Normal fundus
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normal fundus. ophthalmoscopy. Indirect. Direct. normal fundus. normal fundus. normal fundus. normal fundus. Optical Coherence Tomography (OCT) uses a light beam the same way that B-scan ultrasonography uses a sound beam to image the retina in a microscopic slice.

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Normal fundus

normal fundus


Ophthalmoscopy

ophthalmoscopy

Indirect

Direct


Normal fundus1

normal fundus


Normal fundus2

normal fundus


Normal fundus3

normal fundus


Normal fundus4

normal fundus

Optical Coherence Tomography (OCT) uses a light beam the same way that B-scan

ultrasonography uses a sound beam to image the retina in a microscopic slice.


Congenital fundus anomalies

Congenital fundus anomalies

Opaque retinal nerve fibers-

myelinated retinal nerve fibers;

bright, white patch adjanced to the disc often obscuring the retinal vessels running in the white patch.


Congenital fundus anomalies1

Congenital fundus anomalies

  • Opaque retinal nerve fibers


Congenital fundus anomalies2

Congenital fundus anomalies

  • Opaque retinal nerve fibers


Congenital fundus anomalies3

Congenital fundus anomalies

Myopic crescent-

1.white with black pigmented borders rimof atrophic choroid revealing the underlying white sclera in a crescent shape;

2.usually temporal to the disc but may completely surround it;

3.in pathological myopia often associated with myopic choroidoretinal degeneration.


Congenital fundus anomalies4

Congenital fundus anomalies

  • Myopic crescent


Congenital fundus anomalies5

Congenital fundus anomalies


Senile changes

Senile changes

Age related macular degeneration (AMD)

1.the most common cause of registrable blindness

in Western countries;

2.bilateral gradual deterioration of central vision over several years (sometimes sudden), often with symptoms of distortion;

3.the earliest mainifestation, risk factor of AMD - drusen (small yellow spots in macular region, associated with pigment speckling, consist of hyaline, between the retinal pigment epithelium and Bruch`s maembrane, usually cause no visual symptoms).


Drusen

drusen


Senile changes1

Senile changes

Age related macular degeneration (AMD)

4.non- exudative (dry or atrophic):

bilateral progressive atrophy of RPE and the choriocapllares in the macular region secondary to arteriosclerotic degeneration

of choroidal vessels; speckled pigmentation followed by the apperance of areas of retinal atrophy with visibility of choroidal vessels; typically slow gradual to modearte loss

of vision;


Senile changes2

Senile changes


Senile changes3

Senile changes


Senile changes4

Senile changes

Age related macular degeneration (AMD)

5. exudative (dry or atrophic):

in early stages retinal oedema (distortion

of central vision); less common than non- exudative but causes more severe visual loss!!!; two important features- detachment

of RPE and choroidal neovascularisation which may haemorrhage and leads to a fibrous disciform scar at the macula;


Senile changes5

Senile changes

Wet AMD is associated with new blood vessels

(neovascularization) that originate

in the choroid and break through Bruch's membrane

and the RPE layer. 

OCT image below indicates the RPE layer that has

been broken through by the choroidal

new blood vessels.

Age related macular degeneration (AMD)


Senile changes6

Senile changes


Senile changes7

Senile changes

Age related macular degeneration (AMD)


Senile changes8

Senile changes

The end result is scarring and a loss of retinal function in the area affected.

Ninety percent of the cases of severe vision loss from AMD results from wet AMD.

Age related macular degeneration (AMD)


Senile changes9

Senilechanges


Senile changes10

Senilechanges


Senile changes11

Senilechanges


Senile changes12

Senile changes


Senile changes amsler grid as it might appear to someone with age related macular degeneration

Senile changes- Amsler grid as it might appear to someone with age-related macular degeneration.


Senile changes13

Senile changes

Agerelatedmaculardegeneration (AMD)

Treatment

Non- exudative: no treatment

Exudative: argon laser photocoagulation

to destroy a choroidalneovascularmembrane,

photodynamictherapy- PDT (Visudine),

Injectionsintovitreous body (steroids- Triamcinolone, antineovascularizationagents- Macugen, Lucentis, Avastin),

nutrientsupplements (vitamin C and E, zinc, cuprum, betacarotene, lutein).


