Optic Disc - Patient Assessment

Papilledema

*Elevated INTRACRANIAL pressure causes intraaxonal EDEMA along the optic nerve, leading to ENGORGEMENT and SWELLING of the optic disc* Color is PINK, hyperemic Often with loss of venous pulsations Disc vessels more visible, more numerous, curve over the borders of the disc Disc swollen with MARGINS BLURRED The physiologic cup is NOT visible Seen in intracranial mass, lesion, or hemorrhage, MENINGITIS !!!!!!!INCREASED CRANIAL PRESSURE!!!!!!!!!!

Physiologic cup

A small whitish depression in the optic disc, the entry point for the retinal vessels. Although sometimes absent, the cup is usually visible either centrally or toward the temporal side of the disc. Grayish spots are often seen at its base

Hard Exudates

Creamy or yellowish, often bright, lesions with well-defined "hard" borders. They are small and round but may coalesce into larger irregular spots. They often occur in clusters or in circular, linear, or star-shaped patterns. They are lipid residues of serous leakage from damaged capillaries. Causes include DIABETES AND VASCULAR DYSPLASIAS

Preretinal Hemorrhage

Develops when BLOOD ESCAPES into the potential space between the retina and vitreous. HEMORRHAGE IS LARGE Because it is anterior to the retina, it obscures any underlying retinal vessels. In an erect patient, red cells settle, creating a horizontal line of demarcation between plasma above and cells below. Causes include a sudden INCREASE in intracranial pressure

Neovascularization

FORMATION OF NEW BLOOD VESSELS They are more numerous, more tortuous, and narrower than neighboring blood vessels in the area and form disorderly looking red arcades. A common feature of the PROLIFERATIVE STAGE of diabetic retinopathy The vessels may grow into the vitreous, where retinal detachment or hemorrhage may cause loss of vision.

Nonproliferative Retinopathy, Severe

In the superior temporal quadrant, note the large retinal hemorrhage between two cotton-wool patches, BEADING of the retinal vein just above them, and tiny tortuous retinal vessels above the superior temporal artery

Glaucomatous Cupping

Increased INTRAOCULAR pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy. The base of the enlarged cup is pale. PHYSIOLOGIC CUP IS ENLARGED WITH VERY FEW VESSELS Death of optic nerve fibers leads to loss of the tiny disc vessels. INCREASE INTRAOCULAR PRESSURE

Healed Chorioretinitis

Inflammation has destroyed the superficial tissues to reveal a well-defined, irregular patch of white sclera marked with dark pigment. Size varies from small to very large. Toxoplasmosis is illustrated. Multiple, small, somewhat similar looking areas may be due to laser treatments. Here there is also a temporal scar near the macula

Normal Fundus of a Light-Skinned Person

Inspect the optic disc. Follow the major vessels in four directions, noting their relative sizes and any arteriovenous crossings—both are normal here. Inspect the macular area. The slightly darker fovea is just discernible; no light reflex is visible in this subject. Look for any lesions in the retina. Note the striped, or tessellated, character of the fundus, especially in the lower field, that comes from normal underlying choroidal vessels. The fundus of a light-skinned person with brunette coloring is redder

Hypertensive Retinopathy

Marked AV CROSSING CHANGES ARE SEEN especially along the inferior vessels. (vessels detached with curved endings for AV changes) Copper wiring of the arterioles is present. A cotton-wool spot is seen just superior to the disc. Incidental disc drusen are also present but are unrelated to hypertension

Medullated Nerve Fibers

Much less common but dramatic finding. Appearing as irregular white patches with FEATHERED margins, they obscure the disc edge and retinal vessels NOT PATHOLOGIC

Proliferative Retinopathy with Neovascularization

NEW PRERETINAL VESSELS arising on the disc and extending across the disc margins. Visual acuity is still normal, but the risk for visual loss is high. Photocoagulation reduces this risk by >50%

Hypertensive Retinopathy with Macular Star

Note the punctate exudates are readily visible: some are scattered; others radiate from the fovea to form a macular star. Note the two small, soft exudates about 1 disc diameter from the disc. Find the flame-shaped hemorrhages sweeping toward 7, 8, and 10 o'clock; a few more may be seen toward 10 o'clock. These two fundi show changes typical of severe hypertensive retinopathy, which is often accompanied by papilledema

Nonproliferative Retinopathy

Note tiny red dots or microaneurysms. Note also the ring of hard exudates (white spots) located superotemporally. (all the way left to the picture) Retinal thickening or edema in the area of the hard exudates can impair visual acuity if it extends into the center of the macula. Detection requires specialized stereoscopic examination

Rings and Crescents

Often seen around the optic disc. These are developmental variations that appear as either white sclera, black retinal pigment, or both, especially along the temporal border of the disc. NOT PATHOLOGIC (the little black around the circle)

Superficial Retinal Hemorrhages

Small, linear, FLAME SHAPED, RED STREAKS in the FUNDI, shaped by the superficial bundles of nerve fibers that radiate from the optic disc Sometimes the hemorrhages occur in CLUSTERS and look like a larger hemorrhage but can be identified by the linear streaking at the edges. These hemorrhages are seen in severe HYPERTENSION, PAPILLEDEMA, and occlusion of the retinal vein, among other conditions. Occasionally has a white center consisting of fibrin, which has many causes.

Microaneurysms

TINY, round, red spots commonly seen in and around the macular area. They are minute dilatations of very small retinal vessels; the vascular connections are too small to be seen with an ophthalmoscope. A hallmark of DIABETIC RETINOPATHY

Optic Atrophy

The physiologic cup is ENLARGED, occupying more than half of the disc's diameter, at times extending to the edge of the disc. Retinal vessels sink in and under the cup, and may be displaced nasally PHYSIOLOGICAL CUP TAKES UP MAJORITY OF THE DISC, VESSELS GO UNDERNEATH DISC Color is white Tiny disc vessels absent Seen in optic neuritis, MULTIPLE SCLEROSIS, temporal arteritis

Proliferative Retinopathy, Advanced

This is the same eye, but 2 years later and without treatment. Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity LOOKS LIKE A MESS

Normal Optic Disc

Tiny disc vessels give normal color to the disc Color is yellowish orange to creamy pink Disc vessels are tiny Disc margins sharp (except perhaps nasally) The physiologic cup is located centrally or somewhat temporally. It may be conspicuous or absent. Its diameter from side to side is usually less than half that of the disc

Soft Exudates: Cotton-wool patches

White or grayish, ovoid lesions with irregular "soft" borders. They are moderate in size but usually smaller than the disc. They result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of the retinal nerve fiber layer. Seen in HYPERTENSION, DM, HIV, and numerous other conditions

Drusen

Yellowish round spots that vary from tiny to small. The edges may be soft, as here, or hard. They are haphazardly distributed but may concentrate at the posterior pole between the optic disc and the macula. Consist of dead retinal pigment epithelial cells. Seen in normal aging and age-related macular degeneration