2. normal fundus

3. ophthalmoscopy
Indirect
Direct

4. normal fundus

5. normal fundus

6. normal fundus

7. normal fundus
Optical Coherence Tomography (OCT) uses a light beam the same way that B-scan
ultrasonography uses a sound beam to image the retina in a microscopic slice.

9. Congenital fundus anomalies
Opaque retinal nerve fibers-
myelinated retinal nerve fibers;
bright, white patch adjanced to the disc often obscuring the retinal vessels running in the white patch.

10. Congenital fundus anomalies
Opaque retinal nerve fibers

11. Congenital fundus anomalies
Opaque retinal nerve fibers

13. Congenital fundus anomalies
Myopic crescent-
1. white with black pigmented borders rim of atrophic choroid revealing the underlying white sclera in a crescent shape;
2. usually temporal to the disc but may completely surround it;
3. in pathological myopia often associated with myopic choroidoretinal degeneration.

14. Congenital fundus anomalies
Myopic crescent

15. Congenital fundus anomalies

18. Senile changes Age related macular degeneration (AMD)
1. the most common cause of registrable blindness
in Western countries;
2. bilateral gradual deterioration of central vision over several years (sometimes sudden), often with symptoms of distortion;
3. the earliest mainifestation, risk factor of AMD - drusen (small yellow spots in macular region, associated with pigment speckling, consist of hyaline, between the retinal pigment epithelium and Bruch`s maembrane, usually cause no visual symptoms).

19. drusen

20. Senile changes Age related macular degeneration (AMD)
4. non- exudative (dry or atrophic):
bilateral progressive atrophy of RPE and the choriocapllares in the macular region secondary to arteriosclerotic degeneration
of choroidal vessels; speckled pigmentation followed by the apperance of areas of retinal atrophy with visibility of choroidal vessels; typically slow gradual to modearte loss
of vision;

21. Senile changes

22. Senile changes

23. Senile changes Age related macular degeneration (AMD)
5. exudative (dry or atrophic):
in early stages retinal oedema (distortion
of central vision); less common than non- exudative but causes more severe visual loss!!!; two important features- detachment
of RPE and choroidal neovascularisation which may haemorrhage and leads to a fibrous disciform scar at the macula;

24. Age related macular degeneration (AMD)
Senile changes
Age related macular degeneration (AMD)
Wet AMD is associated with new blood vessels
(neovascularization) that originate
in the choroid and break through Bruch's membrane
and the RPE layer. 
OCT image below indicates the RPE layer that has
been broken through by the choroidal
new blood vessels.

25. Senile changes

26. Age related macular degeneration (AMD)
Senile changes
Age related macular degeneration (AMD)

27. Age related macular degeneration (AMD)
Senile changes
Age related macular degeneration (AMD)
The end result is scarring and a loss of retinal function in the area affected.
Ninety percent of the cases of severe vision loss from AMD results from wet AMD.

28. Senile changes

29. Senile changes

30. Senile changes

31. Senile changes

32. Senile changes- Amsler grid as it might appear to someone with age-related macular degeneration.

33. Senile changes Age related macular degeneration (AMD)
Treatment
Non- exudative: no treatment
Exudative: argon laser photocoagulation
to destroy a choroidal neovascular membrane,
photodynamic therapy- PDT (Visudine),
Injections into vitreous body (steroids- Triamcinolone, antineovascularization agents- Macugen, Lucentis, Avastin),
nutrient supplements (vitamin C and E, zinc, cuprum, betacarotene, lutein).

35. generally middle- aged woman;
Senile changes
Macular Hole
generally middle- aged woman;
sudden reduction in central vision to around the 6/60 level;
small round retinal hole centered on the fovea;
Vitreous traction;
Treatment- vitrectomy

36. Macular Hole

37. Macular Hole

39. Senile changes
Myopic Degeneration
High myopia= large eyeball with all retinal layers stretched and thinned;
primary choroidal atrophy may affect the macular region, or breaks in Bruch`s membrane (laquer cracks) through which choroidal neovascularisation and subsequent disciform scarring may develop in a similar manner to AMD

40. Congenital fundus anomalies

42. Separation of the retina from its pigment epithelial layer.
Retinal detachment
Separation of the retina from its pigment epithelial layer.
The separation occurs at this site for embryological reasons: the two walls
of the embryonic optic vesicle become apposed and form respectively the RPE and neuroretina.