Senile changes14

Senile changes

Macular Hole

generally middle- aged woman;

sudden reduction in central vision to around the 6/60 level;

small round retinal hole centered on the fovea;

Vitreous traction;

Treatment- vitrectomy


Macular hole

Macular Hole


Macular hole1

Macular Hole


Senile changes15

Senile changes

Myopic Degeneration

High myopia= large eyeball with all retinal layers stretched and thinned;

primary choroidal atrophy may affect the macular region, or breaks in Bruch`s membrane (laquer cracks) through which choroidal neovascularisation and subsequent disciform scarring may develop in a similar manner to AMD


Congenital fundus anomalies6

Congenital fundus anomalies


Retinal detachment

Retinal detachment

Separation of the retina from its pigment epithelial layer.

The separation occurs at this site for embryological reasons: the two walls

of the embryonic optic vesicle become apposed and form respectively the RPE and neuroretina.


Retinal detachment1

Retinal detachment


Retinal detachment2

Retinal detachment

rhegmatogenous RD

-most common type of RD;

-secondary to a tear or hole in the retina, which often arises as a consequence

of posterior vitreous detachment


Retinal detachment3

Retinal detachment

non- rhegmatogenous RD (exudative and tractional)

-an ucommon type of RD;

-there is no defect in retina;

-result of exudative processes beneath the retina (e.g. scleritis or choroidal neoplasm) or as result of vitreous tractional forces pulling the retina forward (e.g. proliferative diabetic retinopathy).


Retinal detachment4

Retinal detachment

risk factors

-age (over 50);

-high myopia;

-trauma (younger patients);

-systemic conective tissue disorders (Marfan`s syndrome)


Retinal detachment5

Retinal detachment

symptoms

-sudden onset of floating specks or spots associated with flashes of light (typical for posterior vitreous detachment and/ or retinal tear formation);

-„shadow” or „curtain” in the visual field that gradually extends to cover the whole visual field (the same day or days or weeks later);


Retinal detachment6

Retinal detachment

signs

-visual field loss corresponding to the area of detached retina (the temporal retina generally detaches first- nasal field defect);

-reduction in visual acuity (if the macular region becomes detached);


Retinal detachment7

Retinal detachment

signs

-grey retinal folds which quiver as the eye moves;

-the blood vessels on the detached retina have deeper red colour than normal;

-easy contrast between the normal fundus colour and the greyish detached part of retina;


Retinal detachment8

Retinal detachment

signs

-retinal break will be seen at the periphery of detached fundus in the form of a tear (arrowed or „U” shaped), hole

or dialysis (typical for traumatic RD)


Retinal detachment9

Retinal detachment

prevention

laser photocoagulation or retinal cryotherapy in patients with retinal tears and holes and with symptoms of flashes and floaters !!!


Retinal detachment10

Retinal detachment

tratment

surgery

Aim: to seal the retinal break by inducing retinal scarring with laser or cryotherapy and to relieve vitreous traction over the break, either by attaching an indenting implant of silastic to the sclera

or by vitrectomy.


Retinal detachment11

Retinal detachment

prognosis

the visual prognosis depends on the duration of the detachment and whether the macula has been detached!!!


Retinal detachment12

Retinal detachment


Retinal detachment13

Retinaldetachment


Posterior vitreous detachment

Posterior vitreousdetachment


Opacities in the vitreous

opacities in the vitreous


Angioid streaks

Angioid Streaks

-an ophthalmoscopic apperance similar to blood vessels;

-irregural, reddish streaks extend outwards from the optic disc (cracks in Bruch`s membrane);

-usually asymptomatic (unless they affect macular region);


Angioid streaks1

Angioid Streaks

-compications: neovascularisation, disciform scars;

-May be associated with: pseudoxanthoma elasticum, Ehlers- Danlos syndrome, Paget`s disease, sickle- cell anaemi;


Angioid streaks2

Angioid Streaks


Fundus inflammation

Fundus inflammation

main informations:

(choroiditis/ psterior uveitis)

-rapid blurring of vision (usually in one eye);

-spots and hazines over the whole visual field (inflammatory cells in vitreous);

-inflammations of the choroid always affect the overlying retina to produce

a chorioretinitis


Fundus inflammation1

Fundus inflammation

toxoplasmosis:

The parasite (Toxoplasma gondii) probably causes choroiditis by its entry into the bloodstream via ingested infected material from cats. Toxoplasma may be transmitted across the placenta causing congenital toxoplasmosis.


