Ophthalmology Flashcards
1
Optic disc and temporal retina
Clinical features
- Blot haemorrhages in the nasal macular area and superior temporal arcade
- Hard exudates along the inferior temporal arcade
- Micro-aneurysms at the macula area
- Circinate exudates along the inferior temporal arcade
Background diabetic retinopathy and diabetic maculopathy
Macula area (circle area centred on the fovea with its radius extending to the edge of the optic disc) has exudates in it, therefore it is a maculopathy. If the visual acuity was normal and there were micro-aneurysms and haemorrhage only, then this would be background diabetic retinopathy alone.
2
Optic disc and temporal retina
Clinical features
- Multiple dot and blot haemorrhages
- Cotton wool spots (CWS)
- Intra-retinal micro-vascular abnormalities (IRMA)
Pre-proliferative diabetic retinopathy
Pre-proliferative diabetic retinopathy is characterised by retinal ischaemia. CWS represent areas of focal retinal ischaemia. IRMAs are flat and do not grow into the vitreous.
3
Central fundus with the optic disc
Clinical features
- New vessels on the disc
- Haemorrhages
- Exudates
- Pre-retinal fibrosis
Advanced proliferative retinopathy
On-going ischaemia and increase in vaso-proliferative factors. The new vessels grow into the vitreous and are fragile leading to haemorrhage. As the haemorrhage organises, fibrous tissue reaction occurs often resulting in retinal traction and detachment.
4
Optic disc and temporal retinal retinal
Clinical features
- Multiple hard exudates in the macular area, some are circinate
- Haemorrhages and micro-aneurysms
Diabetic maculopathy
The visual acuity may be reduced depending on the location and macular oedema. Circinate hard exudates often have micro-aneurysms at their centre. The darker retinal appearance is normal in Asian or Afro-Caribbean patients.
5
Optic disc and temporal retina
Clinical features
- Multiple laser scars with areas of hyper-pigmentation
- Regressed new vessels at the disc with residual gliosis
Pan retinal laser photocoagulopathy
The overall appearance suggests good response to management and stable retinopathy. The patient will have reduced peripheral vision and a degree of night –blindness.
6
Posterior pole centred on the optic disc
Clinical features
- Disc areas is obscured
- Poorly defined vasculature
Ungradable retinopathy
The suspicion of fibrovascular proliferation at the disc and along the vascular arcade with tractional detachment is very strong. This would be a feature of advanced diabetic eye disease. Urgent referral is indicated.
7
Optic disc and temporal retina
Clinical features
- Optic disc with uniform central cup with cup disc ratio <0.5 and pink neuroretinal rim
- Retinal vessels and macula look normal. This degree of darker redness in the central macular area is normal.
Normal fundus
8
Posterior pole centred on the optic disc
Clinical features
- Large cup disc ratio
- Superior polar notching
- Nasal displacement of centred blood vessels
Glaucomatous optic disc
Glaucomatous damage and its extent is confirmed by visual fields and tomographic imaging techniques.
9
Optic disc and temporal retina
Clinical features
- Disc margins are obscured and swollen and hyperaemic
- Retinal vessels show tortuosity
Papilloedema
Spontaneous venous pulsation may be absent, if present then papilloedema is unlikely. Visual symptoms are absent in early stages. A space occupying lesion must be excluded urgently.
10
Optic disc and temporal retina
Clinical features
- Optic disc pallor with possible cupping
- Large area of macular scarring
Optic atrophy with macular scarring (and possible glaucoma)
Age-related macular degeneration would be the commonest cause of macular scarring.
11
Optic disc and surrounding retina
Clinical features
•Disc margin and emerging vessels obscured by myelinated nerve fibres along superior and nasal areas
Myelinated nerve fibres
This requires no further clinical attention. On examination the blind spot would be expected to be larger, but this would be very difficult to discern clinically.
12
Optic disc and temporal retina
Clinical features
- Focal areas of atrophy of retinal pigment
- Drusens in the macular area
Dry age related macular degeneration
Prescence of haemorrhages and oedema in the macular area would suggest wet changes.
13
Optic disc and temporal retina
Clinical features
- Multiple retinal haemorrhages
- Venous dilatation
Multiple retinal haemorrhages
Hyperviscosity states (polycythaemia, Waldenstrom’s macroglobulinaemia, myeloma) can lead to venous dilatation and haemorrhages. Thrombocytopenia and other bleeding diatheses are other possibilities.
14
Posterior pole centred on the optic disc
Clinical features
- Large optic disc
- Marked peripapillary chorioretinal atrophy
High myopia
Areas of chorioretinal atrophy in the macular are not uncommon in highly myopic patients.
15
Optic disc and temporal retina
Clinical features
- Focal narrowing of arterioles
- Changes at arterio-venous crossings along inferotemporal arcade (A-V nipping)
Hypertensive retinopathy grade 2
Absence of haemorrhages and disc swelling suggest early changes or chronic hypertension.
16
Optic disc and temporal retina
Clinical features
- Pigmented clumps in macular area with chorio-retinal atrophy and scarring.
- Pallor of the optic disc is noted indicating atrophy.
