Practical Approach to Ophthalmoscopic Retinal Diagnosis AK Gupta, Shahana Mazumdar, Saurabh Choudhry
INDEX
A
Abnormal architecture 328
Abnormal course 162
Abnormal course or branching 275
Abnormal fundus 20
Abnormal prominence of light reflex 247
Abnormal retinal vessels 266
classification (Goldberg’s) 280
Coats’ disease 276
examination protocol 278
idiopathic macular telangiectasia 276
Leber's miliary aneurysms 276
prepapillary vascular loops 280
retinal macroaneurysm 276
retinopathy of prematurity (ROP) 276
severity of the disease 277
sickle cell retinopathy 278
vascular tumors 276
zones of retinal involvement 277
Abnormal size 85
Abnormalities
arterioles 244
arteriovenous crossings 249
caliber of the choroidal vessels 264
vasculature of the macula 157
venules 256
Abnormalities in vasculature of macula 157
idiopathic macular telangiectasia 162
idiopathic polypoidal choroidal vasculopathy (IPCV) 164
Yanuzzi et al classification (2006) 163
Acquired syphilis 231
Active retinitis 171
Active vasculitis 257
Acute Elschnig's spots 264
Acute idiopathic maculopathy 100, 151
Acute lymphocytic leukemia 61
Acute macular neuroretinopathy 119
Acute pigment epithelitis 135,138
Acute posterior multifocal placoid pigment epithel 186, 197
Acute pvd 320
Acute retinal necrosis 119, 204
Acute retinal necrosis (ARN) 200
Acute retinal pigment epithelitis 186
Acute sickling maculopathy 280
Adenomas of the RPE 83
Adult Refsum's disease 234, 235
Adult vitelliform dystrophy 150
Advanced pregnancy induced hypertension (PIH) 356
Advanced stages of retinopathy of prematurity 388
Age related macular degeneration 152
Aging 133
Albinism 237, 240
Alcoholism 65
Alstrom's disease 235
Altered blood 168, 379
Altered pigmentation at the macula 124
acute pigment epithelitis 138
angioid streaks 137
bull's eye maculpathy 136
central areolar choroidal dystrophy 138
chloroquine toxicity 136
cone dystrophy 136
myopic maculopathy 139
non-specific patterns 131
photic retinopathy 139
RPE rip 138
solar retinopathy 139
specific patterns 125
Stargardt's disease 138
Altered subretinal hemorrhage 150
Amelanotic melanoma 344
Aminoglycoside toxicity 101
Amsler charting 14
abnormal fundus 20
contrast sensitivity 16
examination 25
fundus biomicroscopy 23
normal fundus 20
ophthalmoscopy 16
methods 16
technique 19
visual field testing 14
Anatomy of the retina 1
histology 2
macular region 4
retinal pigment epithelium 2
sensory retina 3
Ancillary tests 340
Anemia 246, 256, 259
Anemic patients 259
Anemic retinopathy 285
Angioid streaks 131, 137, 238, 279
Angiomatosis retinae 345
Angiotensin-converting enzyme (ACE) 377
Anomalous tissue 78
gray lesions 83
melanocytoma 84
optic disk 84
persistent fetal vasculature 85
persistent hyperplastic primary vitreous (PHPV) 85
on and around ONH 78
pigmented lesions 78
red lesions 79
yellowish–white lesions 81
Anterior ischemic optic neuropathy 62,73
Antiphospholipid syndrome 282
Aortic arch disease 255
Arteriosclerosis 256
Arteriosclerotic changes 247
Arteritic anterior ischemic optic neuropathy 58,62,65
Asteroid hyalosis 373,378
Astrocytic hamartoma 84, 369
Astrocytoma 173
AV 250
crossing phenomenon 251
nicking 250
B
Band or bowtie pallor 68
Bardet Biedl syndrome 235,236
Behçet's disease 258,262
Beitti's crystalline retinopathy 157
Benign concentric annular dystrophy 126
Benign monoclonal gammopathy 259
Bergmeister's papilla 85, 86
Berlin's edema 119,122, 214,215
Best's disease 154
Bietti's crystalline dystrophy 155
Bilateral dilated and tortuous veins 259
Bilateral swollen optic disks with pallor 58
Bilateral swollen optic nerve head with hyperemia 48
Birdshot retinochoroidopathy 187, 197
Black sunburst lesions 279
Blood dyscrasias 256,259,285
Blood supply to the retina 6
Blood vessels 244
abnormal prominence of the light reflex 247
abnormalities at the arteriovenous crossings 249
capillary hemangioma of the retina 255
hypertensive and arteriosclerotic retinopathy 250
malignant hypertension 251
other signs 251
pregnancy-induced hypertension (PIH) 253
von Hippel-Lindau disease (VHL) 255
abnormalities in the arterioles 244
narrowing and straightening 244
abnormalities in the caliber of the choroidal vessels 264
idiopathic polypoidal choroidal vasculopathy (IPCV) 266
abnormalities in the venules 256
Behçet's disease 262
blood dyscrasias 259
retinal vasculitis 260
systemic lupus erythematosus (SLE) 262
dilated and tortuous vessels 247
diseases 244
investigations 263
Irvan syndrome 263
cavernous sinus thrombosis 264
primarily alterations in the caliber 244
Bone spicule pigmentation 229,232
Bradyzoite 174
Branch occlusions 246
Branch retinal arterial occlusion (BRAO) 213 214
Branch retinal vein occlusion (BRVO) 297
Bright-flash ERG 33
Brown mass in the fundus 330
choroidal detachment 334
choroidal melanoma 333
ciliochoroidal effusion 334
Bruch's membrane 6
Bull's eye maculopathy 125,136
Bullous central serous chorioretinopathy 104
Buried drusens 58
Butterfly dystrophy 127
C
Cancer associated retinopathy 246
Cancer related retinopathy 233
Cancer-associated retinopathysyndrome car syndrome 232