43. Retinal detachment

44. - most common type of RD; of posterior vitreous detachment
Retinal detachment
rhegmatogenous RD
- most common type of RD;
- secondary to a tear or hole in the retina, which often arises as a consequence
of posterior vitreous detachment

45. non- rhegmatogenous RD (exudative and tractional)
Retinal detachment
non- rhegmatogenous RD (exudative and tractional)
- an ucommon type of RD;
- there is no defect in retina;
- result of exudative processes beneath the retina (e.g. scleritis or choroidal neoplasm) or as result of vitreous tractional forces pulling the retina forward (e.g. proliferative diabetic retinopathy).

46. - trauma (younger patients);
Retinal detachment
risk factors
- age (over 50);
- high myopia;
- trauma (younger patients);
- systemic conective tissue disorders (Marfan`s syndrome)

47. Retinal detachment
symptoms
- sudden onset of floating specks or spots associated with flashes of light (typical for posterior vitreous detachment and/ or retinal tear formation);
- „shadow” or „curtain” in the visual field that gradually extends to cover the whole visual field (the same day or days or weeks later);

48. - reduction in visual acuity (if the macular region becomes detached);
Retinal detachment
signs
- visual field loss corresponding to the area of detached retina (the temporal retina generally detaches first- nasal field defect);
- reduction in visual acuity (if the macular region becomes detached);

49. - grey retinal folds which quiver as the eye moves;
Retinal detachment
signs
- grey retinal folds which quiver as the eye moves;
- the blood vessels on the detached retina have deeper red colour than normal;
- easy contrast between the normal fundus colour and the greyish detached part of retina;

50. or dialysis (typical for traumatic RD)
Retinal detachment
signs
- retinal break will be seen at the periphery of detached fundus in the form of a tear (arrowed or „U” shaped), hole
or dialysis (typical for traumatic RD)

51. Retinal detachment
prevention
laser photocoagulation or retinal cryotherapy in patients with retinal tears and holes and with symptoms of flashes and floaters !!!

52. Retinal detachment
tratment
surgery
Aim: to seal the retinal break by inducing retinal scarring with laser or cryotherapy and to relieve vitreous traction over the break, either by attaching an indenting implant of silastic to the sclera
or by vitrectomy.

53. Retinal detachment
prognosis
the visual prognosis depends on the duration of the detachment and whether the macula has been detached!!!

54. Retinal detachment

55. Retinal detachment

56. Posterior vitreous detachment

57. opacities in the vitreous

59. - an ophthalmoscopic apperance similar to blood vessels;
Angioid Streaks
- an ophthalmoscopic apperance similar to blood vessels;
- irregural, reddish streaks extend outwards from the optic disc (cracks in Bruch`s membrane);
- usually asymptomatic (unless they affect macular region);

60. - compications: neovascularisation, disciform scars;
Angioid Streaks
- compications: neovascularisation, disciform scars;
- May be associated with: pseudoxanthoma elasticum, Ehlers- Danlos syndrome, Paget`s disease, sickle- cell anaemi;

61. Angioid Streaks

63. (choroiditis/ psterior uveitis)
Fundus inflammation
main informations:
(choroiditis/ psterior uveitis)
- rapid blurring of vision (usually in one eye);
- spots and hazines over the whole visual field (inflammatory cells in vitreous);
- inflammations of the choroid always affect the overlying retina to produce
a chorioretinitis

64. Fundus inflammation
toxoplasmosis:
The parasite (Toxoplasma gondii) probably causes choroiditis by its entry into the bloodstream via ingested infected material from cats. Toxoplasma may be transmitted across the placenta causing congenital toxoplasmosis.

65. Many people are unaware they have had toxoplasmosis chorioretinitis
Fundus inflammation
toxoplasmosis:
Many people are unaware they have had toxoplasmosis chorioretinitis
in childchood or from birth until
a characteristic old fundus is noted
on routine examination in later years.

