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Patient presents with decreased visual acuity and the above finding. What does the patient have?

optic atrophy

(+) palor

(+) decreased visual acuity

Normal

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Pallor

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Normal

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Optic atrophy - piling atrocytes are reflective

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Patient presents with absent venous pulsations on exam and the above fundoscopic findings bilaterally

Papilledema

secondary to increased intracranial pressure

Absent Venous pulsations can be a marker of the onset of papilledema;

flame shaped hemorrhages and soft exudates develop as papilledema worsens.

Mechanism:

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1. Retardation of axoplasmic flow due to increased intercranial pressure

or

2. occlusion of capillaries and venules that leads to the presecence of hemorrhages and edema in between axons.

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How do you tell the difference between papilledema and optic neuritis?

                         No visual loss                                                                                                      (Young females)

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Optic Neuritis

-Ocular Pain

-Acute Central visual loss
-Afferent pupillary defect

Papilledema (left)

No pain

No Visual loss

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How do you tell the difference between papilledema and anterior ischemic optic neuropathy (AION)?

Papilledema: No pain, no visual loss, optic disc swelling

AION: No pain, sudden visual loss, optic disc swelling

secondary to DM and HTN;

5% due to temporal arteritis in patients over 60.

Mechanism: AION is caused by decreased blood flow to optic disc through posterior ciliary arteries.

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What does the patient have?

Glaucoma

(Glaucomatous cupping)

What blood vessel supplies the retina?

"" the photoreceptors?

What is the significance of a cilioretinal artery? From where does it come?

retinal supply: central retinal artery

photoreceptor supply: choroidal circulation (from posterior ciliary artery)

The cilioretinal artery (a branch offthe posterior ciliary artery) can occasionally supply the retina (33%) in addition to the central retinal artery, such that should the central retinal artery become occluded, no loss of the retina will occur due to the secondary supply.

Venous pulsations are normal in more than 50% of normal individuals.

Absent venous pulsations are indicative of increased intracranial pressure and may precede papilledema.

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What disease is this associated with?

AV nicking and copper wiring

chornic moderate hypertension : arterior sclerosis

90% of HTN patients who shoe complete AV crossing (2 disc diameters) also have hypertensive heart disease

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What disease is this associated with?

Silver wiring

chronic moderate hypertension - arterial sclerosis

(increased refractile properties of the arteriole secondar to vessel wall thickening)

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What disease does the patient have?

Copper wiring

AV nicking
tortuosity of retinal arterioles - soft curves of the arterioles, that cross the veins at right angles
diffuse arteriolar narrowing - AV ratio 1:3, 1:4 (normal is 2:3)

chronic moderate hypertension - arterial sclerosis

A.T.S.C. - AV nicking, Tortousity, Silver, Copper

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Patient presents with hemorrhages and papilledema in addition to above fundoscopic finding.

cotton wool exudates - "superficial ischemic swellings"

acute accelerated HTN - Neuroretinitis

resolvable within 4-8 weeks with treatment of the HTN

also can be indicative of nonproliferative diabetic retinopathy (if exclusive finding)

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Patient presents with hemorrhages and papilledema in addition to above fundoscopic finding.

Hard exudates- "protein or lipid deposits in the inner retinal layers that result from transudation of serum across the blood-retinal-barrier"

acute accelerated hypertension - Neuroretinitis

also indicative of non-proliferative diabetic reitnopathy

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Patient presents with above finding. What does he have?

Flame shaped hemorrhages "superficial nerve fiber layers, arterioles"

acute accelerated hypertension - neuroretinitis

(not found in arteriolar sclerosis or diabetic retinopathy)

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What disease is present?

Acute accelerated hypertension - neuroretinitis

CHF

Cotton Wool Exudates

Hard Exudates

Flame shaped hemorrhages

DB NAP

Dot/Blot Hemorrhages

Narrowing Arterioles

Papilledema

Venous beading

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Patient presents with exudates and papilledema in addition to the above finding.

dot and blot hemorrhages - "deeper middle nerve fiber layers, venules"

acute accelerated HTN - neuroretinitis

also can be indicative of proliferative diabetic retinopathy (PRR)

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Patient presents with this finding.

Venous beading - "hypoxia within the venous circulation "

Nonproliferative diabetic retinopathy

MHBCV

Microaneurysm

Hard Exudate

Blot Hemorrhage

Cotton Wool Spot

Venous beading

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This finding is hallmark for what disease?

Microaneurysm

non-proliferative diabetic retinopathy

If leakage => macular edema => affects visual acuity

If no leakage => normal visual acuity

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With this present what disease is more likely to occur?

