1. 26/02/2008

2.  Only place in the body where blood vessels can
be visualized directly
 Mirror the status of the systemic circulation
 Continuity of nerve fibers and meninges
 Reflects specific changes in systemic diseases
 Contribute to diagnosis

3.  Direct ophthalmoscopy
 Indirect opthalmoscopy
Sterioscopical view possible

4.  Ideally fundus should be examined
in a darkened room
 Patient should be asked to fix their gaze on a
distant object
 Examine with corresponding eyes
 The ideal line of approach should bring the
optic disc straight in to view
 If only blood vessels on a pink background are
seen they should be followed , the disk will
eventually come in to view

5.  Media- hazy, clear
 Disc- size, shape, colour, margin, physiological
cup, neuroretinal rim
 Blood vessels- caliber, tortousity, irregularities,
changes in the vessel wall, aneurism,
neovascularisation
 Exudates
 Haemorrhage

6.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

7.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

8.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

9.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

10.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

11.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

12.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

13.  Uniform red to pink
 Disc-pale pink
 1.5 mm in diameter
 Nasal margin slightly blurred
 Vessels emanate from optic cup
 Consist of central cup and
peripheral neuroretinal rim
 Macula temporally
 Fovea 2.5mm-diameter, darker

14.  Tygroid fundus
 Deeply pigmented choroid
 Choroidal vessels are seen
 Polygonal pigmented areas
in between

16.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

17.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

18.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

19.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

20.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

21.  Dot haemorrhages
 Deep within the retina
 Leakage of capillaries, venules
 Common in diabetes
 Flame haemorrhages
 Superficial nerve fibre layer
 Leakage of capillaries, venules
that are ischemic or, in the case of
veins, under high pressure
 Boat haemorrhages (pre-retinal)
 Interface between retina & vitreous
 Sub macular h‟ge, Preretinal h‟ge, Retinal h‟ge

22.  Hard exudate
 Deep yellow with sharp margins
 Often circinate
 Leakage from pre-capillary arterioles
 DM, HTN, VHL disease, radiation
 „Macular star‟
 Soft exudate(cotton wool spot)
 Fluffygray-white, near optic disc
 Retinal nerve fiber layer microinfarction
 HTN, DM, connective tissue disease,HIV

23.  Hard exudate
 Deep yellow with sharp margins
 Often circinate
 Leakage from pre-capillary arterioles
 DM, HTN, VHL disease, radiation
 „Macular star‟
 Soft exudate(cotton wool spot)
 Fluffygray-white, near optic disc
 Retinal nerve fiber layer microinfarction
 HTN, DM, connective tissue disease,HIV

24.  Hard exudate
 Deep yellow with sharp margins
 Often circinate
 Leakage from pre-capillary arterioles
 DM, HTN, VHL disease, radiation
 „Macular fan‟
 Soft exudate(cotton wool spot)
 Fluffygray-white, near optic disc
 Retinal nerve fiber layer microinfarction
 HTN, DM, connective tissue disease,HIV

25.  White centered retinal haemorrhages
 CWS surrounded by h‟mage
 CWS- ischaemic axons
 H‟maghe- precapillary arterioles
 Sub acute bacterial endocarditis
 Leukaemia
 Diabetes

26.  Deposition in ganglion cell layer
 Thickening & loss of
transparency of retina
 Foveola-ganglion cells absent,
thin, so contrast
 Sphingolipidoses
 Central retinal artery occlusion
 Berlins edema

27.  Crack like dehiscence in brusch‟ membrane
 Degenerative process combined with calcium
deposition
 Linear reddish brown lesion
 Lies beneath normal blood vessels
 “Pseu d‟orange”
 Salmon spots, optic nerve drusen
 Pseudoxanthoma elasticum, EDS
 Paget‟s, Hemoglobinopathies

28.  Papillopheblitis (optic disc vasculitis)
 Affects healthyindividuals <50
 Disc edema, cotton wool spots
 Venous dilatation and tortousity
 Retinal haemorrhages
 Retinal vasculitis
 Occurs in sarcoidosis, Behcet‟s disease,
Multiple sclerosis, idiopathic
 Extremely rare in lupus
 Perivenous lymphocytic infiltration
(sheathing)

29.  Diffuse retinal dystrophy(rods)
 Classic clinical triad
 Arteriolarattenuation
 Retinal bone-spicule pigmentation
 Waxy disc pallor
 Starts at mid periphery
 Maculopathy
 Associations
 Bassen-Kornzwieg syndrome,
Refsum‟s disease, Kearn-sayre
syndrome , Usher‟s syndrome
Muchopolysaccharidoses, Lauren‟s
moon biedel syndrome, Friederisch
ataxia

