Optic fundus in clinical medicine
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Transcript of Optic fundus in clinical medicine
![Page 1: Optic fundus in clinical medicine](https://reader036.fdocuments.net/reader036/viewer/2022082309/556e174bd8b42a6a2c8b48fe/html5/thumbnails/1.jpg)
26/02/2008
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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
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Direct ophthalmoscopy
Indirect opthalmoscopySterioscopical view possible
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Tygroid fundus
Deeply pigmented choroid
Choroidal vessels are seen
Polygonal pigmented areas in between
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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
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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
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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
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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
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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
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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
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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)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
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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)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
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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)
Fluffy gray-white, near optic disc
Retinal nerve fiber layer microinfarction
HTN, DM, connective tissue disease,HIV
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White centered retinal haemorrhages
CWS surrounded by h‟mage
CWS- ischaemic axons
H‟maghe- precapillary arterioles
Sub acute bacterial endocarditis
Leukaemia
Diabetes
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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
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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
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Papillopheblitis (optic disc vasculitis)Affects healthy individuals <50
Disc edema, cotton wool spots
Venous dilatation and tortousity
Retinal haemorrhages
Retinal vasculitisOccurs in sarcoidosis, Behcet‟s disease,
Multiple sclerosis, idiopathic
Extremely rare in lupus
Perivenous lymphocytic infiltration (sheathing)
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Diffuse retinal dystrophy(rods)
Classic clinical triadArteriolar attenuation
Retinal bone-spicule pigmentation
Waxy disc pallor
Starts at mid periphery
Maculopathy
Associations Bassen-Kornzwieg syndrome,
Refsum‟s disease, Kearn-sayresyndrome , Usher‟s syndrome Muchopolysaccharidoses, Lauren‟s moon biedel syndrome, Friederischataxia
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Attempt at vascularising ischaemic tissue
Lacks bifurcating pattern
Bleed spontaneously
Diabetic retinopathy
Retinal vein occlusion
Radiation
Sickle cell retinopathy
Retinopathy of prematurity
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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, haradadisease, posterior scleritis, subretinalneovascularisation, severe hypertension
Elevated sheath of retinal tissue with folds
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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, haradadisease, posterior scleritis, subretinalneovascularisation, severe hypertension
Elevated sheath of retinal tissue with folds
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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
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Cholesterol Fibrinoplatelet Calcific
(Hollenhorst plaques)
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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
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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
Cattle-trucking
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Embolism, periarteritis
Retinal cloudiness corresponding to the areas of ischemia
Narrowing of arteries and veins
One or more emboli may be present
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Present in 20% of population
It may be isolated, combined CRVO, combined AION
Localised cloudiness- macula and papillomacular bundle
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Occlusion of short posterior ciliary arteries
Disc is pale
Diffuse or sectoral edema
Splinter shaped h‟mages
„Pseudo-Foster kennedy syndrome‟
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Giant cell arteritis
Cotton wool spots are uncommon
Cilioretinal artery occlusion
Central artery occlusion
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EtiologyArteriosclerosis
Increasing age
Hypertension
Diabetes mellitus
Blood dyscrasiasis
Periphlebitis
Raised intraocular tension
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Dilatation & tortousity of all branches of CRV
Retinal h‟age- superficial & deep throughout
“Blood and thunder”
Cotton wool spots
Optic disc edema
Macular edema
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Venous dilatation and tortousity peripheral to the site of occlusion
Hemorrhages
Retinal edema
Cotton wool spots
Neovascularisation
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Most common cause of legal blindness in 20-65 yrs
Type 1>Type 2 (40% , 20%)
Risk factorsDuration of diabetes
Poor metabolic control
Pregnancy
Hypertension
Nephropathy
Smocking
Obesity
Hyperlipidaemia
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Micro vascular occlusion Microvascular leakage
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Eva kohner‟s classification
Non-proliferative diabetic retinopathy
Pre-proliferative diabetic retinopathy
Proliferative diabetic retinopathy
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Micro aneurysms(earliest lesion)
Hard exudates
Retinal edema
Haemorrhages
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Cotton wool spots
Intra retinal micro vascular abnormalities(IRMA)
Venous changes
Dilatation, looping
Beading, segmentation
Arterial changes
Narrowing, occlusion
Silver wiring
Dark blot haemorrhages
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Involvement of fovea
Perifoveal hard exudates
Dark blot hemorrhages
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Neovascularisation
Venous looping
Venous beading
NVD
NVE
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NVD NVE
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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
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GRADE 1
Generalised arteriolar narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes(Salus sign)
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GRADE 1
Focal arteriolar narrowing
GRADE2
