pale lesions in retinal diseases differentiation

what is the posterior pole

the central part of retina, includes: optic disc, macula and around it

what does ischaemic mean

a lack of blood supply(oxygen) to tissue- causes retinal nerve fibres to malfunction or die

what does retinovitreal mean

attachment between retina and vitreous body

examples of retinovitreal degenerations

• snail track

• lattice

• snowflake( early stage /variant of snail track)

• cobblestone

• retinoschosis

how does normal retinovitreal connection look

even, healthy peripheral retina with smooth reflectivity and no localized whitening or thinning.

early degeneration is

snowflake- small discrete white spots usually benign

what is moderate degeneration

snail track- glistening, frosting ,long snail slime like appearance

its a peripheral retina degeneration of neural layers, often superior or inferior temporal

how would snail track appear in fungus exam

flat and reflective

what is snail tracks clinical importance

high risk or retinal tear of detachment due to thin retina and stuck to vitreous

lattice degeneration- high degeneration

thin elongated, with criss cross white patches and pigmented borders

what is the cause

retinal thinning and liquified vitreous and firm vitro retinal adhesion at edges

high risk for retinal tear/degeneration

white with/without pressure

Translucent gray-white patches,

with pressure - needs indentation of sclerato be seen

due to retinovitreal interface irregularity

retinoschisis

smooth dome shaped transparent elevation of retina- symptomless

intraretinal degeneration - splitting of retinal layers

mimics degeneration

another intraretinal degeneration

microcystoid- peripheral greyish vesicles

doesn’t predispose to retinal detachment

what type of degeneration is cobblestone

chorioretinal

cobblestone/paving

well defined white patches with pigmented rim and visible choroid

benign and no tear risk

due to outer retina and retinal pigmented epithelium loss

is cobblestone normal?

appears in 25% normal eyes

Lets See Shiny White Retina Properly

L- lattice-(risky!)

S- snail track(risky!)

S-snowflake(benign- may progress)

W-white with/without pressure(benign)

R-retinoschosis-(usually benign)

P-paving stone-(benign)

what is this

lattice degenation

what is this

snail track

what is this

snail track

what is this

lattice degeneration

what is this

snowflake

what is this

white with/without pressure

what is this

white with/without pressure

what is this

retinoschosis

what is this

cobble stone

what is honeycomb degeneration

a peripheral retinal degeneration

honeycomb pattern of atrophy and pigmentation- benign so doesn’t predispose to retinal tears of degeneration

pigemtory lesions ( tumours)

CHRPE- congenital hypertrophy of the retinal pigment epithelium

Choroidal naevus

choroidal melanoma

retinitis pigmentosa

CHRPE

bear track

flat

dark grey/black

1-3 disc diamters

unilateral

benign

location CHRPE

peripheral or mid peripheral

what are multiple CHRPEs called

bear track

what should you do if bear track identified

not a bad condition for eye, but refer to GP as its related to colon cancer

choroidal naevus

slight elevation

slate grey/brownish

may have drusen on surface

Indistinct edges

naevus location

mid peripheral or posterior pole

what is procedure once naevus found

monitor for changes in elevation, orange pigment or broth- may develop to melanoma

melanoma

significant elevation

white/greenish grey

more than 10DD

cause serious retinal detachment

melanoma location

posterior pole- near macula

asymptomatic unless detachment occurs

requires urgent referral

retinitis pigmentosa

inherited retinal dystrophy

breakdown of RPE and photoreceptors - pigment distributes( appears like black branches- not always visible)- spicules

retinal arteries become very thin(attenuated)- due to photoreceptor loss

optic disc appears pale

how are the spicules formed

RPE cells migrate to inner retina along blood vessels- carry pigment with them

what does retinitis pigmentosa cause

low vision at night due to loss of rods

peripheral vision lost first- tunnel vision

cones lost later on - cause eventual vision reduction

big difference between nevaus and. melanoma

naevus won’t grow melanoma will with time, so record keeping is important

albinism

lack of pigment

view of all choroidal vessels

poor VA - less than 6/60

nystagmus

Risk of High myopia

higher risk of:

glaucoma

retinal detachment

posterior sub capsular or early onset nuclear sclerosis

optic disc anomalies- peripapillary atrophy

the thinning or loss of tissue around disc

scleral or choral cresecent:

if RPE stretched- choridal- alpha

chord stretched- scleral- beta

what’s this

zones of peripapillary atrophy

Bergmeister’s papilla

normal fetal developmental remnant of hyaloid artery

like a tat at optic disc

mittendorfs dots

small white spot on interior lens capsule

optic disc anomalie- colobloma

incomplete closure of sclera

what’s this

coloboma

what is sx/signs

uni or bilateral

reduced VA

superior field defects

optic disc pit

atypical colobloma

enlarged blind spot

disc drusen

calcified deposits

edge of disc is lumpy

70% bilateral

what it may be confused with

papillodema

hypertension on retina (hypertensive retinopathy) signs 

papillodema(severe)

cotton wool spots(moderate)

flame haemorrage(moderate)

hard exudates(moderate)

arteriovenous nipping (mild)

cotton wool spots

white spots to remember

disruptions to axoplasmic flow in RNFL

seen in diabetic and hypertensive retinopathy

hard to differentiate with hard exudates

cotton wool spots

arteriosclerosis

progressive hardening and narrowing of arteries- thickened tunic media and loss of elasticity

blood vessel signs for arteriosclerosis

• salus sign -cross at 90degrees

• bonnet sign- bulging vein

• gunn sign- tapering of veins

Atherosclerosis

deposition of fatty material in walls- plaque formed

platelets bind

salus sign

bonnet sign

tapering

retinal vascular diseases

retinal artery occlusoon- more serious due to oxygen stopped from reaching tissue

retinal vein occlusion

central retina artery occlusion (CRAO)

painless loss of vision

whitening of retina

red spot at macula

(CRVO)

reduced vision

cotton wool spots

exudates

neovascularisation

haemorrhage in 4 quadrants

CRAO

CRVO