fundus photographs of various lesions of the retina

1. LESIONS OF RETINA 1
• DR SHRUTI LADDHA

2. Anatomy of the retina
• Extends from ora serrata anteriorly to the optic nerve posteriorly.
• Central retina - 5 to 6 mm in diameter centred on the fovea
• Clinically peripheral retina - from equator to ora serrata.
• Equator - vortex vein .

3. Macula (5.5 mm)
Perifovea(1.5 mm)
Parafovea (0.5 mm)
Fovea (1.5 mm)
Foveola(0.35 mm)
umbo

4. • Peripheral retina can be divided into – near ,mid ,far periphery.
• 1.5-mm ring peripheral to the temporal major vascular arcades called the near
periphery.
• The midperiphery consists of an annular area 3 mm wide surrounding the
near peripheral retina.
• The far peripheral retina extends in width 9 to 10 mm beyond the midperipheral
retina temporally and 16 mm nasally.

5. Photograph of a normal disk
• Points to note :
• Color
• Size
• shape
• margins
• the cup
• neuroretinal rim
• vessels
• Spontaneous venous
pulsations
• peripapillary area

6. • Normal arterioles and
venules.
• Thearterioles arethinner,
red in color .
• The venules are broader,
flatter, and darker red in
color.

7. • At arteriovenous crossings the
arterioles may cross over the
venules
• or the venules may cross
over the arterioles
• Though the former is more
common

8. • The retina has an orangish
color which varies with the
degree of pigmentation in the
pigment epithelium.
• Some normal variations of the
pigment in the RPE can allow the
orange stripes of choroidal
vessels to be seen giving it a
tigroid appearance.
• These vessels are better seen in the mid-periphery and beyond.
• Choroidal vessels seen as orange tape like criss-crossing bands

9. The ampulla of a vortex vein is seen as an orange bulb with choroidal veins
draining into it.

10. Variations of normal optic nervehead
A normal disk in which the cup
cannot be appreciated
A normal disk with a small cup

11. Physiologically enlarged cup-
neuroretinal rim healthy pink.
ISNT rule followed.
No bayonetting, notching.
A normal disk with blurred margins
and absent cup giving a false
impression of disk edema

12. Hypermetropic disc-
Small elevated pink disc,
small or no cup, normal
vessels, crowding.
Blurring of the disk margins (initially
the superior and inferior) with absent cup
raises suspicions of early papilledema.
Presence of venous pulsations or the ability to
induce them, suggests absence of it.

13. BILATERAL SWOLLEN DISC WITH HYPERAEMIA

14. Papilledema-hyperemic protuberant disk with blurred margins and obscured cup.
• The blood vessels on the disk appear to climb down from the elevated margins
towards the surrounding retina and at places appear to be hidden by the swollen
fibers.
• The veins of the retina are engorged.
• There is surrounding peripapillary edema.

15. Established papilledema with blurring of
the entire margin of the optic disk with
some elevation, dilated turgid and
tortuous veins, soft exudates and few
retinal hemorrhages.
Chronic papilledema with blurring of the
entire margin of an elevated optic disk
with deposition of hard exudates

16. Patons line :
Circumferential retinal folds
due to papilloedema

17. Hypertensive optic neuropathy - optic nerve head edema is present along with
other signs of hypertensive retinopathy - retinal hemorrhages, cotton-wools spots,
macular edema, macular star, arteriovenous crossing changes.
These changes are bilateral.

18. Diabetic papillopathy - unilateral or more commonly bilateral hyperemic swollen
disks maybe present in association with mild to moderate visual loss. Other
changes of diabetic retinopathy may be absent.

19. TOXIC OPTIC NEUROPATHY
• Hyperemic disks with blurred margins in patients, who have been addicted to alcohol
and tobacco over a prolonged period of time, must be suspected to have (tobacco-
alcohol) toxic optic neuropathy.
• The disk swelling is less and the vascular changes of papilledema are not seen.
• Later in the course of the disease the disks become pale and excavated.

20. METHYL ALCOHOL POSIONING
• A dramatic and bilateral loss of vision with bilateral swollen hyperemic disks
along with marked attenuation of the blood vessels maybe seen in methyl
alcohol poisoning.
• These disks rapidly turn pale. In the majority, by the time the patient presents
the disks are invariably pale.