Macular scar (toxoplasmosis)
Cats hlost toxoplasmosis gondii. This is usually a quiescent lesion often discovered incidently when a child is assessed for impaired vision. An active lesion may show an inflammatory focus with a vitreous haze adjacent to a previous scar and vasculitis. There may be associated anterior uveitis.
17
Temporal retina
Clinical features
•Area of bullous retina showing area of elevation with fluid
Retinal detachment
In the absence of identifiable break and trauma the possibility of choroidal metastasis should be considered. Urgent referral is indicated.
18
Peripheral retina
Clinical features
- Green-gray flat asymptomatic lesion with detractable but not sharp borderes
- Presence of surface drusen
- Areas of atrophy within the lesion
Choroidal naevus
In view of large size >5mm, it is worth monitoring for a period. If there is a change in size then further investigation is indicated.
19
Optic disc and temporal retina
Clinical features
•Dense white areas along vessels with vasculitis along temporal arcade
Cytomegalovirus retinitis
The spread of vasculitis can be relentless from periphery to the disc along retinal vessels. Haemorrhages may be present in fulminating cases.
20
Optic disc and temporal retina
Clinical features
- Papilloedema
- Tortuosity and dilatation of all branches of the central retinal vein
- Retinal haemorrhages – flame shaped, dot and blot in all quadrants
- Cotton wool spots (CWS)
Central retinal vein occlusion (CRVO)
The presence of CWS would suggest significant ischaemic element carrying poor prognosis. Space-occupying lesions in the cerebrum and hyperviscosity have to be excluded. Hypertension alone can cause CRVO.
21
Temporal retina and temporal optic disc
Clinical features
- Attenuation of arteries and veins
- The pale temporal edge of the optic disc is shown
- Central “cherry red spot” with surrounding pale retina
Central retinal artery occlusion (CRAO)
Poor prognosis due to retinal infarction. Retinal cloudiness of pale retina would disappear after a few weeks. Attenuated vessels would remain and consecutive optic atrophy would be evident. The cherry-red spot is seen because the macular arterial supply from the choroid can remain intact. Often there is a band of neural tissue that is not rendered ischaemia by the CRAO, this is seen if there is an adequate cilio-retinal artery supply.
22
Optic disc and surrounding retina
Clinical features
•Yellow orange refractile bodies at an arterial bifurcation (12 o’clock on the optic disc)
Retinal artery cholesterol emboli (Hollenhorst plaque)
Frequently asymptomatic as it rarely causes significant obstruction of the arteriole unlike calcific emboli. Fibrinoplatelet emboli cause transient retinal ischaemic attacks (amaruasis fugax) which may occasionally be complete.
23
Mild peripheral retina
Clinical features
•Multiple bony spicule retinal pigmentation scattered in the periphery of the retina
Retinitis pigmentosa
The associated history of night blindness and family history is often positive. The optic disc may show waxy pallor with attenuation of vessels.
24
Optic disc and surrounding retina
Clinical features
- Linear reddish-brown lesions with irregular edges beneath the normal retinal vessels. This represents breaks in Buch’s membrane and visualisation of the choroidal circulation.
- Peripheral coal chorio-retinal scars may be present
Angioid streaks
Bruch’s membrane is mainly elastin. The condition is associated with connective tissue disorders – pseudoxanthoma elasticum, Ehlers-Danlos syndrome, Marfan’s syndrome
25
Peripheral retina
Clinical features
•Elevated dome shaped grey mass
Malignant melanoma
A secondary retinal detachment may be present. Urgent referral indicated.
26
Optic disc and surrounding area
Clinical features
•Flat pigmented lesion involving inferior aspect of the optic disc
Benign disc naevus
Often difficult to distinguish from malignancy. Seek a specialist opinion if in doubt.
27
Optic disc and temporal retina
Clinical features
•Large macular haemorrhage in the pre-retinal area
Macular haemorrhage
Sudden severe intrathoracic or abdominal pressure can lead to this feature. Macular degeneration and diabetic retinopathy can be considered in presence of additional features. A pre-retinal haemorrhage with a fluid level can be seen in some patients with sub-arachnoid haemorrhage. Small areas of haemorrhage adjacent to blood vessels are seen in bacterial endocarditis (Roth spots).
28
Optic disc and temporal retina
Clinical features
•Pale yellow appearance of vessels in a creamy retinal background
Lipaemia retinalis
This is associated with hypertriglyceridaemia and hypercholesterolaemia. Encountered in lipid disorders, poorly controlled diabetes and alcoholism.
Hypertensive retinopathy grading system
- Microaneurysms are rare in hypertensive retinopathy without diabetes mellitus
- Grade 1 – arteriolar narrowing
- Grade 2 – arterio-venous nipping
- Grade 3 – exudates, haemorrhages, cotton wool spots
- Grade 4 – papilloedema
Classic sequence of looking at the retina
- Light reflex for cataract, arcus, xanthalasma, conjunctiva
- Start at the optic disc
- Superior temporal arcade and inferior temporal arcade
- Macular area
- Superior nasal arcade and inferior nasal arcade
- Peripheral, clockwise sweep to look for peripheral lesions