Candida and aspergillus infections 191
Candida endophthalmitis 373,377
Capillary hemangioma of the retina 255,345
Carotid-cavernous fistula 289, 291
Cavernous hemangioma 344,346
Cavernous sinus thrombosis 256,264
Cells 368
Central areolar choroidal dystrophy 128,138,237,240
Central retina 1
Central retinal arterial occlusion 64, 100
Central retinal artery occlusion (CRAO) 121,213
Central retinal vein occlusion (CRVO) 56,289
Central retinal venous occlusion 287
Central serous chorioretinopathy (CSCR) 95,103,356
Cerebral malaria 284,286
Cerebral venous sinus thrombosis 284
Chalcosis 371
Chediak-Higashi syndrome 240
Cherry red spot 117
Chest x-rays 377
Chiasmal lesions 70
Child abuse syndrome 284,286
Chloroquine 126, 232
Chloroquine toxicity 136,231
Chlorpromazine 234
Choriocapillaris 6
Chorioretinal atrophy 139
Chorioretinal atrophy stage 149
Chorioretinal rupture 224
Chorioretinitis sclopetaria 224, 226
Choroid 6
Choroidal abscess 348
Choroidal coloboma 193,199
Choroidal detachment 331,334
Choroidal folds 110,112
Choroidal granuloma 175,191,343,345
Choroidal inflammations 237
Choroidal melanoma 333
Choroidal metastases 349
Choroidal neovascular membrane (CNVM) 99, 145,153
Choroidal nevi 221
Choroidal osteoma 85,346,349,365
Choroidal pigmented lesions 221
Choroidal ruptures 196,200
Choroidal sclerosis 264
Choroidal tear 141
Choroidal vascular occlusions 280
Choroidal vascular system 6
Choroideremia 238,241
Choroiditis 141
Christmas disease 259
Chronic central serous chorioretinopathy 104
Chronic form 123
Chronic macular edema 140
Chronic myelogenous leukemia 275
Chronic retinal detachment 275
Chronic sickling maculopathy 280
Cigar/spindle shaped lesions 311
lattice degeneration 313
snail-track degeneration 314
Ciliochoroidal effusion 334
Cilioretinal artery occlusion 100, 118,122, 163,214
Circinate girdle 178
Classic (typical) central serous chorioretinopathy 104
Classification (Goldberg’s) 280
Cloquet's canal 7
CMV retinitis 204, 208, 297
Coarse pigments 229
Coats’ disease 267,276,300,308,356
Cobblestone 325
Coccidiodes immitis 192
Coccidiodomycosis 191
Cockayne's syndrome 235
Collateral channels 84
Color code 20
Color vision 13
Combined hamartoma of retina 221
Commotio retinae 122,215
Compression of the optic nerve 63
Compressive and hereditary optic neuropathy 73
Compressive optic neuropathy 69
Cone dystrophies 67,125,135,136,236
Cone-rod dystrophy 235
Confocal scanning laser ophthalmoscopy 30
Congenital cmv 213
Congenital hypertrophy of the retinal pigment epithelium (CHRPE) 83,220
Congenital pit 97
Congenital syphilis 227,229, 231
Congenital toxoplasmosis 141, 174, 196
Congenital vascular loops 84
Conjunctival vessels 279
Connective tissue disorders 259
Consecutive optic atrophy 69
Contrast sensitivity 16
Copper foreign bodies 369
Copper foreign body 382
Copper wiring 250
Cotton-wool spots 173,301,308
Cryopexy 173, 356
Cryotherapy-induced chorioretinitis 176
Cryptococcosis 191
Cryptococcus neoformans 192
Crystalline deposits 155
Beitti's crystalline retinopathy 157
crystalline drug deposits 157
Crystalline drug deposits 157
CT scans 377
Cyst like lesions 321
Cystic (large) retinal tufts 322
Cystoid macular edema 92, 102
Cytomegalovirus retinitis 207
D
Deeper retinal hemorrhages 167
Degenerated vitreous 367
Demarcation line 273, 276, 349
Diabetes mellitus 256
Diabetic papillopathy 50
Diabetic retinopathy 275, 299,301
Diagnostic surgical procedures 44
Diffuse choroidal hemangioma 227, 365
Diffuse choroidal melanomas 365
Diffuse generalized pigmentation 224
Diffuse infiltrating pattern 339
Diffuse macular edema 90
Diffuse mass lesions 364
Diffuse unilateral subacute neuroretinitis (DUSN) 188,191,224
Diffusely infiltrating retinoblastoma 365
Dilated and tortuous vessels 247
Direct ophthalmoscopy 16
Disk collaterals 84
Disks 85
abnormal size 85
megalopapilla 87
tilted discs 87
Disk edema 259
Disk sign of sickling 279
Dislocated crystalline or intraocular lenses 375
Disseminated and diffuse choroiditis 197
Disseminated generalized pigmentary lesions 229
Disseminated generalized pigmentation 226
Disseminated intravascular coagulation (DIC) 259
Disseminated yellow lesions 188
Dominant cystoid macular dystrophy 93,103
Dominant drusen 144
Dominantly inherited peripheral retinal neovascula 275
Drug deposits 155
Drug toxicities 229,230
Drugs 92
Drusen 58,142,151
Drusenoid peds 143
Dry armd 133
Dry or nonexudative form 152
DUSN (diffuse unilateral subacute neuroretinitis) 232
Dystrophy 311
E
Eales’ disease 258, 260
Early CMV retinitis 171
Early patch of diffuse unilateral subacute neurore 226
Early proliferative diabetic retinopathy 302
Early treatment of diabetic retinopathy study (ETDRS) classification 302
Ectatic and dilated capillaries 266
Electrooculogram (EOG) 38
Electrophysiological tests 32
Electroretinography (ERG) 32
Elschnig's spots 251
Encephalitis 65
Enclosed oral bay 319,328
Endophthalmitis 382,384
Endophytic hemangioma 84
Endophytic pattern 339
Endophytic retinoblastoma 335
End-stage disease 237
Entral retinal arteriolar occlusion 246