30.  Attempt at vascularising ischaemic tissue
 Lacks bifurcating pattern
 Bleed spontaneously
 Diabetic retinopathy
 Retinal vein occlusion
 Radiation
 Sickle cell retinopathy
 Retinopathy of prematurity

31.  Separation of sensory retina from
pigment epithelium
 Rhegmatogenous RD
 Non-rhegmatogenous RD
 Tractional- PDR, ROP, sickle cell
retinopathy, penetrating posterior
segment trauma
 Exudative- choroidal tumours,
exophytic retinoblastoma, harada
disease, posterior scleritis, subretinal
neovascularisation, severe
hypertension
 Elevated sheath of retinal tissue
with folds

32.  Separation of sensory retina from
pigment epithelium
 Rhegmatogenous RD
 Non-rhegmatogenous RD
 Tractional- PDR, ROP, sickle cell
retinopathy, penetrating posterior
segment trauma
 Exudative- choroidal tumours,
exophytic retinoblastoma, harada
disease, posterior scleritis, subretinal
neovascularisation, severe
hypertension
 Elevated sheath of retinal tissue
with folds

34.  Atherosclerosis, embolism
 Retina appears white
 Attenuation of arteries and
veins
 Cherry red spot
 Investigate for
 Valvular heart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders

35. Cholesterol Fibrinoplatelet Calcific
(Hollenhorst plaques)

36.  Atherosclerosis, embolism
 Retina appears white
 Attenuation of arteries and
veins
 Cherry red spot
 Investigate for
Valvular heart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders

37.  Atherosclerosis, embolism Cattle-trucking
 Retina appears white
 Attenuation of arteries and
veins
 Cherry red spot
 Investigate for
Valvular heart disease,
endocarditis, mural thrombi,
Carotid artery disease, systemic
vasculitis, hematological
disorders

38.  Embolism, periarteritis
 Retinal cloudiness
corresponding to the areas of
ischemia
 Narrowing of arteries and
veins
 One or more emboli may be
present

39.  Present in 20% of population
 It may be isolated, combined
CRVO, combined AION
 Localised cloudiness- macula
and papillomacular bundle

40.  Occlusion of short posterior ciliary arteries
 Disc is pale
 Diffuse or sectoral edema
 Splinter shaped h‟mages
 „Pseudo-Foster kennedy syndrome‟

41.  Giant cell arteritis
 Cotton wool spots are uncommon
 Cilioretinal artery occlusion
 Central artery occlusion

42.  Etiology
Arteriosclerosis
Increasing age
Hypertension
Diabetes mellitus
Blood dyscrasiasis
Periphlebitis
Raised intraocular tension

43.  Dilatation & tortousity
of all branches of CRV
 Retinal h‟age- superficial
& deep throughout
 “Blood and thunder”
 Cotton wool spots
 Optic disc edema
 Macular edema

44.  Venous dilatation and
tortousity peripheral to
the site of occlusion
 Hemorrhages
 Retinal edema
 Cotton wool spots
 Neovascularisation

45.  Most common cause of legal blindness in 20-65 yrs
 Type 1>Type 2 (40% , 20%)
 Risk factors
 Duration of diabetes
 Poor metabolic control
 Pregnancy
 Hypertension
 Nephropathy
 Smocking
 Obesity
 Hyperlipidaemia

46.  Micro vascular occlusion  Microvascular leakage

47. Eva kohner‟s classification
 Non-proliferative diabetic retinopathy
 Pre-proliferative diabetic retinopathy
 Proliferative diabetic retinopathy

48.  Micro aneurysms
(earliest lesion)
 Hard exudates
 Retinal edema
 Haemorrhages

49.  Cotton wool spots
 Intra retinal micro vascular abnormalities(IRMA)
 Venous changes
 Dilatation,looping
 Beading, segmentation
 Arterial changes
 Narrowing, occlusion
 Silver wiring
 Dark blot haemorrhages

50.  Involvement of fovea
 Perifoveal hard exudates
 Dark blot hemorrhages

51. Neovascularisation
Venous looping
NVD
Venous beading
NVE

52. NVD NVE

53.  Primary response to HTN- vasoconstriction
 Narrowing depend on pre-existing sclerosis
 Narrowing seen in its pure form only in
young individuals
 Sustained HTN-inner BRB disrupted
 Increased vascular permeability
 Narrowing and sclerosis suggests duration of
hypertension

54.  GRADE 1  GRADE2
 Generalised arteriolar  Exaggeration of light reflex
narrowing  AV crossing changes
(Salus sign)

55.  GRADE 1  GRADE2
 Focal arteriolar  Exaggeration of light reflex
narrowing  AV crossing changes
(Salus sign)

56.  GRADE 3  GRADE 4
 Prominent AV changes  Features of grade 3
(Bonnet, Gunn signs)  Papilloedema
 Retina edema, CWS
 Flame h‟mages