66. Primary infection in adults: - mild febrile illness;
Fundus inflammation
toxoplasmosis:
Primary infection in adults:
- mild febrile illness;
- the eye symptoms

67. - very hazy view of the fundus (inflammatory cells in vitreous);
Fundus inflammation
toxoplasmosis:
Signs and symptoms:
- reduced vision;
- very hazy view of the fundus (inflammatory cells in vitreous);
- localised white fluffy area in the fundus;

68. - reccurent episode (the active focus arieses from an area adjanced
Fundus inflammation
toxoplasmosis:
forms:
- reccurent episode (the active focus arieses from an area adjanced
to pigmented choroidal scar);
- primary episode;

69. of congenital toxoplasmosis in primary infection!!!
Fundus inflammation
toxoplasmosis:
It is very important to distinguish reccurent from primary disease in pregnancy because there is very high risk
of congenital toxoplasmosis in primary infection!!!

70. Serum antitoxoplasma antibody:
Fundus inflammation
toxoplasmosis:
diagnosis:
Serum antitoxoplasma antibody:
1. IgM- 2 to 6 months after initial infection, 2. IgG after 6 months)

71. Is usually commenced in severe vitritis
Fundus inflammation
toxoplasmosis:
treatment:
Is usually commenced in severe vitritis
and if active lesion is close to the macula
or optic disc.
Systemic corticosteroids (p.o. or i.v) +
Pyrimethamine;
Sulphadiazine;
or Clindamycine.

72. Fundus inflammation
toxoplasmosis:

73. Toxocariasis (Toxocara canis):
Fundus inflammation
Toxocariasis (Toxocara canis):
Infection- contact with dog`s infected excreta; eggs of toxocara hatch in the gut and the larvae migrate throughout the body via the blood and lymphatic system.
In children larvae invading the eye may cause a focal chorioretinitis or an edophtalmitis and leucocoria.

74. Acquired Immunodeficiency Syndrome(AIDS):
Fundus inflammation
Acquired Immunodeficiency Syndrome(AIDS):
Human immunodeficiency virus (HIV)
an RNA retrovirus which infects T- helper lymphocytes impairing their function and causing a state
of immunodeficiency.

75. AIDS- ocular manifestations:
Fundus inflammation
AIDS- ocular manifestations:
1. HIV retinopathy (especially cotton wool spots, less frequently microaneurysms and oedema like in diabetic retinopathy);

76. AIDS- ocular manifestations:
Fundus inflammation
AIDS- ocular manifestations:
2. Opportunistic ocular infections –Cytomegalovirus (CMV) retinitis= 25%
of AIDS patients; usually asymptomatic until the macula or optic nerve
is affected. The clinical apperance
is of slowly progressive, necrotising retinitis.
Fundus: white areas of retinal infiltrate and necrosis and haemorrhage within and along necrotic area (pizza fundus)

77. AIDS- ocular manifestations: CMV retinitis Treatment:
Fundus inflammation
AIDS- ocular manifestations:
CMV retinitis
Treatment:
Antiviral treatment-
Ganciclovir or foscarnet (intravenously
or by intravitreal injection or implant.

78. CMV retinitis

79. CMV retinitis

80. CMV retinitis

81. CMV retinitis

82. CMV retinitis

83. ARN syndrome

84. PORNS

85. AIDS- ocular manifestations: Treatment- Radiotherapy.
Fundus inflammation
AIDS- ocular manifestations:
3. Kaposi sarcoma
A purple or red higly vascular lesion (vascular malignancy) which may occur on the eyelids or conjunctiva.
Treatment- Radiotherapy.

86. AIDS- ocular manifestations:

88. Retinitis pigmentosa (RP):
Retinal dystrophies
Retinitis pigmentosa (RP):
- an inherited primary retinal degeneration;
- sometimes associated with systemic disorders (Usher`s syndrome= RP + congenital senorineural deafness)

89. Retinitis pigmentosa (RP): Symptoms: - night blindness in childchood
Retinal dystrophies
Retinitis pigmentosa (RP):
Symptoms:
- night blindness in childchood
or adolescence (initial symptom);
- gradual and progressive peripherial visual field loss leading to tunnel vision.

90. Retinitis pigmentosa (RP):
Retinal dystrophies
Retinitis pigmentosa (RP):
Signs:
- Fundus- classical mid- periphery scattered bone spicule pigmentation, marked narrowing of the retinal vessels and optic atrophy;
- Visual field- ring scotoma (early stages), tunnel vision (advanced RP).