Entral serous chorioretinopathy 141
Epiretinal membrane (ERM) 107,111, 114
ERG waveform 33
Evere degenerative myopia 195
Examination protocol 278
Excavation 72
Exophytic pattern 339
Exophytic retinoblastoma 336
Expulsive hemorrhage 335
Extensive hemorrhages 281,287,292
Extensive ill-defined yellowish-white lesions 200
extensive lesions with hemorrhages 205
cytomegalovirus retinitis 207
extensive lesions with severe inflammation 207
fungal endophthalmitis 208
immune recovery uveitis 208
toxoplasmosis 208
extensive lesions without/with occasional hemorrhages 200
acute retinal necrosis 204
CMV retinitis indolent form 204
geographic helicoid peripapillary choroidopathy (GHPC) 204
progressive outer retinal necrosis (PORN) 204
serpiginous choridopathy 204
Extensive lesions 200
with hemorrhages 205
with severe inflammation 207
without/with occasional hemorrhages 200
Extensive well-demarcated white lesions 193
choroidal coloboma 199
choroidal ruptures 200
gyrate atrophy 200
myopic chorioretinal degeneration 199
External limiting membrane 3, 4
Extrafoveal 153
Extraretinal fibrovascular proliferation 276
Extraretinal proliferation 273
Exudative retinal detachment 356,360
F
Familial dominant drusen 182
Familial exudative vitreoretinopathy 275
Familial/dominant drusen 179
Far peripheral retina 5
FFA 144
Ffa microaneurysms 160
Fibrovascular proliferation (FVP) 271
Fibrovascular proliferations 85
Field testing 365
Fine pigments 229
Flecked retinas 179
Flynn-Aird syndrome 235
Focal abnormality 36
Focal folds 354
Focal macular edema 90
Focal narrowing 251
Focal necrotizing retinitis 174
Foster Kennedy syndrome 55
Fovea 5
Foveal hypoplasia 124
Foveola 4
Freidrich's ataxia 235
Frosted branch angiitis 259
Frosted branch appearance 213
Fuchs spot 221
Full thickness macular hole 112
Fulminant form 208, 211
Fundus albipunctatus 180, 183
Fundus biomicroscopy 23
Fundus camera 26
Fundus flavimaculatus 129, 179, 183
Fundus fluorescein angiography 27, 101
Fundus photography 26
Fungal endophthalmitis 173, 176, 208, 213
Fungal granulomas 192
Fungi 191
G
Ganglion cell layer 4
Gangliosidosis 123
Generalized pigmentation 224
Geographic atrophy 133
Geographic helicoid peripapillary choroidopathy 135, 204
Geographical helicoidal progressive choroiditis 197
Giant retinal tear (GRT) 316,320
Glaucomatous nerve fiber 73
Goldmann Favre dystrophy 67, 110
Goldmann-Favre syndrome 231,370
Goldmann-Favre vitreoretinal degeneration 233
Granulomas 172, 348
Granulomatous lesions 188
Gray lesions 83
Grayish elevation in the fundus 349
differentiation 364
exudative retinal detachment 360
retinoschisis 363
rhegmatogenous retinal detachment 359,364
Grayish, pale optic discs 67
Grey/white lesions 324
pars planitis 327
white with and without pressure 327
Grouped pigmentation 136, 221
Gunn's sign 250, 251
Gyrate atrophy 196,200,238,240
H
Hamartoma of the RPE 83, 85
Hard drusen 142
Hard exudates 177
Hard exudates in the peripheral retina 178
Heerfordt syndrome 376
Helicoid peripapillary chorioretinal degeneration 238
Hemi-central retinal vein occlusion (CRVO) 298
Hemiretinal vein occlusion 294
Hemoglobin C 279
Hemoglobin S 279
Hemoglobinopathies 283
Hemophilia 259
Hemorrhage 115
Hemorrhagic choroidal detachment 335
Hemorrhagic choroidals 332
Hemorrhagic pigment epithelial detachment 121
Hereditary choroidal dystrophies 237
Hereditary optic neuropathies 64
Hereditary optic neuropathies 72
Hereditary vitreoretinal degenerations 367
Hermansky Pudlak syndrome 240
High-risk proliferative diabetic retinopathy 302
Histology 2
HIV retinopathy 213, 300, 308
Hodgkin's lymphoma 192
Honeycomb dystrophy 128
Honeycomb or reticular degeneration 324
Hurler's syndrome 235
Hydrodynamic effusion 334
Hypermetropia 48
Hypermetropic eyes 248
Hypertension 256
Hypertensive and arteriosclerotic retinopathy 250
Hypertensive choroidopathy 251
Hypertensive optic neuropathy 50
Hyperviscosity 259, 283
Hyperviscosity syndromes 275
Hypervolemic hypertension 256
Hypopigmented fundus 237
albinism 240
central areolar choroidal dystrophy 240
choroideremia 241
gyrate atrophy 240
peripapillary choroidal dystrophy 240
I
Idiopathic macular telangiectasia 130, 157, 162, 266, 276
Idiopathic occlusive arteritis 275
Idiopathic polypoidal choroidal vasculopathy (IPCV) 159, 164, 265, 266
Idiopathic uveal effusion 334,357
Immune recovery uveitis 208, 213
Impending macular hole 124
Incomplete albinism 237
Indirect ophthalmoscopy 18
Indocyanine green angiography (ICG angiography) 29
Indolent form 204
Indolent variant 212
Infantile form 123
Infantile refsum's disease 234, 235
Infiltrative optic neuropathy 62
Inflammatory conditions 334
Inner nuclear layer 4
Inner plexiform layer 4
Inner retina 36
Internal limiting membrane (ILM) 4
Intraocular iron foreign body 369
Intraocular lymphoma 370
Intraretinal microvascular abnormalities (IRMA) 301
Inverse retinitis pigmentosa 226
Investigations 26, 263
adverse reactions 27
complication 27
confocal scanning laser ophthalmoscopy 30
electrophysiological tests 32
electroretinography (ERG) 32