57. Grade 0
Grade 4 Grade 1
Grade 3 Grade 2

58.  Rare, occurs in hypertensive crisis
 „Elschnig spots‟
 „Siegrist streaks‟
 Exudative retinal detachment

59.  Creamy appearance of the
vessels in the posterior
pole and peripheral area
 Triglycerides >2500mg/dl

60.  Micro vascular occlusion and
ischemia
 Severe head trauma, chest
compression injury, Embolism,
a/c pancreatitis, carcinoma,
connective tissue diseases,
Lymphoma, TTP, Bone
marrow transplantation
 Multiple superficial white
retinal patches
 Superficial pericapillary
haemorrhages

62.  Sickle cell anaemia & Sickle cell thalassemia
are associated severe ocular manifestations
 Proliferative changes
 Seafan neovascularisation
 Haemorrhages

63. STAGING
5 1 1. Peripheral arteriolar
occlusion
2. Peripheral AV
anastomosis
4 2 3. Sprouting new vessels
4. Vitreous haemorrhage
5. Retinal detachment
3

64.  Venous tortousity
 Silver wiring of arterioles
 „Salmon patches‟
 „Black sunbursts‟
 Macular depression sign
 Peripheral retinal holes
 Artery & vein occlusion
 Angioid streaks

65.  Venous tortousity
 Silver wiring of arterioles
 „Salmon patches‟
 „Black sunbursts‟
 Macular depression sign
 Peripheral retinal holes
 Artery & vein occlusion
 Angioid streaks

66.  Rarely diagnostic importance
 Duration &type don‟t influence
 Pale fundus
 Haemorrhages
 Cotton wool spots
 Roth spot
 Venous tortousity-related severity of anemia

67.  More common in a/c leukaemia
 Primary- infiltration
 Secondary- anemia, thrombocytopaenia,
hyperviscosity, infection
 Superficial haemorrhages
 Roth spot
 Cotton wool spot

68.  Peripheral retinal vascularisation
 Pigment epitheliopathy- ‛leopard spot‟

69.  Venous dilatation
 Segmentation
 Venous tortousity
 Retinal haemorrhages

70.  Viral
 CMV
 HIV
 Rubella
 Bacterial
 Tuberculosis
 Syphilis
 Parasitic
 Toxoplasmosis
 Fungal

71.  Most common ocular infection in AIDS
 Indolent retinitis
 Startsin the periphery
 Mild granular opacification
 Fulminating retinitis
 Dense white opacification
 Vasculitis, mild vitritis
 Hemorrhages
 Extension along blood vessels
 Involve optic nerve head

72.  60% of AIDS patients
 Retinal microangiopathy
 Multiple cotton wool spots
 Non infectious

73.  Salt & pepper retinopathy,
most marked at macula
 Disc & vessels normal
 Pigmentery disturbance at
posterior pole
 Optic neuritis

74.  Intractable chronic uveitis
 Focal/multi focal choroiditis
 Choroidal granuloma
 Periphlebits
 Panuveitis

75.  Quiscent
 Bilateral/unilateral healed chorio
retinal scars
 Reactivation retinochoroiditis
 Adjacent to old scar
(satellite lesion)
 Vasculitis,
 Severe vitritis
(headlight in the fog‟ appearance)
 Papillitis (secondary to
juxtapapillary retinitis)
 Atypical lesions

76.  Quiscent
 Bilateral/unilateral healed chorio
retinal scars
 Reactivation retinochoroiditis
 Adjacent to old scar
(satellite lesion)
 Vasculitis,
 Severe vitritis
(headlight in the fog‟ appearance)
 Papillitis (secondary to
juxtapapillary retinitis)
 Atypical lesions

77.  Quiscent
 Bilateral/unilateral healed chorio
retinal scars
 Reactivation retinochoroiditis
 Adjacent to old scar
(satellite lesion)
 Vasculitis,
 Severe vitritis
(headlight in the fog‟ appearance)
 Papillitis (secondary to
juxtapapillary retinitis)
 Atypical lesions

79.  Retinal periphlebitis
 „Candle wax drippings‟
 Branch retinal vein occlusion
 Cotton ball vitreous opacities
 Haemorrhages,
 Granulomas
 Optic nerve edema and
granuloma

80.  Optic disc granuloma  Retinal granuloma
‟Landers sign‟

81.  Optic disc granuloma  Retinal granuloma
‟Landers sign‟

82.  A/c recurrent Hypopyon uveitis
 Retinitis- superficial infiltrates
 Retinal vasculitis
 Periphlebitis& periarteritis
 Vascular occlusion
 Vascular leakage
 Optic disc edema
 Retinal exudation
 Vitritis

83.  Optic disc edema
 Multifocal detachments of
the sensory retina
 Exudative retinal
detachment
 Numerous, residual, small,
atrophic scars
(‛sunset glow‟ fundus)