Fundus inflammation2

Fundus inflammation

toxoplasmosis:

Many people are unaware they have had toxoplasmosis chorioretinitis

in childchood or from birth until

a characteristic old fundus is noted

on routine examination in later years.


Fundus inflammation3

Fundus inflammation

toxoplasmosis:

Primary infection in adults:

-mild febrile illness;

-the eye symptoms


Fundus inflammation4

Fundus inflammation

toxoplasmosis:

Signs and symptoms:

-reduced vision;

-very hazy view of the fundus (inflammatory cells in vitreous);

-localised white fluffy area in the fundus;


Fundus inflammation5

Fundus inflammation

toxoplasmosis:

forms:

-reccurent episode (the active focus arieses from an area adjanced

to pigmented choroidal scar);

-primary episode;


Fundus inflammation6

Fundus inflammation

toxoplasmosis:

It is very important to distinguish reccurent from primary disease in pregnancy because there is very high risk

of congenital toxoplasmosis in primary infection!!!


Fundus inflammation7

Fundus inflammation

toxoplasmosis:

diagnosis:

Serum antitoxoplasma antibody:

1.IgM- 2 to 6 months after initial infection, 2.IgG after 6 months)


Fundus inflammation8

Fundus inflammation

toxoplasmosis:

treatment:

Is usually commenced in severe vitritis

and if active lesion is close to the macula

or optic disc.

Systemic corticosteroids (p.o. or i.v) +

Pyrimethamine;

Sulphadiazine;

or Clindamycine.


Fundus inflammation9

Fundus inflammation

toxoplasmosis:


Fundus inflammation10

Fundus inflammation

Toxocariasis (Toxocara canis):

Infection- contact with dog`s infected excreta; eggs of toxocara hatch in the gut and the larvae migrate throughout the body via the blood and lymphatic system.

In children larvae invading the eye may causea focal chorioretinitisoran edophtalmitis and leucocoria.


Fundus inflammation11

Fundus inflammation

Acquired Immunodeficiency Syndrome(AIDS):

Human immunodeficiency virus (HIV)

an RNA retrovirus which infects T- helper lymphocytes impairing their function and causing a state

of immunodeficiency.


Fundus inflammation12

Fundus inflammation

AIDS- ocular manifestations:

1.HIV retinopathy (especially cotton wool spots, less frequently microaneurysms and oedema like in diabetic retinopathy);


Fundus inflammation13

Fundus inflammation

AIDS- ocular manifestations:

2.Opportunistic ocular infections –Cytomegalovirus (CMV) retinitis= 25%

of AIDS patients; usually asymptomatic until the macula or optic nerve

is affected. The clinical apperance

is of slowly progressive, necrotising retinitis.

Fundus: white areas of retinal infiltrate and necrosis and haemorrhage within and along necrotic area (pizza fundus)


Fundus inflammation14

Fundus inflammation

AIDS- ocular manifestations:

CMV retinitis

Treatment:

Antiviral treatment-

Ganciclovir or foscarnet (intravenously

or by intravitreal injection or implant.


Cmv retinitis

CMV retinitis


Cmv retinitis1

CMV retinitis


Cmv retinitis2

CMV retinitis


Cmv retinitis3

CMV retinitis


Cmv retinitis4

CMV retinitis


Arn syndrome

ARN syndrome


Porns

PORNS


Fundus inflammation15

Fundus inflammation

AIDS- ocular manifestations:

3.Kaposi sarcoma

A purple or red higly vascular lesion (vascular malignancy) which may occur on the eyelids or conjunctiva.

Treatment- Radiotherapy.


Aids ocular manifestations

AIDS- ocular manifestations:


Retinal dystrophies

Retinal dystrophies

Retinitis pigmentosa (RP):

-an inherited primary retinal degeneration;

-sometimes associated with systemic disorders (Usher`s syndrome= RP + congenital senorineural deafness)


Retinal dystrophies1

Retinal dystrophies

Retinitis pigmentosa (RP):

Symptoms:

-night blindness in childchood

or adolescence (initial symptom);

-gradual and progressive peripherial visual field loss leading to tunnel vision.


Retinal dystrophies2

Retinal dystrophies

Retinitis pigmentosa (RP):

Signs:

-Fundus-classical mid- periphery scattered bone spicule pigmentation, marked narrowing of the retinal vessels and optic atrophy;

-Visual field- ring scotoma (early stages), tunnel vision (advanced RP).