fundus fluorescein angiography (FFA) 27
indocyanine green angiography (ICG angiography) 29
normal angiogram 28
optical coherence tomography (OCT) 29
phases 28
technique 26
ultrasonography 31
Iridescent spot 279, 324
Iron deficiency 281
Irvan syndrome 263
Irvine-Gass syndrome 102
Ischemic central retinal vein occlusion 289
Ischemic optic neuropathy 60
Isolated/primary retinal vasculitis 260
J
Juvenile form 123
Juvenile retinoschisis 359
Juxtafoveal 153
K
Kaposi's sarcoma 259
Kearns-Sayre disease 235
L
Lamellar macular hole 113, 121
Lamina suprachoroidea 6
Large areas of greyish-white opalescence 208
Berlin's edema 215
branch retinal arterial occlusion (BRAO) 213
central retinal artery occlusion 213
cilioretinal artery occlusion 214
commotio retinae 215
retinal contusion 215
retinal vasculature 213
Large opacities 379
endophthalmitis 384
Terson's syndrome 383
vitreous hemorrhage 383
Larger cystic tufts 323
Larval infestations 173
Laser 176
Late stages of several diseases 239
Lattice degeneration 313
Lattice palisade degeneration 311
Laurence Moon-Bardet-Biedl syndrome 236
Leber's congenital amaurosis 235, 236
Leber's hereditary optic neuropathy 51, 53
Leber's miliary aneurysm 267, 276
Leber's multiple miliary aneurysm disease 308
Lesions 310, 311, 328
abnormal architecture 328
oral bay 328
Leukemias 282
Leukemic and lymphoma cells 369
Leukemic retinopathy 282
Lipid storage disorders 64, 119, 123
Localized pallor of the optic disc 68
Localized retinal pigmentation 216
Lofgren syndrome 376
Lymphoma 61, 192
Lymphoma associated retinopathy 235
M
Macular and optic nerve head changes 279
Macular cyst 121, 114
Macular ectopia 162
Macular edema 90, 102, 301
Macular GHPC 135
Macular hole 112, 120
Macular pucker 108
Macular region 4
Macular star 94,103,178
Macular thinning 114
Macular vein occlusion 163, 296
Malignant hypertension 251
Malignant melanoma 221, 330, 382
Measles 232
Medications 110
Medium sized opacities 372
asteroid hyalosis 378
Candida endophthalmitis 377
ocular cysticercosis 378
posterior vitreous detachment (PVD) 375
retained intraocular foreign body 379
sarcoidosis 376
synchysis scintillans 378
Megaloblastic 282
Megalopapillae 87
Melanocytoma 78, 84, 221, 369
Melanoma associated retinopathy (MAR) syndrome 235, 239
Melanosis bulbi 227
Meningitis 65
Meridional complex 328
Meridional fold 328
Metastases 181
Metastatic carcinoma 61
Methods 16
Methyl alcohol poisoning 51, 59, 65
Methyl alcohol toxicity 59
Microaneurysms 160, 165, 167, 259
Microvascular anomalies 308
Midperiphery 5
Miliary tuberculosis 172
Moderate NPDR 302
Morning glory anomaly 75, 78
Mucopolysaccharidoses 235
Mulberry 338
Multifocal and bilateral lesions 365
Multifocal choroiditis 197
Multifocal choroiditis with panuveitis 185
Multifocal erg 33
Multiple evanescent white-dot syndrome (MEWDS) 188
Multiple myeloma 256, 259, 282
Multiple sclerosis 258
Multiple, medium sized, yellow lesions 184
Multiple, small, yellow lesions 177
Multiple-disseminated yellowish lesions 177
disseminated yellow lesions 188
diffuse unilateral subacute neuroretinitis (DUSN) 191
fungal granulomas 192
lymphomas 192
retinal and choroidal granuloma 192
subretinal fibrosis 191
uveitis syndrome 191
multiple, medium sized, yellow lesions 184
multiple, small, yellow lesions 177
familial dominant drusen 182
fundus albipunctatus 183
fundus flavimaculatus 183
retinal and choroidal metastases 184
retinitis pigmentosa 183
Stargardt's disease 183
Myelinated nerve fibers 84, 170, 173
Myopia 320
Myopic chorioretinal degeneration 199
Myopic eye 73
Myopic maculopathy 131, 139
N
Nasopharyngeal carcinoma 61
Near periphery 5
Necrotizing retinitis 196
Neimann-Pick disease 123
Neovascularization 269, 301
Neovascularization at the disc (NVD) 272
Nerve fiber layer 4
Nerve fiber layer infarcts 169, 173
Neuromyelitis optica 51
Neuronal ceroid lipofuscinosis 234
Neuroretinitis 55,57, 174
Neurosensory elevation 95
Nevus of ota 227
New vessels 84
Nfective vasculitis 261
NHL-CNS 192
Non-arteritic anterior ischemic optic neuropathy (NAAION) 62
Non Hodgkin's lymphoma of CNS 369
Nonphakic eye 320
Nonspecific patterns 131
Nonarteritic anterior ischemic optic neuropathy 55
Noncystic retinal tufts 322
Noncystic tufts 323
Non-Hodgkin's lymphoma (NHL) 192,370
Nonischemic central retinal vein occlusion 288
Nonproliferative diabetic retinopathy (NPDR) 302
Normal angiogram 28
Normal eyes 248
Normal fundus 8, 20
appearance 12
examination 12
history 12
visual function 12
Normal fundus 20
Norrie's disease 388, 389
North carolina macular dystrophy 128
O
Occlusion 117
central retinal artery 117
cilioretinal artery 214
peripheral small vessels 279
Occult CNVMS 153
Ocular albinism 237
Ocular cysticercosis 340
Ocular cysticercosis 378
Ocular disorders 260
Ocular features 259
Ocular ischemic syndrome 245
Ocular metastases in systemic NHL 192
Ocular syphilis 175
Ocular toxocariasis 340
Ocular toxoplasmosis 174
Ocular tuberculosis 175
Oculocutaneous albinism 237
Oculodermal melanosis 227
Oguchi's disease 227
Onchocerciasis 230, 232
Oocysts 174
Ophthalmoscopy 16
Optic atrophy 63, 69