84.  No typical features
 Retinopathy
 Haemorrhages
 Cotton wool spots
 Vascular occlusions

86.  Hyaline like calcific material within optic disc
 Often bilateral, 0.3%
 Buried drusen
 Elevated disc, scalloped margin
 No physiological cup
 No hyperaemia
 Vessels not obscured
 Venous pulsation present
 Exposed drusen
 Waxy pearl like irregularities

87.  Hyaline like calcific material within optic disc
 Often bilateral, 0.3%
 Buried drusen
 Elevated disc, scalloped margin
 No physiological cup
 No hyperaemia
 Vessels not obscured
 Venous pulsation present
 Exposed drusen
 Waxy pearl like irregularities

88.  Hyaline like calcific material within optic disc
 Often bilateral, 0.3%
 Buried drusen
 Elevated disc, scalloped margin
 No physiological cup
 No hyperaemia
 Vessels not obscured
 Venous pulsation present
 Exposed drusen
 Waxy pearl like irregularities

89.  Incomplete closure of the choroid fissure
 Discrete, focal, glistening, white,
bowl shaped excavation
 Disc may enlarged
 Retinal vasculature normal
 Complication- RD
 Trisomy 13, 18, 22
 CHARGE

90.  Visual acuity very poor
 Enlarged disc with funnel shaped excavation
 Central core -whitish glial tissue
 Spokes of wheel appearance
 Complication- RD
 Frontonasal dysplasia
 Neurofibromatosis type-2

91.  Myelination extend to retina
 Don‟t interfere with vision
 Larger & denser than CWS
 Always connected to optic disc
 No overlying vitreous haze

92. Normal vertical cup-disc ratio 0.3 or less

93.  Inflammatory, infective or demyelinating process
 Retrobulbar neuritis
 Opticdisc normal
 Most common type in adult, MS
 Papillitis
 Hyperemia & edema of optic disc
 Flame h‟mage
 Neuroretinitis
 Papiiltiswith retinal nerve fibre layer inflammation
 Macular star
 Viral infection , cat scratch fever, syphilis

94.  Inflammatory, infective or demyelinating process
 Retrobulbar neuritis
 Opticdisc normal
 Most common type in adult, MS
 Papillitis
 Hyperemia & edema of optic disc
 Flame h‟mage
 Neuroretinitis
 Papiiltiswith retinal nerve fibre layer inflammation
 Macular star
 Viral infection , cat scratch fever, syphilis

95.  Inflammatory, infective or demyelinating process
 Retrobulbar neuritis
 Opticdisc normal
 Most common type in adult, MS
 Papillitis
 Hyperemia & edema of optic disc
 Flame h‟mage
 Neuroretinitis
 Papiiltiswith retinal nerve fibre layer inflammation
 Macular star
 Viral infection , cat scratch fever, syphilis

96.  Swelling of optic nerve head secondary to
raised intracranial pressure
 Early papilloedema
 Optic disc- hyperemia
& mild elevation
 Disk margins indistinct
 Loss of spontaneous
venous pulsation

97.  Established papilloedema
 Hyperaemia of optic disc
 Blurred, elevated margin
 Obliterated cup
 Venous engorgement
 Flame shaped hemorrhages
 Cotton wool spots
 Hard exudates-‛macular fan‟

98.  Chronic papilloedema
 Optic disc elevated and white
‛champagne cork appearance‟
 Usual cause chronic elevated ICT
 Corpora amylacea
 Irreversible visual loss
 Cotton wool spot & h‟mage
absent

99.  Retro laminar portion of optic
nerve to lateral geniculate body
 Lesion anterior to optic chiasma-
unilateral
 RB neuritis, hereditary,
compressive lesions, toxic&
nutritional optic neuropathy
 Without antecedent swelling of
optic disc
 Pale flat disc, clear margins
 Reduction in no. of small BV on
the disc- „Kestenbaum sign‟
 Atrophy may be diffuse/sectoral

100.  Retro laminar portion of optic
nerve to lateral geniculate body
 RB neuritis, hereditary,
compressive lesions, toxic&
nutritional optic neuropathy
 Without antecedent swelling of
optic disc
 Lesion anterior to optic chiasma-
unilateral
 Pale flat disc, clear margins
 Reduction in no. of small BV on
the disc- „Kestenbaum sign‟
 Atrophy may be diffuse/sectoral

101.  Preceded by swelling
 Papilloedema, AION, Optic neuritis
 Dirty grey slightly raised disc
 Ill defined margins –gliosis
 Sheathed vessels
 Reduction in small vessels

103.  Clinical opthalmology- Jack J.Kanski 5th Ed.
 “The Eyes Have It”-University of Michigan
 Harrison‟s Principles of internal medicine 16th Ed.
 Parsons‟ Diseases of the Eye 20th Ed.
 New England Journal of Medicine