Retinal dystrophies3

Retinal dystrophies

Retinitis pigmentosa (RP):

Signs:


Retinal dystrophies4

Retinal dystrophies

  • Pigment degeneration and pigment clumping of a retina suffering from retinitis pigmentosa.


Retinal dystrophies5

Retinal dystrophies

Retinitis pigmentosa (RP):

treatment:

-at the present time there is no known effective treatment.


Retinal dystrophies6

Retinal dystrophies

Macular dystrophies

Hereditary, progressive degeneration of the macula in children and young adults leading to slow deterioration in central vision (Best`s disease, Stargard`s disease, cone dystrophy, pattern dystrophy);


Retinal dystrophies7

Retinal dystrophies

Macular dystrophies

Signs- Reduced visual acuity;

Fundus- abnormal deposits or pigmentation at the macula (Bulls eye);

Diagnosis- electrophysiological tests;

Treatment- no;

Low vision aids (telescopic spectacles)


Stargard s disease

Stargard`s disease


Neuro ophthalmology

Neuro- ophthalmology

Optic disc swelling

Swelling of the optic disc is produced

by oedema within the nerve head.


Neuro ophthalmology1

Neuro- ophthalmology

Optic disc swelling


Neuro ophthalmology2

Neuro- ophthalmology

Optic disc drusen


Neuro ophthalmology3

Neuro- ophthalmology

Optic disc swelling- causes:

1.Raised intracranial pressure- tumors or impaired CSF drainage; raised intracranial pressure is transmitted to the meningeal sheath surrounding the optic nerve (papillooedema); normal axoplasmic flow is interrupted with consequent intra- axonal swelling.

The vascular features (hyperaemia, venous congestion and haemorrhage) are all secondary.


Neuro ophthalmology4

Neuro- ophthalmology

  • The initial change in the ophthalmoscopic examination in a patient with increased intracranial pressure is the loss of pulsations of the retinal vessels. This is followed by blurring of the optic disc margin and possibly retinal hemorrhages.


Optic disc swelling

Optic disc swelling


Neuro ophthalmology5

Neuro- ophthalmology

Optic disc swelling- causes:

2.Ischaemic optic neuropathy- arteritic, embolic or atherosclerotic blockage of the posterior ciliary arteries which supply the optic nerve head (ONH); ischaemia of ONH, interruption of axoplasmic flow and disc swelling (central retinal vein occlusion, malignant hypertension).


Anterior ischemic optic neuropathy aion

ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)


Neuro ophthalmology6

Neuro- ophthalmology

Optic disc swelling- causes:

3.Inflammation- papillitis or optic neuritis; idiopathic or associated with multiple sclesosis, diabetes or post viral.


Neuro ophthalmology7

Neuro- ophthalmology

Optic disc swelling- causes:

4.Compression- raised intraorbital pressure (Graves` disease, retrobulbar hemorrhage, orbital tumors).


Neuro ophthalmology8

Neuro- ophthalmology

Optic disc swelling- causes:

5.Infiltration- lymphoma.


Neuro ophthalmology9

Neuro- ophthalmology

Optic disc swelling- causes:

6.Toxic- steroids, ethambutol, tobacco; optic disc swelling and its pallor.


Neuro ophthalmology10

Neuro- ophthalmology

Optic disc swelling- causes:

7.Trauma- direct or indirect optic nerve trauma; optic disc swelling and its atrophy.


Neuro ophthalmology11

Neuro- ophthalmology

Optic disc swelling:

The term papillooedema should be restricted to a swollen optic disc due to raised intracranial pressure!!!


Neuro ophthalmology12

Neuro- ophthalmology

Optic disc swelling- symptoms:

1.Impaired vision- very rapid and severe visual loss is typical for ischaemic or inflammatory optic disc swelling.

Raised intracranial pressure may causes no visual symptoms (they are rather secondary);


Neuro ophthalmology13

Neuro- ophthalmology

Optic disc swelling- symptoms:

2.Visual field loss- ishaemic optic neuropathy- altitudinal visual field defect; compression and toxicity- central or centrocaecal visual field defect.

Raised intracranial pressure may causes no syptomatic field loss (sometimes enlargement of the blind spot);


Neuro ophthalmology14

Neuro- ophthalmology

Optic disc swelling- symptoms:

3.Impaired colour vision- particularly to red stimuli;

4.Pain on eye movements- retrobulbar optic neuritis!!!