Optic disc 84
coloboma 78
drusen 59
disc pit 77
Optic nerve 7, 72
excavation 72
other excavations 74
morning glory anomaly 78
optic disc coloboma 78
optic disc pit 77
optic nerve avulsion 78
physiological cup 72
Optic nerve avulsion 75, 78
Optic nerve head 5
Optic nerve pit 74
Optic neuritis 57
Optical coherence tomography (OCT) 29
Ora serrata 5,324
Oral bay 328
Orbital mass 55
Osmolar imbalance 334
Other excavations 74
Other fungal infections 373
Other healed necrotizing retinitis 232
Other inherited retinal conditions 235
Other manifestations 175
Outer nuclear layer 3
Outer plexiform layer 4
P
Pale optic nerve head 63
grayish, pale optic discs 67
localized pallor of the optic disc 68
chiasmal lesions 70
compressive optic neuropathy 69
hereditary optic neuropathies 72
optic atrophy 69
traumatic optic neuropathy 71
pale white discs 63
with ill defined margins 66
with well defined margins 63
pale, waxy yellow discs 67
Pale white discs 63
Pale, waxy yellow discs 67
Panretinal photocoagulation 232, 356
Papilledema 49, 51, 256
Papillitis 57, 256
Papillitis or optic neuritis 53
Papillophlebitis 56, 291
Parafoveal area 5
Paraneoplastic syndromes 232, 233
Paraprotienemias 256, 282
Pars plana cysts 321
Pars planitis 275, 324, 327
Pattern dystrophies 127
Pattern ERG 33
Pavingstone 325
Pericentral retinitis pigmentosa 126, 224, 226
Pericentric RP 235
Perifoveal central retina 5
Peripapillary choroidal dystrophy 238, 240
Peripapillary pigment epithelial dystrophy 238
Peripheral capillary angioma 247
Peripheral capillary hemangioma 269
Peripheral microcystoid degeneration 321
Peripheral pigmentary degeneration 324
Peripheral retina 1, 5, 309
Peripheral retinal excavation 328
Peripheral retinal hemorrhages 318
Peripheral retinal neovascularisation 272, 318
Peripheral retinal vascularization 321
Peripheral retinoschisis 326
Peripheral tapetoretinal degeneration 323
Persistent fetal vasculature 85
Persistent hyperplastic primary vitreous (PHPV) 85, 387, 389
Photic retinopathy 133, 139
Photocoagulation 141, 197
Photoreceptor layer 3
Physiological cup 72
Pigment blotches at the macula 221
Pigment cells 369
Pigment clumping 324
Pigment epithelial detachment (PED) 97
Pigment epithelial layer 1
Pigmented lesions 215
localized retinal pigmentation 216
choroidal nevi 221
choroidal pigmented lesions 221
combined hamartoma 221
congenital hypertrophy of the retinal pigment epithelium (CHRPE) 220
Fuch's spot 221
grouped pigmentation 221
Siegrit's streak 221
segmental retinal pigmentation 222
bone spicule pigmentation 232
cancer-associated retinopathy syndrome car syndrome 232
chloroquine toxicity 231
chorioretinal rupture 224
chorioretinitis sclopetaria 224
cone dystrophy 236
congenital syphilis 227
diffuse generalized pigmentation 224
diffuse unilateral subacute neuroretinitis (DUSN) 224
disseminated generalized pigmentation 226
drug toxicities 230
generalized pigmentation 224
Goldmann-Favre syndrome 231
Hurler's syndrome 235
Leber's congenital amaurosis (LCA) 236
mucopolysaccharidoses 235
onchocerciasis 230
pericentral retinitis pigmentosa 224
pigmented paravenous retinochoroidal atrophy (PPRCA) 224
Refsum's syndrome 236
retinitis pigmentosa (rp) 234
rubella retinopathy 227
Scheie's syndrome 235
Stickler's syndrome 231
Sturge-Weber syndrome 226
systemic associations 235
viral retinitis 228
Pigmented lesions 78, 323
Pigmented paravenous retinochoroidal atrophy (PPRC) 224, 226
Plus disease 277
POHS (presumed ocular histoplasmosis syndrome) 188
Polyarteritis nodosa 261
Polycythemia 259
Polycythemia vera 256,282
Posterior scleritis 97, 105, 357
Posterior segment 175
Posterior vitreous detachment 320, 372, 375
Postoperative endophthalmitis 385
Predominantly or minimally classic 153
Predominantly subretinal lesions 142
age related macular degeneration 152
Best's disease 154
choroidal neovascular membranes (CNVM) 153
drusen 151
Sorsby's fundus dystrophy 154
vitelliform macular dystrophy 154
Pregnancy-induced hypertension (PIH) 253
Prepapillary loops 84
Prepapillary vascular loops 280
Pre-retinal hemorrhage 380
Prethreshold and threshold retinopathy of premature 273
Pre-threshold ROP 277
Pre-vitelliform stage 149
Primarily alterations in the caliber 244
Primary heredofamilial amyloidosis of the vitreous 374
Primary optic atrophy 69
Primary syphilis 175
Primary systemic infection 174
Primary vitreous 7
Prodromal stage (first stage) 361
Progressive outer retinal necrosis (PORN) 204
Proliferative diabetic retinopathy 302, 386
Proliferative retinopathies 386, 388
Proliferative vitreoretinopathy (PVR) 353, 360
Pseudohole 109, 114
Pseudohypopyon or cyst stage 149
Pseudo-operculum 120
Pseudotumor cerebri 52
Pulseless disease 255
Punctate inner choroidopathy (PIC) 186
Punctate outer retinal lesions 174
Putscher's retinopathy 284, 285
Q
Quadrant 68
R
Radial lattices 311
Radiation retinopathy 275, 307
Radiation treatment 300
Rare presumed ocular histoplasmosis 197
Receptors 36
Recurrent multifocal choroiditis 185
Red blood cells 368
Red color lesions 167
Red lesions 79
Red popcorn 319