Exaggeration of light reflex
AV crossing changes(Salus sign)
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GRADE 3
Prominent AV changes (Bonnet, Gunn signs)
Retina edema, CWS
Flame h‟mages
GRADE 4
Features of grade 3
Papilloedema
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Grade 0
Grade 1Grade 4
Grade 2Grade 3
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Rare, occurs in hypertensive crisis
„Elschnig spots‟
„Siegrist streaks‟
Exudative retinal detachment
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Creamy appearance of the vessels in the posterior pole and peripheral area
Triglycerides >2500mg/dl
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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 pericapillaryhaemorrhages
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Sickle cell anaemia & Sickle cell thalassemia are associated severe ocular manifestations
Proliferative changes
Seafan neovascularisation
Haemorrhages
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STAGING
1. Peripheral arteriolar occlusion
2. Peripheral AV anastomosis
3. Sprouting new vessels
4. Vitreous haemorrhage
5. Retinal detachment
1
24
5
3
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Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioid streaks
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Venous tortousity
Silver wiring of arterioles
„Salmon patches‟
„Black sunbursts‟
Macular depression sign
Peripheral retinal holes
Artery & vein occlusion
Angioid streaks
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Rarely diagnostic importance
Duration &type don‟t influence
Pale fundus
Haemorrhages
Cotton wool spots
Roth spot
Venous tortousity-related severity of anemia
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More common in a/c leukaemia
Primary- infiltration
Secondary- anemia, thrombocytopaenia, hyperviscosity, infection
Superficial haemorrhages
Roth spot
Cotton wool spot
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Peripheral retinal vascularisation
Pigment epitheliopathy- ‛leopard spot‟
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Venous dilatation
Segmentation
Venous tortousity
Retinal haemorrhages
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Viral
CMV
HIV
Rubella
Bacterial
Tuberculosis
Syphilis
Parasitic
Toxoplasmosis
Fungal
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Most common ocular infection in AIDS
Indolent retinitis
Starts in the periphery
Mild granular opacification
Fulminating retinitis
Dense white opacification
Vasculitis, mild vitritis
Hemorrhages
Extension along blood vessels
Involve optic nerve head
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60% of AIDS patients
Retinal microangiopathy
Multiple cotton wool spots
Non infectious
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Salt & pepper retinopathy, most marked at macula
Disc & vessels normal
Pigmentery disturbance at posterior pole
Optic neuritis
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Intractable chronic uveitis
Focal/multi focal choroiditis
Choroidal granuloma
Periphlebits
Panuveitis
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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
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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
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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
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Retinal periphlebitis
„Candle wax drippings‟
Branch retinal vein occlusion
Cotton ball vitreous opacities
Haemorrhages,
Granulomas
Optic nerve edema and granuloma
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Optic disc granuloma Retinal granuloma ‟Landers sign‟
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Optic disc granuloma Retinal granuloma ‟Landers sign‟
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A/c recurrent Hypopyon uveitis
Retinitis- superficial infiltrates
Retinal vasculitis
Periphlebitis & periarteritis
Vascular occlusion
Vascular leakage
Optic disc edema
Retinal exudation
Vitritis
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Optic disc edema
Multifocal detachments of the sensory retina
Exudative retinal detachment
Numerous, residual, small, atrophic scars(‛sunset glow‟ fundus)
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No typical features
Retinopathy
Haemorrhages
Cotton wool spots
Vascular occlusions
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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
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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
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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
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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
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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
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Myelination extend to retina
Don‟t interfere with vision
Larger & denser than CWS
Always connected to optic disc
No overlying vitreous haze
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Normal vertical cup-disc ratio 0.3 or less
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Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
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Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
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Inflammatory, infective or demyelinating process
Retrobulbar neuritis
Optic disc normal
Most common type in adult, MS
Papillitis
Hyperemia & edema of optic disc
Flame h‟mage
Neuroretinitis
Papiiltis with retinal nerve fibre layer inflammation
Macular star
Viral infection , cat scratch fever, syphilis
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Swelling of optic nerve head secondary to raised intracranial pressure
Early papilloedema
Optic disc- hyperemia & mild elevation
Disk margins indistinct
Loss of spontaneousvenous pulsation
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Established papilloedema
Hyperaemia of optic disc
Blurred, elevated margin
Obliterated cup
Venous engorgement
Flame shaped hemorrhages
Cotton wool spots
Hard exudates-‛macular fan‟
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Chronic papilloedema
Optic disc elevated and white ‛champagne cork appearance‟
Usual cause chronic elevated ICT
Corpora amylacea
Irreversible visual loss
Cotton wool spot & h‟mageabsent
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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
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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
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Preceded by swelling
Papilloedema, AION, Optic neuritis
Dirty grey slightly raised disc
Ill defined margins –gliosis
Sheathed vessels
Reduction in small vessels
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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
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