Fundus

What are the considerations when you do not get red reflex?

Answer

• Cataract
• Detached retina
• Artificial eye

Describe the location, size and color of the optic disc.

Answer

• Location
  • fovea is the center of fundus
  • optic disc is medial to fovea and at slightly higher level
• Size
  • 1.5 mm in diameter (this gets magnified 15 times by ophthalmoscope)
• Shape

  • round or oval

• Margin
  • clear and visible
• Color:
  • yellowish orange
  • supplied by small vessels
  • well perfused and vital 
• Surface
  • flat
  • arteries and veins cross the disc at the same level of adjacent fundus
  • optic cup in the middle

Describe the characteristics of optic cup.

Answer

• The diameter of the cup is less than half to that of the entire disc
• The position of the cup is central or slightly temporal
• Does not touch rim at any point

• Cup disc ratio is < 0.5

• Arteries and veins radiate from the center of the cup

How do you distinguish arteries from veins?

Answer

• Arteries
  • light red
  • narrower than veins
  • light reflex
• Veins
  • dark red
  • wider than artery
  • no light reflex
  • pulsatile (this is not a mistake. However I never can appreciate this)

What is the normal relationship between veins and arteries?

Answer

• Arteries are narrower than veins, the ratio being approximately 2:3
• Arteries cross over veins
• Veins do not appear constricted at the intersections

Where is fovea located?  How do you recognize it?

Answer

• Center of fundus
• Fovea is located 2.5 disc distance temporal to disc 
• No vessels are noted around fovea 
• It may be slightly pigmented 

Where is the macula is located? How do you recognize it?

Answer

• The macula surrounds fovea 

List optic disc abnormalities.

Answer

• Papilloedema
• Optic atrophy
• Pathologic cupping

• Papillitis

What are the funduscopic findings of papilloedema?

Answer

• Optic disc 
  • edematous
  • hyperemic
  • margins blurred and indistinct
  • optic cup not visible
  • disc is thick and is elevated
    • vessels over disc and adjacent retina not in focus simultaneously
• Retinal veins engorged and do not pulsate
• Retinal hemorrhages

What does papilloedema indicate? How do you measure the optic disc's thickness in papilloedema?

Answer

• Increased intracranial pressure

• By focusing on vessels over and around the disc

  • vessels over disc and adjacent retina not in focus simultaneously
  • focus on vessels over disc, note the diopter
  • now focus on vessels adjacent to disc
  • difference in diopters indicates the measure of  thickness of disc

How do you distinguish papilloedema from papillitis?

Answer

• They look alike
• The following are helpful:
  • clinical picture
  • unilateral or bilateral
  • visual field defects

What are the findings of optic atrophy?

Answer

• Disc is pale white
• No small vessels to give the live color

• Sharp margins  

What is the significance of optic atrophy?

Answer

• Optic neuritis
  • blindness

When do you consider the optic cup as pathological?

Answer

When the optic cup is wider and deeper than normal, it is considered abnormal.

• Wider
  • the diameter of the cup is more than half that of the entire disc
    • optic cup/ disc ration is > 0.5
  • it encroaches towards the rim of optic disc
• Deeper
  • arteries and veins bend at the margin of cup
  • vessels in the cup and over the disc, not in focus simultaneously

What are the characteristic findings of vessel changes in hypertension? 

Answer

• Spasm
  • narrow arteries
• Thickening of vessel wall
  • beading
• Copper wire
  • widened light reflex

• Silver wire

  • vessel wall not translucent
  • blood column not visible
• Av nicking

What are the fundus changes that indicate accelerated or "malignant" hypertension?

Answer

• Papilloedema

List common conditions where you can see retinal hemorrhage. How do you classify them?

Answer

• Common conditions 
  • diabetes
  • hypertension
  • raised intra-cranial tension
  • retinal vein thrombosis
• Superficial
  • linear and flame shaped
• Deep
  • small round red spots

List common conditions where you can see retinal exudates. How do you classify them?

Answer

• Hard exudates
  • margins are sharp
• Soft exudates
  • indistinct edges
  • caused by infarcted nerve fibers
• Seen in:
  • diabetes
  • hypertension

What does tortuous widened retinal veins indicate?

Answer

• Raised intra-cranial tension
• Retinal vein thrombosis

• Macroglobulinemia

What is macular star?

Answer

• Exudates in a radiating pattern around the macula
• Seen in hypertension

How will macular degeneration look? What is the significance?

Answer

• Non-exudative degeneration
  • drusen over macula
  • large confluent and more numerous
  • pigmentation over macula
• Exudative degeneration

What is neovascularization? In what conditions do you see it? Why does it occur?

Answer

• New vessel formation
• As a consequence to ischemia, new vessels form
• Diabetes mellitus (proliferative form) is the most common condition where neovascularization occurs
  • vessels are more tortuous and narrower than normal vessels
  • form disorderly looking arcs
  • grow into vitreous
    • hemorrhage
    • retinal detachment

What is retinitis pigmentosa? How will you recognize it?

Answer

• Irregular black clumped pigments along the periphery of retina
• Pigments resembling bony spicules
• If interested, read about it

What are the findings of retinal detachment?

Answer

• Loss of red reflex
• Fuzzy fundus

What are the characteristics of nevus?

Answer

• Flat area of pigmentation
• Difficult to distinguish from melanoma in early stages
• Size remains stable, unlike melanoma where there is progressive increase in size

What are the characteristics of melanoma?

Answer

• Area of pigmented lesion
• Irregular surface
• Progressively increases in size
• Mass like

What are the characteristics of coloboma?

Answer

• Moderate size
• Oval in shape
• White visible sclera
• Developmental abnormality

What are the characteristics of medullated optic nerve?

Answer

• Dramatic appearance, large irregular shaped disc
• Disc is not round or oval
• Feathered margins obscuring disc edges and retinal vessels
• The medullated fibers are opaque

What is drusen?

Answer

• Yellow round deposits
• Small and discrete
• Age related
• Feature of macular degeneration

How do you classify fundus changes of diabetes mellitus?

Answer

• Non-proliferative
• Proliferative

Describe non-proliferative fundus changes of diabetes mellitus.

Answer

• Deep retinal hemorrhages
  • small red round spots
  • deeper layer of retina
• Micro aneurysms
  • tiny red round spots
  • minute dilatations of retinal vessels
• Exudates