i. Superficial
Flame shaped hemorrhages (Figure 4.1)
• bleeding near the surface of retina in nerve fiber layer
• follows nerve fiber, giving flame‐shaped appearance
• located usually in relation to optic nerve head or posterior pole, seldom in peripheral retina where nerve fiber layer is thin.
• causes: retinal vein occlusion, diabetic retinopathy, optic nerve disease (acute papilloedema, anterior ischemic optic neuropathy), retinal periphlebitis Figure 4.1 Flame‐shaped hemorrhage
Notice the unidirectional smudge‐smear like of the hemorrhage, forming the characteristic flame appearance.
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ii. Deep
Dot and blot hemorrhages (Figure 4.2)
• bleed from deep retinal capillaries
• dot hemorrhages are small round and with uniform density
• blot hemorrhages are larger, with irregular shape and density, forming an irregular patch of bleeding, and darker in color
• dots and blots are mostly found in the peripheral retina where retinal nerve fiber is usually thinner
• causes: retinal vein occlusion, non‐proliferative diabetic retinopathy, ocular ischemic syndrome
Figure 4.2 A clear cut dots and blots hemorrhage appearance
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Preretinal Hemorrhage (Figure 4.3)
Also known as: Subhyaloid hemorrhage
• Bleeding on the surface of retina, between the retina and hyaloid membrane of vitreous
• Usually solitary and located at the posterior pole
• Well defined margin with vessels sometimes seen crossing BELOW the hemorrhage area. (Not over the hemorrhage)
• Initally round but later settle with gravity, giving the “boat‐
like” apperance due to pooling of the blood.
• Causes: Proliferative retinopathy, retinal artery
macroaneurysm, wet ARMD, choroidal neovascularization, trauma
Figure 4.3 Preretinal hemorrhage
A round preretinal hemorrhage (left) with vessels seen crossing below it. The picture on the right show a large preretinal hemorrhage which settled into a boat‐like appearance or
pooling of blood.
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Subretinal Hemorrhage (Figure 4.4)
• Bleeding between the photoreceptors and retinal pigment epithelium
• Usually large and bright red with indistinct margin
• Vessels are clearly seen ABOVE the hemorrhage (not below the hemorrhage)
• Causes: choroidal neovascularization, retinal tear, Coat’s disease, sickle cell anemia, blunt trauma
Figure 4.4 Subretinal hemorrhage
Note that the vessels are crossing above the hemorrhage area.
Key Points
Retinal hemorrhage Superficial: Flame‐shaped Deep: Dots and blots
Preretinal hemorrhage Blood vessels cross BELOW the hemorrhage area Subretinal hemorrhage Blood vessels cross ABOVE the hemorrhage area
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Cotton Wool Spots ( Figure 4.5)
• Represents microinfarction of the nerve fiber layer of the retina
• Consist of axoplasmic debris
• small, white, superficial lesions with indistinct margin, giving it a fluffy appearance of cotton wool .
• Causes: Retinal vein occlusion, non‐proliferative diabetic retinopathy, vasculitides (SLE, scleroderma), hypertensive retinopathy, AIDS microvasculopathy, microembolic retinal artery occlusion
Figure 4.5 Cotton Wool Spots
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Hard Exudates ( Figure 4.6)
• Leakage of high protein and lipid due to break in blood retinal barrier
• Yellowish glistening intraretinal lesion, usually with a well‐
defined margin.
• Commonly seen in any conditions that are associated with chronic vascular leakage , such as::
1. Diabetic retinopathy 2. Hypertensive retinopathy 3. Choroidal neovascularization
Figure 4.6 Hard Exudates
Notice the picture on the right where a circinate ring is being formed.
*In fundus with massive hard exudates, check the patient’s lipid profile for hypercholesteremia. It is essential to control the cholesterol level as well!
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Drusen (Figure 4.7)
• Drusens are yellowish deposits external to neuroretina and retinal pigment epithelium.
• It may be well‐defined and small (hard) or ill‐defined (soft).
• Drusen may be discrete or confluent (coalesce with one
another) and usually are the hallmarks of age‐related change.
• Drusens can occur anywhere, in the peripheral retina or macula, but those occuring at the macula are the ones with clinical
significance as they may be related to central visual loss..
