP is higher than pressure in vein = at that point the CRV is squashed by the pressure and blood is pushed out of it
  • As IOP drops again CRV opens up and refills with blood = pulsing effect on vein in optic disc
53
Q

What is cilio retinal artery and where does it come from, what is its function

A
  • Extra blood vessel into retina
  • Derived from choroid -Provides extra source of blood to inner retina
  • Come from choroid next to optic disc
54
Q

Cilio retinal artery relevance:

A

If healthy eye has ciliary retinal artery, its not relevant – doesn’t mean much BUT
If a problem arises e.g in central retinal artery occlusion = loss of vision
If person has ciliary retinal artery this extra blood vessel = they have extra blood supply to retina which will continue to feed their central vision = sight saving feature

55
Q

Features of optic disc - surroundings:

A

Certain layers of the fundus can stop short of the disc, causing characteristic surrounds:

  • Scleral ring
  • Choroidal crescent

Pigment spots:

  • Build up of more than the usual amount of pigment at the edge of the disc
  • Pigment rings or crescent
56
Q

What is scleral ring

A
  • RPE and Choroid stop short of the disc
  • White crescent around disc
  • Neither RPE nor choroid extend to the optic nerve head.
  • The sclera is visible as a relatively pale region.
57
Q

What is Choroidal crescent

A
  • RPE stops short of the disc
  • Choroid but not retinal pigment epithelium (RPE) extend to the optic nerve head – this allows the choroid to be visible as a dark region.
  • Greyish around optic disc
  • a common form of hyper-pigmentation
58
Q

What are pigment spots

A

Build up of more than the usual amount of pigment at the edge of the disc

59
Q

Pigmentation at the optic disc margins

A

Hyper-pigmentation of disc margins

Hypo-pigmentation of disc margins

60
Q

What is Hyper-pigmentation

A

More pigmentation

61
Q

What is Hypo-pigmentation

A

Less pigmentation around disc margins

62
Q

Ring vs crescent:

A
  • Ring = all way around optic disc

- Crescent = part way around optic disc

63
Q

How does choroidal crescent arise

A

Arises because choroid has extended to optic nerve head but not the RPE

64
Q

Feature of scleral crescent:

A

White or pale ring or crescent

65
Q

Properties of scleral or choroidal crescent

A 
- Asymptomatic
    = No visual loss
 - Generally isolated findings
 - Associated with 
      = High myopia – more common in myopic eyes
      = ‘Tilted disc’ – disc slanted – normal 
- ONH margins harder to recognize
 - No treatment
66
Q

Features of the disc - Other normal variations

A

Myelinated nerve fibres

67
Q

Features of the disc - myelinated nerve fibres

A
  • NFs not normally myelinated until level of lamina cribrosa
  • Sometimes NFs retain their myelin sheath on the disc or the retina
  • Normally transparent NFs appear a bright white against the fundus background
  • Non progressive
  • Uncommon
  • Nerve fibres arise from where the optic disc is
68
Q

What does having myelinated nerve fibres result in:

A
  • As nerve fibers come out through into the retina, they’re supposed to lose their myelination – lose that protection as this is what allows photoreceptors to pickup light
  • Myelinated nerve fibres = blocking light from photoreceptors = associated with blind sport = scotoma on px visual field
  • Myelination is on top of retina so obscures underlying blood vessels fully or partially

Clinical skills year 2 (3 decks)

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