21. LEBERS HEREDITERY OPTIC NEUROPATHY
• Bilateral hyperemic disks with blurred margins may be seen in young patients,
usually male, in Leber’s hereditary optic neuropathy.
• The optic disks look hyperemic with tortuous and telangiectatic vessels and
blurred margins. However, the disk prominence is mild.
• A peculiar swelling of the fibers around the disk has also been described
(pseudoedema). The two eyes are involved in rapid succession which then
proceeds to optic atrophy

22. Acute stage – hyperaemic disc swelling with blurring of disc
margins
Marked telangiectatic microangiopathy
Late stage- atrophic appearance

23. • Patients on chronic therapy with the antiarrhythmic drug Amiodarone
may develop an optic neuropathy showing hyperemic disks with blurred
margins.
• The cornea shows superficial brown deposits of the drug in
characteristic whorls.

24. UNILATERAL SWOLLEN DISC WITH
HYPERAEMIA

25. Optic neuritis – peripapillary flame shaped hemorhages and a macular star

26. • Hyperemic swollen disks are the hallmark of optic neuritis which is usually
unilateral in adults but can be bilateral in children.
• If it is associated with paraplegia or other neurological defects that may occur
before or after the optic neuritis it is likely to be neuromyelitis optica.
• Bilateral optic neuritis in adults is rare and usually associated with extensive
sinusitis and syphilitic meningitis.

27. • Mild optic disk edema associated with retinal
edema and hard exudates deposited as and
incomplete macular star in Neuroretinitis.
• The disk edema is relatively milder than in
optic neuritis and the macular star appears
early
• Long standing neuroretinitis showing
features of chronic disk and macular
edema, resolving macular star,
dilated epipapillary vessels and
retinal striae (Paton’s lines)

28. Hyperemic disk edema associated
with central retinal vein occlusion
Papillophlebitis. There are multiple soft
exudates, some hemorrhages and
patches of retinal edema especially in the
inferior retina

29. Hyperemic disk edema
associated with posterior
uveitis (Vogt Koyanagi Harada
syndrome).
Multiple patches of choroiditis
are seen at the posterior pole

30. BILATERAL OPTIC NERVE HEAD SWELLING
WITH PALLOR

31. • Optic nerve head studded with refractile
globular deposits of varying size that reflect
light brightly, in a patient with optic nerve
head drusen
• The drusen exhibit autofluorescence.
• This feature clinches the diagnosis.

32. • A pale swollen disk in
anterior ischemic optic
neuropathy (the fuzzy
looking swollen tissue
along with pallor gives
the disk a ‘milky
appearance’).
• On FFA the disk shows
patches of
hypoflourescence due to
nonperfusion (arrows)

33. • Atrophy of the papillomacular bundle
results in temporal pallor and
commonly occurs following retrobulbar
neuritis and bilaterally in pituitary
tumors.
• A band or bowtie pallor with
sparing of the superior and inferior
parts of the disk implies optic tract
involvement.

34. PRIMARY OPTIC ATROPHY
•no prior optic disc edema
A process affecting the visual pathways from the
retrolaminar portion of the optic nerve to the lateral
geniculate nucleus
• White disc with a clearly delineated outline
• Reduction in the number of small vessels on the disc.
• Attenuation of the peripapillary vessels.
• Thinning of the retinal nerve fibre layer.
• Optic neuritis
• Trauma
• Nutritional deficiency
• Toxic
• Pituitary tumours
• Optic nerve tumours

35. SECONDARY OPTIC ATROPHY
Long-standing swelling of the optic nerve head.
• Dirty grey slightly raised disc with poorly
delineated margins
• Reduction in number of small vessels on the disc.
• Surrounding ‘water marks’ – paton lines.
• Chronic papilloedema.
• Anterior ischaemic optic neuropathy.
• Papillitis.

36. CONSECUTIVE:
• Diseases of the inner retina or its blood supply
1. Vascular attenuation or sheathing
• Old CRVO or ophthalmic artery Occlusion
• Retinitis pigmentosa
• Toxic optic neuropathy
• Old vasculitis as in Behçet disease
2. Macular lesions giving rise to temporal disc pallor
• Toxoplasmosis
• Cone dystrophy
3. Chorioretinal
• Degenerative myopia
• Extensive pan retinal photocoagulation
4. Diffuse retinal necrosis
• Cytomegalovirus retinitis
• Acute retinal necrosis
• Progressive outer retinal necrosis

37. GLAUCOMATOUS OPTIC ATROPHY
• Large cup with notching and thinning of
the neuroretinal rim, and bayoneting
of blood vessels
• ‘ISNT’ rule is broken.
• Disc pallor and peripapillary atrophy.
• Retinal nerve fibre layer defects best
seen with red-free light