Cotton wool spots - "ischemic infarcts w/in the nerve fiber layer that occur near the disc because the nerve fiber layer is thicker there"

non-proliferative diabetic retinopathy

also manifest in acute accelerated HTN - neuroretinitis

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What disease is this finding associated with?

Neovascularization - "A process whereby leaky retinal vessels proliferate widely in response to retinal ischemia"

Proliferative diabetic retinopathy

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Neovascularization and scar formation

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What disease is this associated with?

Fibrous proliferation secondary to

neovascularization due to

Proliferative diabetic retinopathy

Associated with blindness since vessels grow outward into the vitreous, starting with the optic disc and the macula.

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What disease is this condition secondary to?

Neovascular glaucoma secondary to

neovascularization occluding the aqueous outflow tract, growing over the surface of the iris

Proliferative diabetic retinopathy

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What disease is this secondary to?

Rubeosis iridis (found on the surface of the iris) secondary to

Neovascularization due to

Proliferative Diabetic retinopathy

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Elderly patient presents with this fundoscopic finding.

Normal.

Tigroid retinas (Stripes of Dark pigment) are normal

in elderly patients.

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What is this associated with?

Cherry red macula

Central Retinal artery occlusion (CRAO)

Assoc. w/

Cherry red macula - since the macula receives its blood supply from the choroid

Hollenhorst plaques

Sudden and painless unilateral loss of vision

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What is this associated with?

Hard drusen- "small yellow well demarcated deposits" which can be found in individuals as early as 20-30s.

Benign. Do not signify macular degeneration.

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What is this associated with?

Soft Drusen - "sligtly larger and have indistinct borders, develop after age 55"

Mark beginning of macular degeneration.

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What disease does this mechanism illustrate?

Dry Macular Degeneration

• Slow onset

•Soft Drusen under macula => thinning and drying of macula => loss of macular function

• central vision loss (slow)

• fluctating vision

• not preventable with surgery

Blue rays make both types worse.

Eat fruits and green leafy vegetables.

Vitamin C & E

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What disease does the illustrated mechanism show?

Wet Macular Degeneration (Rapid)

• Neurovascularziation develops beneat the retina and macula => new blood vessels leak => macula bulges => lifts up => becomes ischemic

• Rapid visual loss

•Dark spots in center of vision

•Straight lines look wavy

•Correctable by laser surgery

HTN and smoking make wet type worse.

Blue rays make both types worse.

Eat fruits and green leafy vegetables.

Vitamin C & E

Only 10 – 20% of MD cases are of the wet variety
but 90% of visual loss is caused by the wet variety

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What disease is associated with this finding?

Roth spots "white-centered" hemorrhages in the center of flame-shaped or blot hemorrhages (nerve fiber, or outer plexiform layer)

bacterial endocarditis

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What disease is indicated here?

Branch retinal arterial occlusion -due to embolus

Patient experiences amaurosis fugax from retinal ischemia if occlusion is transient or permanent visual loss if occlusion is long lasting.

Assoc. w/

hollenhorst plaques - cholesterol emboli that reside at Y intersections (either from ulcerating atheromatous plaque from ipsilateral carotid artery or abnormal heart valve)

sudeen painless unilateral loss of visual field in the field opposite the retinal occlusion:

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Left eye inferior visal loss from a superior branch occlusion.

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Elderly patient presents with a history of chronic HTN and DM.

Central retinal vein occlusion (CRVO)

leads to multiple hemorrhages involved with quadrants drained by the occluded vein;

painless blurry vision,

loss of vision,

or

loss of visual field.

Associated findings: edematous disc, flame-shaped hemorrhages and cotton wool spots, neovascularization, acute glaucoma

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Veins appear like links of sausage between AV crossing points.

Hyperviscosity syndrome - inc. in viscosity of blood

(e.g. Waldenstroms macroglobulinemia)

stasis of blood in smaller circulations like retina

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What is shown here?

Retinal detachment - separation of the retina into two layers -> RPE and the sensory retina

sudden cape like visual loss, like a curtain coming down

etiology: blunt head trauma, traction from retinal scar formation, or tearing from a vitreous detachment

assoc signs: floaters and flashing lights

(if fovea is inovlved, decreased visual acuity and afferent pupillary defect)

lighter colored red reflex

visual loss permanent if not repaired quickly

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What disease is this finding associated with?

Asteroid hyalosis - highly refractile calicium lipid comlexes that swirl through the vitreous with movement; don't impair vision

vitreal detachment

mech: as people age, vitreous liquefies to pull away from retina => flashing lights, "electric sparks", "floaters" =>

assoc with:

opacities (seeing spots before eyes) that move in the direction of patient vision; e.g. when patient looks left, floaters move left (in front of the eye)

behind the eye: pat. looks left, floaters move right