Reddish-orange mass in the fundus 341
angiomatosis retinae 345
capillary hemangioma of the retina 345
cavernous hemangioma of the retina 346
choroidal hemangioma 345
Sturge-Weber syndrome 345
von Hippel-Lindau disease (VHL) 345
Reduplication 256
Refsum's disease 229
Refsum's syndrome 236
Regressing drusen 143
Retained intraocular foreign body 379
Reticular degenerative retinoschisis 364
Reticular drusen 145
Reticular dystrophy of the retinal pigment epithelium 180
Reticular retinoschisis 359
Retinal and choroidal granuloma 192
Retinal and choroidal metastases 184
Retinal angiomatous proliferation (RAP) 161
Retinal astrocytoma 338, 340
Retinal break 320
Retinal capillary hemangioma 269, 341
Retinal contusion 215
Retinal cyst 322
Retinal detachment 310, 311, 320, 349, 364
Retinal dialysis 317, 320
Retinal exudates 298
diabetic retinopathy 301
diseases 298
early treatment of diabetic retinopathy study (ETDRS) classification 302
lesions 310,311
nonproliferative diabetic retinopathy (NPDR) 302
Coats’ disease 308
early proliferative diabetic retinopathy 302
high-risk proliferative diabetic retinopathy 302
HIV retinopathy 308
moderate NPDR 302
proliferative diabetic retinopathy 302
radiation retinopathy 307
severe NPDR 302
very severe NPDR 302
retinal detachment 310,311
Retinal hemorrhages 281
diseases 281
extensive hemorrhages 281
anemic retinopathy 285
blood dyscrasias 285
cerebral malaria 286
child abuse syndromes 286
Putscher's retinopathy 285
Terson's syndrome 286
Valsalva's retinopathy 286
extensive hemorrhages 292
branch retinal vein occlusion (BRVO) 297
hemi-central retinal vein occlusion (CRVO) 298
extensive hemorrhages all over the fundus 287
central retinal vein occlusion (CRVO) 289
unilateral 287
Retinal hemorrhages 301, 308
Retinal hole 314, 319
Retinal lymphomas 188
Retinal macroaneurysm 268, 276
Retinal pigment epithelial detachment (RPED) 105
Retinal pigment epithelium 2,221
Retinal tags 322, 323
Retinal tears 319
Retinal tufts 322, 323
Retinal vasculature 213
Retinal vasculitis 249,260
Retinal vein occlusions 275
Retinitis 14, 140,174
Retinitis pigmentosa 67, 183, 234, 325, 246
Retinitis pigmentosa sine pigmento 235
Retinitis punctata albescens 181, 235
Retinoblastoma 173, 339, 369, 382
Retinopathy of prematurity (ROP) 276, 326
Retinoschisis 363
Retrobulbar neuritis 57
Rhegmatogenous retinal detachment 351, 359, 364
Ridge 273, 276
Ring 178
Rounded dilatation 268
RPE rip 138
Rubella infection 229
Rubella retinopathy 227
Rush disease 277
S
Salmon patch hemorrhage 279, 318
Salt and pepper 229
Salus sign 249, 251
Sandhoff disease 123
Sarcoidosis 172, 258, 275, 373., 376
Scars 140, 196
congenital toxoplasmosis 141
Schaffer's sign 353
Scheie's syndrome 235, 236
Scleral buckle or band 327
Scleral buckling 356
Scleritis 174
Scrambled egg stage 149
Scurvy 259
Secondary optic atrophy 69
Secondary syphilis 175
Secondary vitreous 7
Sector RP 235
Sectoral laser ablation 226
Sectoral pallor limited horizontally 68
Sectoral retinitis pigmentosa 226
Segmental optic atrophy 69
Segmental retinal pigmentation 222
Sensory retina 1, 83, 85
Sensory retina 3
Serpiginous choridopathy 204
Serpiginous choroiditis 204, 238
Serum calcium 377
Serum lysozyme testing 377
Severe anemia 281
Severe hypertensive retinopathy 299
Severe ischemic CRVO 299
Severe NPDR 302
Severe vasculitis 300
Severity of disease 277
Sheathing 256
Short and long ciliary nerves 6
Sickle cell disease 283, 324
Sickle cell retinopathy 248, 256, 278
Sickling maculopathy 279
Siderosis 246, 371
Siegrist's streaks 222, 251, 265
Silver-wiring 250
Simultaneous bilateral occurrence 215
Situs inversus 87, 162
Sjogren's disease 180
Sjogren's reticular dystrophy 128
Small opacities 367
chalcosis 371
Goldmann-Favre syndrome 370
siderosis 371
Stickler's syndrome 370
vitreous degeneration 369
vitreous seeding by tumors 370
Small punctate inner retinal patches of retinitis 174
Small triangular tent like lesions 322
retinal tags 323
retinal tufts 323
Small white fluffy lesions 169
choroidal granulomas 175
Cotton-wool spots 173
cryotherapy-induced chorioretinitis 176
fungal endophthalmitis 176
laser 176
myelinated nerve fibers 173
nerve fiber layer infarcts 173
ocular syphilis 175
ocular tuberculosis 175
other manifestations 175
retinitis 174
soft exudates 173
syphilitic retinitis 175
toxoplasma retinitis 174
Snail track degeneration 313, 314
Snowflake degeneration 325
Snowflake vitreoretinal degeneration 328
Soft drusen 142
Soft exudates 173
Solar retinopathy 139
Sorsby pseudoinflammatory macular dystrophy 145, 300
Sorsby's fundus dystrophy 154
Specific patterns 125
Sphingomyelin lipidoses 123
Spontaneous resolution of retinal detachment 226
Stargardt's disease 128, 138, 183
Steroid induced 259
Stickler's syndrome 231, 370
Stroma 6
Sturge-Weber syndrome 226, 345
Subfoveal 153
Subhyaloid hemorrhages 169, 380
Submacular cysticercus 151
Subretinal cysticercus 337
Subretinal fibrosis 191
Subretinal fibrosis with uveitis syndrome 199
Subretinal hard exudates 178
Subretinal hemorrhage 221, 332
Subretinal membranes 355