38. • A small, oval disk that is abnormallytilted
such that the long axis of the disk lies
obliquely is called a tilted disk.
• There is thinning and hypopigmentation of
the inferonasal retinal pigment epithelium
and choroid
• A severely tilted disk in which the diskappears
to be almost horizontally placed.
• Obliquity in the anteroposterior axis causes the
disk to look small as seen ‘end on’

39. HYPOPLASTIC DISC
• A congenital, unilateral or bilateral
• Small disc surrounded by a halo of pigmentary
change (double-ring sign)
• Blood vessels have normal calibre although they
are often tortuous
• Albinism and foveal hypoplasia
• Microphthalmos
• Aniridia
• Persistent hyaloid artery

40. LARGE DISC
HIGH MYOPIA
The appearance of the large disc may
be exaggerated by surrounding
chorioretinal atrophy
Coloboma
A unilateral or bilateral, congenital,
condition caused by failure of fusion of
the fetal fissure and contains a partial
inferior excavation that has a glistening
appearance

41. CONGENITAL PIT
• An isolated, usually unilateral, congenital,
condition that is associated with mild
enlargement of the optic nerve head.
• The pit is a round or oval depression of
variable size, most frequently involving the
temporal margin of the disc
COMBINED COLOBOMA AND PIT
Temporal pit and an inferior coloboma is an
extremely rare anomaly

42. MEGALOPAPILLA
• A very rare usually bilateral
congenital condition in which the disc
diameter is 2.1 mm or more.
• Large cup–disc ratio with a round or
horizontally oval cup without vertical
notching
• Reduced distance between the
temporal edge of the disc and the
foveola by approximately one disc
diameter.

43. DRAGGED’ DISC
• Retinopathy of prematurity
• A bilateral proliferative retinopathy that affects premature
infants of low birth weight who have been exposed to high
ambient oxygen concentrations.
• Temporal disc and macula dragging occurs in advanced
cicatricial disease
PERSISTENT HYPERPLASTIC PRIMARY VITREOUS
is seen as a membrane that fans out from the optic nerve
head extending anteriorly and is often associated with a fold
of the retina

44. MYELINATED NERVE FIBRES-
• Feathery white patches seen fanning
out from the disc
BERGMEISTER’SPAPILLA
• Small grayish wisp of tissue attached
to the disk surface is likely to be an
embryonic remnant of the hyaloid
system .

45. • MELANOCYTOMA OF THE OPTIC
NERVE HEAD appearing as a black
mass obscuring the disk

46. SPLINTER HEMORRHAGES
• uncontrolled glaucoma,
• anterior ischemic optic neuropathy,
• central retinal vein occlusion

47. • NEW VESSELS ON THE DISK (NVD)
appear as a network of fine vessels
arborising on the surface of the disk- the
rest of the retina shows features of the
underlying disease such as retinal
hemorrhages, exudates
• COLLATERALS ON THE OPTIC DISK
appear as small clumps of vessels that are
tortuous and curly

48. • FIBROVASCULAR PROLIFERATION on the
optic disk look like grayish white membranes
situated on the disk surface and growing into
the vitreous.
• Proliferating vessels are seen within the
membrane. These vessels can disappear as
the proliferation regresses leaving a sheet of
dense fibrous tissue.
• The rest of the fundus shows features of the
causative retinal pathology

49. LESIONS OF VITREOUS

50. SMALL VITROUS OPACITIES
• Dull fundal glow.
• Small white opacities with thread like
aggregates floating in a more liquified
vitreous are likely due to degenerated
vitreous.
• Due to aging.
• May occur early in myopia, inflammation ,
trauma, surgery, hereditary vitreoretinal
degeneration .