91. Retinitis pigmentosa (RP): Signs:
Retinal dystrophies
Retinitis pigmentosa (RP):
Signs:

92. Retinal dystrophies
Pigment degeneration and pigment clumping of a retina suffering from retinitis pigmentosa.

93. Retinitis pigmentosa (RP): treatment:
Retinal dystrophies
Retinitis pigmentosa (RP):
treatment:
- at the present time there is no known effective treatment.

95. Retinal dystrophies
Macular dystrophies
Hereditary, progressive degeneration of the macula in children and young adults leading to slow deterioration in central vision (Best`s disease, Stargard`s disease, cone dystrophy, pattern dystrophy);

96. Signs- Reduced visual acuity;
Retinal dystrophies
Macular dystrophies
Signs- Reduced visual acuity;
Fundus- abnormal deposits or pigmentation at the macula (Bulls eye);
Diagnosis- electrophysiological tests;
Treatment- no;
Low vision aids (telescopic spectacles)

97. Stargard`s disease

99. Swelling of the optic disc is produced
Neuro- ophthalmology
Optic disc swelling
Swelling of the optic disc is produced
by oedema within the nerve head.

100. Neuro- ophthalmology
Optic disc swelling

101. Neuro- ophthalmology
Optic disc drusen

102. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
1. Raised intracranial pressure- tumors or impaired CSF drainage; raised intracranial pressure is transmitted to the meningeal sheath surrounding the optic nerve (papillooedema); normal axoplasmic flow is interrupted with consequent intra- axonal swelling.
The vascular features (hyperaemia, venous congestion and haemorrhage) are all secondary.

103. Neuro- ophthalmology
The initial change in the ophthalmoscopic examination in a patient with increased intracranial pressure is the loss of pulsations of the retinal vessels. This is followed by blurring of the optic disc margin and possibly retinal hemorrhages.

104. Optic disc swelling

105. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
2. Ischaemic optic neuropathy- arteritic, embolic or atherosclerotic blockage of the posterior ciliary arteries which supply the optic nerve head (ONH); ischaemia of ONH, interruption of axoplasmic flow and disc swelling (central retinal vein occlusion, malignant hypertension).

106. ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)

107. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
3. Inflammation- papillitis or optic neuritis; idiopathic or associated with multiple sclesosis, diabetes or post viral.

108. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
4. Compression- raised intraorbital pressure (Graves` disease, retrobulbar hemorrhage, orbital tumors).

109. Optic disc swelling- causes: 5. Infiltration- lymphoma.
Neuro- ophthalmology
Optic disc swelling- causes:
5. Infiltration- lymphoma.

110. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
6. Toxic- steroids, ethambutol, tobacco; optic disc swelling and its pallor.

111. Optic disc swelling- causes:
Neuro- ophthalmology
Optic disc swelling- causes:
7. Trauma- direct or indirect optic nerve trauma; optic disc swelling and its atrophy.

112. Neuro- ophthalmology
Optic disc swelling:
The term papillooedema should be restricted to a swollen optic disc due to raised intracranial pressure!!!

114. Optic disc swelling- symptoms:
Neuro- ophthalmology
Optic disc swelling- symptoms:
1. Impaired vision- very rapid and severe visual loss is typical for ischaemic or inflammatory optic disc swelling.
Raised intracranial pressure may causes no visual symptoms (they are rather secondary);

115. Optic disc swelling- symptoms:
Neuro- ophthalmology
Optic disc swelling- symptoms:
2. Visual field loss- ishaemic optic neuropathy- altitudinal visual field defect; compression and toxicity- central or centrocaecal visual field defect.
Raised intracranial pressure may causes no syptomatic field loss (sometimes enlargement of the blind spot);

116. Optic disc swelling- symptoms:
Neuro- ophthalmology
Optic disc swelling- symptoms:
3. Impaired colour vision- particularly to red stimuli;
4. Pain on eye movements- retrobulbar optic neuritis!!!