Neuro ophthalmology15

Neuro- ophthalmology

Optic disc swelling- signs:

-dilatation of the retinal veins;

-reddish disc colour, blurred and raised disc margins;

-absence of physiological optic disc cup;

-small haemorrhages at the disc margin;

-abnormal pupill reflexes;

-enlarged blind spot or other charakteristic visual field defects;

-impaired colour vision


Neuro ophthalmology16

Neuro- ophthalmology

Optic disc swelling- hypertensive retinopathy:

-the ocular apperances depend on the sevserity and duration of the blood pressure elevation;

-only an acute severe rise (grades III and IV) in blood pressure cause visual symptoms;


Neuro ophthalmology17

Neuro- ophthalmology

Optic disc swelling- hypertensive retinopathy:

Grading:

Grade I- mild ht (arteriolar attenuation, copper wiring);

Grade II- moderate ht (AV nipping, silver wiring, occasional hard exudate or haemorrhage);

Grade III- severe ht (flame haemorrhages, hard exudates, cotton wool spots);

Grade IV- malignant ht- as for grade III with optic disc swelling.


Neuro ophthalmology18

Neuro- ophthalmology

Optic disc swelling- hypertensive retinopathy:

Grades III and IV can usually be reversed by adequate blood pressure control.

Grades I an II are more resistant to reversal, even if blood pressure is normalised.


Neuro ophthalmology19

Neuro- ophthalmology

Optic disc swelling- Multiple Sclerosis (MS):

-most common in temperate climates;

-young adults (15- 35 years);

-F > M;

-aetiology- unknown (virus infection of CNS);

optic neuritis (ON) is the main ophthalmological sign which arises as a result of demyelination

of optic nerve axons.


Neuro ophthalmology20

Neuro- ophthalmology

Optic disc swelling- Multiple Sclerosis (MS):

symptoms:

-blurring of vision in one eye occuring over a few days (the visual loss from minimal to even light perception- usually about 0,1);

-central scotoma in visual field;

-pain on moving the eye;

-RAPD (relative afferent pupil defect);

-gradual recovery of vision (even without

a treatment, over several weeks)


Neuro ophthalmology21

Neuro- ophthalmology

Optic disc swelling- Multiple Sclerosis (MS):

symptoms:

-the disc swelling is not typical for ON

in MS because in more cases it is

a retrobulbar neuritis; there is no fundus anomaly in retrobulbar ON!!!


Neuro ophthalmology22

Neuro- ophthalmology

Optic disc swelling- Multiple Sclerosis (MS):

Neurological signs:

-ataxia,

-parashesiae,

-nystagmus,

-strabismus;

-plaques of demyelination in MRI scans;


Neuro ophthalmology23

Neuro- ophthalmology

Optic disc swelling- Multiple Sclerosis (MS):

Following an isolated attack of adult optic neuritis the risk of developing MS

is approximately 50 per cent!!!


Neuro ophthalmology24

Neuro- ophthalmology

Optic Atrophy:

Any damage to the optic nerve from whatever cause, will result in degeneration of the optic nerve fibres and destruction of their myelin nerve sheaths. The dead nerve fibre axons are replaced by glia which give the atrophic disc its typical ophthalmoscopic pale apperance.


Neuro ophthalmology25

Neuro- ophthalmology

Optic Atrophy:

Primary- often hereditary basis;

Secondary- any cause of optic disc swelling may be followed by the development of optic atrophy!!!, several of these diseases may cause optic atrophy without an observed episode of disc swelling (optic nerve compression, toxic optic neuropathy).


Neuro ophthalmology26

Neuro- ophthalmology

Optic Atrophy:

Secondary- certain retinal disorders don`t cause optic disc swelling but do cause optic atrophy (glaucoma- typical ON atrophy with cupping of the ONH!!!, retinitis pigmentosa, central retinal artery occlusion).


Neuro ophthalmology27

Neuro- ophthalmology

Optic Atrophy- signs and symptoms:

-focal or generalised disc pallor;

-sharper disc margins;

-diminished visual acuity;

-visual field defects;


Neuro ophthalmology28

Neuro- ophthalmology

Optic Atrophy- signs and symptoms:


Neuro ophthalmology29

Neuro- ophthalmology

Optic Atrophy- signs and symptoms:


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