Subretinal migration of silicone oil 151
Superficial retinal hemorrhages 167
Suprachoroidal hemorrhage 332
Surface wrinkling maculopathy 107
Swollen optic nerve head 48
bilateral swollen optic disks with pallor 58
methyl alcohol toxicity 59
optic disc drusen 59
bilateral swollen optic nerve head with hyperemia 48
Leber's hereditary optic neuropathy 53
papilledema 51
pseudotumor cerebri 52
toxic and nutritional neuropathy 52
unilateral swollen disc with hyperemia 53 optic neuritis 57
unilateral swollen disc with pallor 60
anterior ischemic optic neuropathy 62
arteritic anterior ischemic optic neuropathy (AAION) 62
infiltrative optic neuropathy 62
nonarteritic anterior ischemic optic neuropathy (NAAION) 62
Sympathetic ophthalmia 237, 356
Symptoms 234, 320
Synchiasis scintillans 373, 378
Syphillis 172,191,192
Systemic associations 235
Systemic disease 261, 285
Systemic hypertension 244
Systemic lupus erythematosus (SLE) 262
Systemic NHL 192
T
T sign 335
Takayasu's arteritis 248, 255
Tay-Sachs disease 123
Tear 320
Technique 19, 26
Telangiectasia 266
Temporal pallor 68
Terson's syndrome 284, 286, 383
Tertiary syphilis 175
Thalassemia 279, 283
Thickening/elevation of the macula 90
bullous central serous chorioretinopathy 104
central serous chorioretinopathy (CSCR) 103
chronic central serous chorioretinopathy 104
classic (typical) central serous chorioretinopathy 104
cystoid macular edema (CME) 102
dominant cystoid macular dystrophy 103
Irvine-Gass syndrome 102
macular edema 102
macular star 103
posterior scleritis 105
retinal pigment epithelial detachment (RPED) 105
Thioridazine 232
Thioridazine toxicity 233
Threshold ROP 277
Thrombocytopenia 259
Tilted discs 87
Tobacco-alcohol optic neuropathy 73
Tortuosity of the retinal vasculature 279
Total retinal detachment 276
Toxic and nutritional neuropathy 52
Toxic optic neuropathy 51
Toxocara granuloma 141
Toxocariasis 173
Toxoplasma retinitis 174
Toxoplasmic papillitis 174
Toxoplasmosis 208, 213
Toxoplasmosis retinitis 171
Tractional retinal detachment 358
Trauma 65, 320
Traumatic macular hole 114
Traumatic optic neuropathy 71
Traumatic retinopathy 232
Trophozoite 174
True macular coloboma 141
Tubercular vasculitis 261
Tuberculosis 172, 191, 258, 373
Tuberous sclerosis 341
Typical degenerative retinoschisis 363
Typical retinoschisis 359
U
Ultrasonography 31
UMBO 4
Unilateral 287
Unilateral swollen disc 53
with hyperemia 53
with pallor 60
Usher's syndrome 235
Uveitis syndrome 191
V
Valsalva's retinopathy 285, 286
Varicella-zoster 232
Varicella-zoster virus retinitis 204
Vascular endothelial growth factor (VEGF) 153
Vascular tumors 276
Vascularized PED 121
Vasculitis 297
Venous beading 256
Venous caliber abnormalities 301
Venous occlusions 256
Very severe NPDR 302
Viral retinitis 228, 229
Visual evoked response 41
diagnostic surgical procedures 44
Visual field defects 70
Visual field testing 14
Visual function 12
Vitamin A deficiency 181
Vitelliform macular dystrophy (Best's disease) 149, 154
Vitelliform stage 149
Vitreomacular traction (VMT) 93
Vitreoretinal traction 320
Vitreous 7
Vitreous base avulsion 317
Vitreous degeneration 369
Vitreous hemorrhage 383, 379
Vitreous liquefaction 320
Vitreous membranes 386
Norrie's disease 389
persistent hyperplastic primary vitreous (PHPV) 389
proliferative retinopathy 388
Vitreous seeding 369
by neoplasms 369
by tumors 370
VKH 237
Vogt Koyanagi Harada syndrome 356
Vogt-Koyanagi-Harada disease 205
Von Hippel Lindau disease (VHL) 255, 269,342,345
W
Wagner's syndrome 370
Waldenstrom's macroglobulinemia 259, 282
Wegener's granulomatosis 261
Well-defined red lesion 112
Berlin's edema 122
central retinal artery occlusion (CRAO) 121
cilioretinal artery occlusion 122
commotio retinae 122
gangliosidosis 123
hemorrhagic pigment epithelial detachment 121
lipid storage disorders 123
macular hole 120
Neimann-Pick disease 123
Sandhoff's disease 123
sphingomyelin lipidoses 123
Tay-Sachs disease 123
vascularized PED 121
Well-demarcated red areas 314
factors 320
giant retinal tears (GRT) 320
peripheral retinal vascularization 321
retinal break 320
retinal detachment 320
retinal dialysis 320
retinal holes 319
retinal tears 319
Wet or exudative form 152
White mass in the fundus 335
ancillary tests 340
ocular cysticercosis 340
ocular toxocariasis 340
retinal astrocytoma 340
White or pearly pink mass 335
White with and without pressure 324, 327
White-dot syndromes 184
With ill-defined margins 66
With well-defined margins 63
Wrinkling of the macula 105
epiretinal membranes (ERM) 111
X-linked juvenile retinoschisis (XLJR) 111
Wyburn-Mason syndrome 247, 254
X
X-linked juvenile retinoschisis 109, 111
Y
Yanuzzi et al classification (2006) 163
Yellow mass in the fundus 346
choroidal metastases 349
choroidal osteoma 349
Yellowish-white lesions 81
Z
Zones of retinal involvement 277
Zonular traction tuft 322, 323
×
Chapter Notes

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1Practical Approach to Ophthalmoscopic Retinal Diagnosis2
3Practical Approach to Ophthalmoscopic Retinal Diagnosis