117. Neuro- ophthalmology Optic disc swelling- signs:
- dilatation of the retinal veins;
- reddish disc colour, blurred and raised disc margins;
- absence of physiological optic disc cup;
- small haemorrhages at the disc margin;
- abnormal pupill reflexes;
- enlarged blind spot or other charakteristic visual field defects;
- impaired colour vision

118. Optic disc swelling- hypertensive retinopathy:
Neuro- ophthalmology
Optic disc swelling- hypertensive retinopathy:
- the ocular apperances depend on the sevserity and duration of the blood pressure elevation;
- only an acute severe rise (grades III and IV) in blood pressure cause visual symptoms;

119. Optic disc swelling- hypertensive retinopathy: Grading:
Neuro- ophthalmology
Optic disc swelling- hypertensive retinopathy:
Grading:
Grade I- mild ht (arteriolar attenuation, copper wiring);
Grade II- moderate ht (AV nipping, silver wiring, occasional hard exudate or haemorrhage);
Grade III- severe ht (flame haemorrhages, hard exudates, cotton wool spots);
Grade IV- malignant ht- as for grade III with optic disc swelling.

120. Optic disc swelling- hypertensive retinopathy:
Neuro- ophthalmology
Optic disc swelling- hypertensive retinopathy:
Grades III and IV can usually be reversed by adequate blood pressure control.
Grades I an II are more resistant to reversal, even if blood pressure is normalised.

121. Neuro- ophthalmology Optic disc swelling- Multiple Sclerosis (MS):
- most common in temperate climates;
- young adults ( years);
- F > M;
- aetiology- unknown (virus infection of CNS);
optic neuritis (ON) is the main ophthalmological sign which arises as a result of demyelination
of optic nerve axons.

122. Neuro- ophthalmology Optic disc swelling- Multiple Sclerosis (MS):
symptoms:
- blurring of vision in one eye occuring over a few days (the visual loss from minimal to even light perception- usually about 0,1);
- central scotoma in visual field;
- pain on moving the eye;
- RAPD (relative afferent pupil defect);
- gradual recovery of vision (even without
a treatment, over several weeks)

123. Optic disc swelling- Multiple Sclerosis (MS):
Neuro- ophthalmology
Optic disc swelling- Multiple Sclerosis (MS):
symptoms:
- the disc swelling is not typical for ON
in MS because in more cases it is
a retrobulbar neuritis; there is no fundus anomaly in retrobulbar ON!!!

124. Optic disc swelling- Multiple Sclerosis (MS):
Neuro- ophthalmology
Optic disc swelling- Multiple Sclerosis (MS):
Neurological signs:
- ataxia,
- parashesiae,
- nystagmus,
- strabismus;
- plaques of demyelination in MRI scans;

125. Optic disc swelling- Multiple Sclerosis (MS):
Neuro- ophthalmology
Optic disc swelling- Multiple Sclerosis (MS):
Following an isolated attack of adult optic neuritis the risk of developing MS
is approximately 50 per cent!!!

127. Neuro- ophthalmology
Optic Atrophy:
Any damage to the optic nerve from whatever cause, will result in degeneration of the optic nerve fibres and destruction of their myelin nerve sheaths. The dead nerve fibre axons are replaced by glia which give the atrophic disc its typical ophthalmoscopic pale apperance.

128. Primary- often hereditary basis;
Neuro- ophthalmology
Optic Atrophy:
Primary- often hereditary basis;
Secondary- any cause of optic disc swelling may be followed by the development of optic atrophy!!!, several of these diseases may cause optic atrophy without an observed episode of disc swelling (optic nerve compression, toxic optic neuropathy).

129. Neuro- ophthalmology
Optic Atrophy:
Secondary- certain retinal disorders don`t cause optic disc swelling but do cause optic atrophy (glaucoma- typical ON atrophy with cupping of the ONH!!!, retinitis pigmentosa, central retinal artery occlusion).

130. Optic Atrophy- signs and symptoms: - focal or generalised disc pallor;
Neuro- ophthalmology
Optic Atrophy- signs and symptoms:
- focal or generalised disc pallor;
- sharper disc margins;
- diminished visual acuity;
- visual field defects;

131. Optic Atrophy- signs and symptoms:
Neuro- ophthalmology
Optic Atrophy- signs and symptoms:

132. Optic Atrophy- signs and symptoms:
Neuro- ophthalmology
Optic Atrophy- signs and symptoms: