Fundoscopy

Diabetic retinopathy
1. Hard exudates, blot haemorrhages, microaneurysms= background retinopathy
2. Cotton wool spots, flame haemorrhages= pre-proliferative retinopathy
3. Neoascularization of disc, panretinal photocoagulation = proliferative
4. Look at macula (‘look into the light’; temporal to disk) if this is involved then ‘diabetic maculopathy’
5. Evidence of panretinal photocoagulation

Hypertensive retinopathy
1. Look for AV nipping – this is quite easy to see.
Arteriolar narrowing, tortuous and vary in calibre, silver wiring
= Grade I-II hypertensive retinopathy.
2. Look for flame haemorrhages, blot haemorrhages, cotton wool = grade III hypertensive retinopathy
3. If papilloedema then grade IV
DDX of papilloedema
- Intracranial SOL, tumour, abscess, haematoma (check other neurology esp. VI palsy)
- Accelerated hypertension
- Benign intracranial hypertension (obese female 15-45 yo)
- Meningitis esp. TB
- Hpercapnoea (cyanosis, flapping tremor)
- Gravaes ophthalmopathy, Carvernous sinus thrombosis, hypoparathyroidism, severe anaemia, GBS,
Paget’s disease, Hurler’s syndrome (dwarf, large head, coarse features, heart murmur,
hepatosplenomegaly), poisoing with vitaminA, lead, tetracyclines, naladixic acid, ocular toxoplasmosis

Papilloedema causes enlargement of blind spot, constriction of peripheral field, normal acuity
Papillitis (optic neuritis): central scotoma, diminished visual acuity, tender, papillary reflex defect

Old Choroidoretinitis
1. Patch of white / yellow/ grey at … region suggesting exposed sclera due to atrophy of the choroidoretina
secondary to old choroiditis
2. Pigmented patches due to proliferation of retinal pigment epithelium
Causes
- Unknown (most cases)
- Toxoplasma
- Sarcoidosis (? Lupus pernio, chest signs)
- Tuberculosis, Syphilis, Toxocara

Optic atrophy
This disc is pale and clearly delineated and the pupil reacts consensually to light but no directly.
There is central scrotoma. The well-defined disc edge suggests that it is not secondary to papilloedema (yellow-
grey disc with blurred margins)
Causes (PALE DISCS)
- Pressure:
o Compression (tumour-frontal brain tumor, aneurysm)
 Foster-Kennedy syndrome (papilloedema in one eye due to raised ICP, and optic
atrophy in the other due to direct compression by the tumour)
 Glaucoma (pathological cupping: sides of disc are steep and retinal vessels appear being
broken off at the margin- i.e. Sharply angulated vessels)
 Paget’s disease
- Ataxia: Friedreich’s ataxia
- Leber’s hereditary optic atrophy: tremors, numbness or weakness in limbs, or loss of ankle reflexes
- Dietary: b12; Degenerative: retinitis pigmentosa
- Ischaemia: central retinal artery occlusion
- Syphilis and other infection e.g. CMV, toxoplasmosis
- Cyanide and other toxins e.g. alcohol, lead, tobacco
- Sclerosis: MS

Test for relative afferent papillary defect if one eye optic atrophy
Retinitis pigmentosa
There is widespread scattering of black pigment in a pattern resembling bone corpuscles. The macula is spared.
There is tunnel vision.
Causes
- Idiopathic
- ATAXIC: Abetalipoproteinaemia, Friedrich’s ataxia
o + DEAF: Refsums’s disease (AR, papillary abnormalities, cerebellar ataxia, deafness, peripheral
neuropathy, cardiomyopathy, icthyosis)
o + PTOSIS, PACEMAKER: Kearns-Sayre
- DEAF: Refsums (+Ataxic, icthyosis), Kearns-Sayre, Usher’s, Laurence-Moon-Biedl (+polydactyly)
- POLYDACTYLY: Laurence-Moon-Biedl (AR; blind, truncal obesity, short stature, polydactyly, MR,
hypogonadism)
- ICHYOSIS: Refsum’s disease

‘Do any of your relatives have similar problem’ – multiple possible inheritance patterns. Also need to rule out
consanguity.

Causes of tunnel vision: papilloedema, glaucoma, choroidoretinitis, migraine, hysteria

Notes
Differential diagnosis: Panretinal photocoagulation, scars tend to be rounded with smooth edges compared to
irregular scars in RP. Note that the signs of diabetic retinopathy can sometimes be not very obvious after
panretinal photocoagulation. Very advanced angioid streaks e.g. in PXE can also look similar. If macula is
involved in the pigmentation this makes panretinal photocoagulation highly unlikely – ophthalmologist will not
laser retina!

Retinal artery occlusion: fundus is pale, arterioles are thin and scanty, cherry-red spot at macula (5-10D)
- Central: acute~ whole fundus milky white due to retinal oedema; later optic atrophy
- Branch: limited to one area with field defect opposite to the quadrant of affected retina
? AF/ carotid stenosis (aspirin, endarterectomy)
? giant cell arteritis (steroid)

Retinal vein occlusion:

- Central: veins are tortuous and engorged, haemorrhages are scattered riotously over the whole retina,
irregular and superficial, like bundles of straw alongside the veins (papilloedema, soft exudates)
o DM, HT, hyperlipidaemia, underlying hyperviscosity syndrome (Waldenstroms’
macroglobulinaemia- LN, liver, spleen, bruising, purpura), myeloma, CTD
o Secondary glaucoma due to new vessels formation (tx by panretinal photocoagulation)
- Branch: usually at an AV crossing with the changes confined to the sector beyond this (haemorrhages and
cotton-wool spots spread out in a wedge from the AV crossing, macular odeam
o Similar to viral retinitis e.g. CMV choroidoretinitis

CMV choroidoretinitis (AIDS):

- Discrete areas of white or yellow retinal opacification with associated haemorrhage and vascular sheathing
- Scrambled egg and tomato sauce, cottage cheese and jam

DEFECT in MELANOGENESIS
Albinism: pale (marked hypomelanosis), very white hair, nystamus, irides are translucent, pale fundus
= oculocutaneous alinism (AR)
- tyrosinase-negative= no darkening of hair bulb, more eye danage
- tyroxinase- positive = some pigemented naevi and less eye damage
Phenylketonuria: diffuse hypopigmentation, light hair, blue eyes
- AR, defect of enzyme that converts phenylalanine to tyrosine)

Drusen: multiple, discrete, round, yellow-white dots of variable size scattered around macula and posterior pole
of eye