eyes to know.pdf

7/23/2019 EYES TO KNOW.pdf

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optic disc and temporal retina

Main clinical features:

Blot hemorrhages in the nasal macular area and superior temporal arcade

Hard exudates along the inferior temporal arcade

Micro aneurysms at the macula area

Circinate exudates along the inferior temporal arcade

Diagnosis: BACKGROUND DIABETIC RETINOPATHY AND DIABETIC MACULOPATHY

Comments

Macular area, as defined by a circle area centred on the fovea with its radius extending to the edge of the optic disc, has

exudates in it. This makes the condition maculopathy. If the visual acuity was normal and there are micro-aneurysms

and hemorrhage only, then this would be Background diabetic retinopathy alone.


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MCF: optic disc and temporal retina (alignment marker is shown)

Multiple dot and blot hemorrhages

Cotton wool spots (CWS)

Intra-retinal micro-vascular abnormalities (IRMA)

Dx: PRE PROLIFERATIVE DIABETIC RETINOPATHY

Chikka:

Pre-proliferative diabetic retinopathy is characterized by retinal ischemia.

CWS represent areas of focal retinal ischemia and IRMA are a pathological attempt at micro-revascularization. IRMAs

are flat and do not grow into the vitreous.


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Central fundus with the optic disc

MCF:

New vessels on the disc

Hemorrhages

Exudates

Pre0retinal fibrosis

DX: ADVANCED PROLIFERATIVE RETINOPATHY

Chikka:On-going ischaemia and increase in vaso-proliferative factors. The new vessels grow into the vitreous and are fragile

leading to haemorrhage. A the hemorrhage organizes, fibrous tissue reaction occurs often resulting in retinal traction

and detachment


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Optic disc and temporal retina

MCF

Multiple hard exudates in the macular area, some are circinate

Haemorrahges and micro-aneurysms

DX: DIABETIC MACULOPATHY

Chichi:

The visual acuity may be reduced depending on the location and macular edema.

Circinate hard exudates odten have micro-aneurysms at their center.The darker retinal appearance is normal in an asian or afro-caribbean patient.


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Optic disc and temporal retina (alignment marker is shown)

MCF:

Multiple laser scars with areas of hyper pigmentation

Regressed new vessels at the disc with residual gliosis

DX: PAN RETINAL LASER PHOTOCOAGULATION

Chismis:

The overall appearance suggests good response to management and stable retinopathy. Patient will have reduced

peripheral vision and a degree of night blindness (compare with retinitis pigmentosa)


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Posterior pole centered on the optic disc

MCF:

Disc area is obscured

Poorly defined vasculature

DX UNGRADABLE RETINOPATHY

Chichi:The suspicion of fibrovascular proliferation at the disc and along the vascular arcade with tractional detachment is very

strong. This would be a feature of advanced diabetic eye disease. Clearly, urgent referral is indicated.


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MCF:

Optic disc with uniform central cup with cup disc ratio of


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MCF:

Large cup disc ratio

Superior polar notching

Nasal displacement of central blood vessels

DX: GLAUCOMATOUS OPTIC DISC

Cheezesm:

Glaucomatous damage and its extent is confirmed by visual fields and tomographic imaging techniques.


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MCF:

Disc margins are obscured and swollen and hyperaemic

Retinal vessels show tortousity

DX PAPILLEDEMA

Insider info:

Spontaneous venous pulsation may be absent. If present, papilledema is unlikely. Visual symptoms are absent in early

stages. A space occupying lesion must be excluded urgently.


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Optic disc and temporal retina sorry natapat sa no sim cameral roll hahaha

MCF:

Optic disc pallor with possible cupping

Large area of macular scarring

DX OPTIC ATROPHY with MACULAR SCARRING (AND POSSIBLE GLAUCOMA)

Chichi:

Age-related macular degeneration would be the commonest o diba commonest yun talaga nakalagay dun sa manual

cause of macular scarring


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Optic disc and surrounding retina ito ata natapat sa butones

MCF

Disc margin and emerging vessels obscured by myelinated nerve fibers along superior and nasal areas

DX: MYELINATED NERVE FIBERS

Intel:

This requires no further clinical attention. On clinical examination, the blind spot would be expected to be larger, but

this would be very difficult to discern clinically.


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MCF:

Focal areas of atrophy and retinal pigment

Drusens in the macular area

DX AGE RELATED MACULAR DEGENERATION

Chikka:

Presence of hemorrhages and edema in the macular area would suggest wet changes


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MCF:

Multiple retinal hemorrhages

Venous dilation

DX MULTIPLE RETINAL HEMORRHAGES

Comment:

Hyperviscosity states (polycythemia, waldenstroms macro-globulinemia, myeloma) can lead to venous dilation and

hemorrhages. Thrombocytopenia and other bleeding diatheses are other possibilities


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MCF:

Large optic disc

Marked peripapillary chorioretinal atrophy

DX HIGH MYOPIA

Comments

Areas of chorioretinal atrophy in the macular area are not uncommon in highly myopic patients


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MCF

Focal narrowing of arterioles

Changes at arterio-venous crossings along inferotemporal arcade (AV nipping)