• Association: Age‐related macular degeneration (ARMD), autosomal dominant drusens (ADD
Figure 4.7 Drusens on the macular area
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Tigroid retina /fundus (Figure 4.8)
• A normal fundus to which a deeply pigmented choroid gives the appearance of dark polygonal areas between the choroidal vessels, especially in the periphery. Causes: Highly myopic eyes or racial variations.
• Sometimes, it refer to the lacking pigment so that underlying choroid vessels are visible as irregular stripes. Causes: albinism
• The dark stripes at the background resemble the tiger stripes, which therefore give rise to its name: Tigroid fundus
Figure 4.8 Tigroid fundus
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With this, the book has come to an end of the basics of fundoscopy.
The author did not touch on certain aspects such as fibrosis in retinal detachment but nevertheless important once you have grasp the basics in this book. This book does not intend to replace any
textbook in fundoscopy teachings, thus readers are advised to read up more from recommended Ophthalmology textbooks. Last but not least, enjoy your fundoscopy experience!!
Credits:
1. Jack J.Kanski. Clinical Ophthalmology‐ A Systematic Approach.
6th edition 2007.
2. Jack K Kanski, Ken K Nischal. Ophthalmology – Clinical Signs and Differential Diagnosis. 1999
3. Jane Oliver, Lorraine Cassidy. Opthalmology at a Glance. 2005.
4. E‐Medicine specialties: Ophthalmology, http://emedicine.medscape.com
5. Digital Reference of Ophthalmology, Edward S. Harkness Eye Institute. http://dro.hs.columbia.edu/index.htm
6. Prof. Dr Che Muhaya Hj Mohamad. Ophthalmology Checklist for Undergraduates. Universiti Kebangsaan Malaysia (National
University of Malaysia)
7. Dr Zaid Shalchi. Eyes Made Easy.http://eyesmadeeasy.net
8. Dr Faridah Hanom Annuar, our supervisor who had inspired us to work hard and was always there to guide us in our lessons.
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EXTRAS: Systematic Ophthalmic Examination
In a systemic ophthalmic examination, there are 5 essential components to perform, which includes:
1. Visual Acuity
2. External Eye Examination 3. Extraocular Movements 4. Visual Field Test
5. Fundoscopy Visual Acuity
There are 2 aspects of the visual acuity which should be tested for, namely the distance and the near vision.
Distance vision should be formally done with a Snellen Chart or its equivalent for pediatric cases, at 6 meter. If the acuity is too poor, let the patient try reading at 5 meters instead. For worse cases, check for counting fingers and hand movement.Then, try shining a
pentorch from the peripheral retina, to test for light perception. In cataract, light perception is usually preserved.
Near vision can be tested with a Test Chart at 15 inches or 33cm away from the eyes.
*Vision should be checked with and without glasses and pinhole glasses.
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External Eye Examination
From general inspection, look for any ptosis, symmetry of the face particularly the eyelids or any obvious changes which have include discoloration of the sclera or a serious red eye. This can be done as soon as your patient steps into the clinic!
1. Lids
• The upper lid should cover around 1mm of the upper limbus.
• Lower lid should cover just at the lower limbus.
• Palpebral aperture should be normal and look at the lashes for possible malalignment for trichiasis. A normal lash should be pointing anteriorly and laterally.
• Look for the margins for lumps, bumps and any pigmentation.
2. Conjunctiva
• The conjunctiva consist of the palpebral, fornix and bulbar conjunctiva. Inspect each side closely.
• Look for any papillae, follicles, dilatation of vasculature (injection) or subconjunctiva hemorrhage.
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Next would be the Anterior Segment which consist of cornea, anterior chamber, pupil/iris and the lens.
3. Cornea
• Looks at the size(normal adult diameter 10‐13mm) and shape of the cornea which should be round and equal size.
• Sharp and pointy cornea is suggestive of keratoconus.
• The cornea should be clear and avascular.
(A generalized cloudy cornea is suggestive of corneal edema)
• Look out for any sutures or scar especially at the superior cornea for signs of previous cataract surgery.
4. Anterior chamber
• Inspect the content of the anterior chamber, whether if it is clear, hypopyon or hyphaema.