AK Gupta MS (AIIMS), FAMS Director (Academic), ICARE Eye Hospital and Postgraduate Institute, NOIDA, UP, India Director (Academic), Shroff Eye Centre, Kailash Colony, New Delhi, India Formerly, Director, Guru Nanak Eye Centre, New Delhi, India Dean, Maulana Azad Medical College, New Delhi, India Dean, Medical faculty, University of Delhi, India Shahana Mazumdar MS, DNB Fellowship in Vitreoretina, Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India Senior Consultant (Vitreoretina) ICARE Eye Hospital and Postgraduate Institute, NOIDA, UP, India Sitaram Bhartia Institute of Science and Research, New Delhi, India Saurabh Choudhry MD, DO, DNB Senior Consultant (Anterior Segment and Medical retina) ICARE Eye Hospital and Postgraduate Institute, NOIDA, UP, India
4Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Practical Approach to Ophthalmoscopic Retinal Diagnosis
© 2010, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2010
9788184488777
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset
5Preface
Most books on the subject of retina are compilations on retinal diseases which then further describe the details of various signs seen ophthalmoscopically. However when we actually teach resident doctors about retina, we advise them to first observe and pick up retinal signs such as hemorrhages, exudates, edema, pigmentation, changes in the optic disk, etc. They are then encouraged to analyze and group the different signs observed to arrive at the possible diagnoses. We have been following this format of teaching for a number of years. The present book is an attempt to put this tried and tested methodology of teaching into book form. The book progresses from the stage of observed clinical signs as its starting point and goes on to organize the contents along the path to the diagnosis. In addition, concise information about important clinical disease entities is provided as background material in a different color print. The reader can refer to these according to his needs.
 
HOW TO USE THIS BOOK
In spite of the development of several advanced diagnostic tools, accurate clinical assessment remains the cornerstone in the diagnosis of lesions of the retina.
This book has been designed to help in the accurate identification of the signs observed and the scheme to be followed to reach a clinical diagnosis. The chapters have been segregated by the structure primarily involved by the lesion, i.e. the optic nerve, macula, retinal vasculature, the retina proper, peripheral retina or the vitreous.
Within the chapters the observations are grouped by the morphological features and color. The reader is encouraged to observe the lesions and identify the descriptive group most apt to the lesion being identified. The finer differentiating points within that group will clinch the identity of the lesion.
For example, if the lesion is found to involve the optic nerve the reader must turn to the chapter on optic nerve head. The lesion is then examined again and classified into one of the broad categories given in the chapter namely swollen optic nerve, pale optic nerve, excavated optic nerve or is there presence of anomalous tissue on the optic nerve or is it of an abnormal size. If the reader thinks that the optic nerve is swollen then the lesion is further categorized as whether the swollen optic nerve is hyperemic or pale and whether the involvement is bilateral or unilateral. If there is hyperemia and blurring of the disk margins, bilaterally, venous pulsations are elicited, the pupils are reacting normally, one should refer to the refractive status. A refractive error of +4.0D clinches the diagnosis as hypermetropic disks.
AK Gupta
Shahana Mazumdar
Shaurabh Choudhry6
7Acknowledgments
We gratefully acknowledge the help of Mr Nem Singh and Mr Jamsher Khan for painstakingly taking all the photographs. We thank our colleagues Dr Nishant Taneja, Dr Charu Tandon, Dr Uma Sridhar and Dr Reena Choudhry, Dr Umesh Bareja, Dr AS Lata for referring their patients and providing us unconditional support. We thank all our postgraduate students, especially Dr Navneet Mehrotra, for their curiosity and questioning, forcing us to improve our teaching methods. We are grateful to Dr Cyrus Shroff and Dr Shishir Narain for solving our problems from time to time and for providing rare photographs. We also acknowledge the help given by Dr Bhavna Sharma and Mr Sanjay Mishra for the electrophysiological data.
We acknowledge the steadfast support of our institutions ICARE Eye Hospital, NOIDA, UP, India, Shroff Eye Centre, Kailash Colony, New Delhi, India and Sitaram Bhartia Institute for Science and Research, New Delhi, India.
We thank Shri JP Vij, Chairman and Managing Director and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers for their support in the publication of the book. We are grateful to Ms Yashu Kapoor for formatting the entire book and Mr Manoj Pahuja for his help with the figures and illustrations.
Finally, we thank all our patients who gave us the opportunity to examine them.