DX: HYPERTENSIVE RETINOPATHY GRADE 2

Comment

Absence of hemorrhages (flame shaped) and disc swelling suggest early changes or chronic hypertension. The gradingsystem is:

Micro aneurysms are rare in hypertensive retinopathy without DM

Grade 1: arteriolar narrowing

Grade 2: arteior venous nipping

Grade 3: exudates, hemorrhages, cotton wool spots

Grade 4: papilledema


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MCF

Pigmented clumps in the macular area with chorio-retinal atrophy and scarring. Pallor of the optic disc is noted

indicating atrophy

DX MACULAR SCAR (TOXOPLASMOSIS)

CommentsThe cat is definitive host for toxoplasma gondii. This is usually a quiescent lesion often discovered incidentally when a

child is assessed for impair vision. An active lesion may show an inflammatory focus with a vitreous haze and adjacent to

a previous scar and vasculitis. There may be associated anterior uveitis.


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Temporal retina

MCF

Areas of bullous retina showing elevation with fluid

DX RETINAL DETACHMENT

Comment:

In the absence of identifiable break and trauma, the possibility of choroidal metastasis should be considered. Clearly

urgent referral is needed.


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Peripheral retina

MCF

Green grey flat asymptomatic lesion with detactable but not sharp borders

Presence of surface drusens

Areas of atrophy within the lesion

DX CHOROIDAL NEVUS

Comment

In view of the larger size >5mm, it is worth monitoring for a period. If there is a change in size, further investigation is

indicated.


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MCF

Dense white areas along vessels with vasculitis along temporal arcade.

DX: CYTOMEGALOVIRUS RETINITIS

Comment:

The spread of vasculitis can be relentless from periphery to the disc along retinal vessels. Hemorrhages may be presentin fulminating cases.


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Optic disc and tempura retina

MCF:

Papilledema

Tortousity and dilation of all branches of the central retinal vein

Retinal hemorrhages: flame shaped, dot and blot in all quadrants

Cotton wool spots

DX CENTRAL RETINAL VEIN OCCLUSION

Comment:

The presence of CWS would suggest significant ischemic element carrying poor prognosis. Space occupying lesions in thecerebrum and hyperviscosity have to be excluded. Hypertension alone can cause CRVO


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Temporal retina and optic disc

MCF:

Attenuation of arteries and veins

Pale temporal edge of the optic disc is shown

Central cherry red spot with surrounding pale retina

DX CENTRAL RETINAL ARTERY OCCLUSION

Comments:

Poor prognosis due to retinal infarction. Retinal cloudiness of pale retina would disappear after a few weeks. Attenuated

vessels would remain and consecutive optic atrophy would be evident. The cherry red spot is seen because of maculararterial supply from the choroid can remain intact. Often there is a band of neural tissue that is not rendered ischemic

by the CRAO, this is seen if there is an adequate cilio-retinal artery supply


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Optic disc and surrounding retina

MCF

Yellow Orange refractile bodies at an arterial bifurcation (12 oclock on the optic disc) asan di ko Makita.ahahahha

DX RETINAL ARTERY CHOLESTEROL EMBOLI (HOLLENHORST PLAQUE)

Comments

Frequently asymptomatic as it rarely causes significant obstruction of the arteriole unike calcific emboli. Fibrinoplatelet

emboli cause transient retinal ischemic attacks (amaurosis fugax) which may occasionally be complete.


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Mid peripheral retina

MCF

Multiple bony spicule retinal pigmentation scattered in the periphery of the retina

DX RETINITIS PIGMENTOSA

Comments

The associated history of night blindness and family history is often positive.

The optic disc may show waxy pallor with attenuation of vessels.


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Optic disc and surrounding retina

MCF

Linear reddish brown lesions with irregular edges beneath the normal retinal vessels. This represents breaks in Bruchs

membrane and visualization of the choroidal circulation

Peripheral focal chorio retinal scars may be present

DX ANGIOID STREAKS

CommentsBruchs membrane is mainly elastin. The condition is associated with connective tissue disorders. This includes:

pseudoxanthoma elasticum, Ehler-Danlos syndrome, Marfans. Rarely: Pagets disease, acromegaly, and certain

hemoglobinopathies


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Peripheral retina

MCF

Elevated dome shaped grey mass

DX MALIGNANT MELANOMA

A secondary retinal detachment may be present. Urgent referral indicated


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Optic disc surrounding retina

MCF

Flat pigmented lesion involving inferior aspect of the optic disc

DX BENIGN DISC NEVUS

Often difficult to distinguish from malignancy. If in douct seek a specialist opinion


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MCF

Large macular hemorrhage in the pre retinal area

DX MACULAR HEMORRHAGE

Sudden severe intrathoracic or abdominal pressure and lead to this feature. Macular degeneration and diabetic

retinopathy can be considered in the presence of additional features. A pre retinal hemorrhage with a fluid levelcan be

seen in some patients with sub-arachnoid hemorrhage. Small areas of hemorrhages adjacent of blood vessel are seen in

bacterial endocarditis (Roths spot)


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MCF

Pale yellow appearance of vessels in a creamy retinal background

DX LIPAEMIA RETINALIS

This is associated with hypertriglyceridemia and hypercholesterolemia. This is usually encountered in lipid disorders,

poorly controlled diabetes and alcoholism

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