• Shine a torch perpendicular to the limbus from the lateral aspect and observe the shadow to gauge the depth of anterior chamber. A deep anterior chamber should have no shadow at the medial iris.
5. Pupils/Iris
• The pupils should be equal, round and central.
• The color of the iris should be same for both eyes, otherwise it would be heterochromis iridis.
• Look out for any previous scars suggestive of peripheral iridectomy or iridotomy!
• Pupillary reflex may be examined, the direct light reflex, consensual light reflex and relative afferent pupillary defect.
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6. Lens
• Check for the eye’s red reflex if possible. Shining a torch at the lens may show a dislocated lens or sometimes an intraocular lens in the anterior chamber.
• Shine a light at the cornea through the pupil. Pseudophakic patients may reveal an obvious double light reflex, a second glistening reflex.
• Also, check for the presence of cataract if the red reflex is absent. The cataract can be anterior subcapsular, posterior subcapsular, nuclear sclerosis or cortical cataract.
Note: There are a total of 4 light reflexes from the eye media when the light is shone thorugh the media (cornea and lens).
However, only 1 can be obviously seen as you manouver the light source in a circular motion.
Summary:
External Eye Examination:
Lids + conjunctiva + Anterior Segment
= Lids + conjunctiva + (Cornea + Anterior Chamber + Pupils/Iris + Lens)
Anterior Segment Examination:
Cornea + Anterior Chamber + Pupils/Iris + Lens
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Principles of RAPD (Relative Afferent Pupillary Defect)
RAPD
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Extraocular Movement
Extraocular movement is only done in certain patients most of the time. It is not aroutine examination, thus you won’t see such
examination done in a patient on diabetic retinopathy follow up.
Indications for such a test include:
• Symptoms of double vision (diplopia)
• Strabismus
• Patients with also neurological problems
• History of trauma to the orbit
There are 2 methods to test for extraocular movement:
i. Bisected H
The typical H shape drawn in the air with a target object
(pentop or finger). Be sure to not exceed the patient’s range of vision, otherwise you may cause a physiological nystagmus!
Bisected H pathway for extraocular movement
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ii. “Union Jack”
This is a test using a pentorch with the light directed at both eyes. With this, the corneal light reflex can be observed while doing the extraocular test, which can rule out pseudosquint if present.
This method use a different pathway but applies the same principles as the bisected H.
Pathway for the “Union Jack” extraocular movement test
The actions of the IIIrd, IVth and VIth nerves on the eye movements of the right eye. III= Oculomotor, IV=trochlear, VI= abducent
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*Note:
• Test for accomodation as well by bringing the target to around 20 cm from the patient’s eyes and observe the pupil
constriction and eye convergence.
• remember to gently pull up the eyelid as the patient looks down to have a clear view of the eyeball positions.
• Observe for the smoothness(smooth pursuit) of the eye
movement as it follows the moving target. They can be smooth or jerky.
• Always ask the patient if they see any double vision during the extraocular movement test.
• If there is limitation of the eye movement, you may try
occluding the normal eye. That way, you may test if the defect is vergence or version.
• Know the muscles involved in each eyeball movement and the supplying cranial nerves.
The eye muscle movements are:
Abduction‐adduction
Elevation‐depression
Intorsion – extorsion
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Visual Field Test
• This can be done with a confrontation test (1 meter apart and on the same level with the patient) with a white neuropin.
Peripheral vision utilizes rods which is predominant in peripheral retina, thus it detects black and white, not color vision.
• Make sure the patient could see in each eye before testing for visual field.
• Remember to bring the neuropin all the way to the center from the peripheral. You might miss a scotoma defect or a central visual defect !
• Blind spot should also be tested with a red neuropin. This is due to the fact that the blind spot is enlarged in disc edema. As the macula is near to the optic disc (blind spot area in your eye), color acuity is the best, thus red pin is used instead of white.
• Move around the blind spot once you found it. Move up or down to check if it is enlarged, and make sure that the reason the patient can’t see the target is not because it is beyond his visual field’s limit!
Fundoscopy
Fundoscopy is the last part of the examination, and it has been
described in the early section of the book. Thus, I am sure you would have no difficulty in doing this.
Red pin is also used to test for optic nerve function by checking for red desaturation in all 4 quadrants of the visual field.
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