51. MEDIUM SIZE OPACITY
Weiss ring-PVD

52. Inflammatory exudates that form clumps and form snow ball like
opacities, often seen over inferior retina

53. Glittering yellow deposits of synchiasis
scintillans which fly around within the
liquefied vitreous. At rest, they settle down
only to be scattered like a ‘golden shower
‘with the next eye movement
Multiple small yellowish- white deposits
of Asteroid hyalosis suspended in a
formed vitreous gel and hence move
very little with movements of the eye

54. INTRAOCULAR FOREIGN BODY

55. INTRAVITREAL
CYSTICERSOSIS
A Translucent milky white cyst with
dense white spot within, floating
within in the vitreous cavity

56. Subhyloid or preretinal
haemorrhage.
Diffuse reddish haze of vitreous
cavity due to fresh vitreous
haemorrhage
LARGE VITROUS OPACITIES

57. A large clot of blood in fresh vitreous haemorrhage

58. Large clumps of tumour cells in vitreous in patient with retinoblastoma

59. Dirty yellow exudates in vitreous cavity in patient with
endophthalmitis

60. Vitreous membrane in proliferative diabetic retinopathy.

61. FUNDUS LESIONS 2

62. RED COLOURED LESIONS

63. • Feathery flame shaped
hemorrhages in RNFL
• In the retinal periphery
superficial retinal
hemorrhages are not flame-
shaped and look rounded .
• This is because in the
periphery the nerve fibers
are separated and form a
loose network.
SUPERFICIAL RETINAL HAEMORRHAGE

64. DEEP RETINAL HAEMORRHAGES
Punctate or rounded
hemorrhages, looking like
‘dots and blots’ are hemorrhages
in deeper layers of the retina

65. MICROANEURYSMS
Small round punctate microaneurysms
in temporal macula. There are clusters
of hard exudates around the
microaneurysms
On FFA microaneurysms appear as
hyperfluorescent punctate lesions
whereas the retinal hemorrhages
block the underlying fluorescence
(black arrows)

66. SUBRETINAL HAEMORRHAGE
Subretinal hemorrhage adjacent to a choroidal neovascular membrane. As
the hemorrhage is under the retina the retinal vessels can be seen
traversing over it

67. PRE RETINAL HAEMORRHAGE
Preretinal hemorrhages (arrow
head) and multiple ‘Roth’s spots
(arrows) in anemic retinopathy
Boat shaped subhyaloid
haemorrhage

68. SMALL WHITE FLUFFY LESIONS

69. COTTON WOOL EXUDATES
A cluster of cotton-wool spots below
the disk due to an inferior hemiretinal
vein occlusion
Multiple cotton-wool spots, retinal
hemorrhages,disk edema in the
posterior pole seen in hypertensive
retinopathy

70. MYELINATED NERVE FIBRES
• They can rarely resemble nerve fiber layer
infarcts in appearance but are usually
larger, often extend from the disk and
show striations of the nerve fibers.
• They can partially obscure blood vessels.
• They are not associated with other
microvascular anomalies that are usually
found with soft exudates.
• These lesions are seen from birth and are
present throughout life.
• They are usually innocuous but when
extensive can cause large field defects
corresponding to their shape

71. RETINITIS
A focus of active retinitis looks like a
fluffy white lesion as the involved
retina becomes thickened, elevated
and edematous
Patch of retinitis adjacent to an old scar
suggests the possibility of
toxoplasmosis.

72. Progressive cytomegalovirus retinitis with some retinal
hemorrhages and vasculitis

73. Early choroidal granulomas appear as lesions that are located
deeper in the retina or choroid, larger in size and whitish-
yellow in color

74. Multiple, round white spots, that are regularly spaced, in a
specific pattern due to recent laser application

75. MULTIPLE YELLOW LESIONS

76. HARD EXUDATE
Shiny, yellow globular clumps of hard exudates along with retinal
hemorrhages and microaneurysms in diabetic retinopathy

77. DRUSEN
Deposits are larger near the fovea and later
coalesce to form large clumps

78. FUNDUS FLAVIMACULATUS
In fundus flavimaculatus the yellowish flecks are in small curvilinear shapes
resembling commas or small fish occurring bilaterally and symmetrically in the
posterior pole up to the midperiphery. Patches of RPE atrophy at the macula
(Stargardt’s dystrophy) maybe present

79. • Densely packed multiple yellow white spots of fundus albipunctatus
in a patient complaining of night blindness. The arterioles are of
normal caliber

80. In retinitis punctata albescens the arterioles are attenuated and the fundus later
shows progressive degeneration with pigmentary changes.
• Also visual field and ERG changes are present in these patients along with
progressively failing night vision.
• in fundus albipunctatus the fundus features and the symptoms are stationary

81. CHOROIDAL METASTASIS
• Choroidal metastases seen as a yellow sharply demarcated elevated lesion.
These deposits are initially flat but increase in size and prominence over time.
They are typically deposited in and around the posterior pole

82. CHOROIDITIS
Patches of active choroiditis seen as moderate sized yellow lesions
with fuzzy margins. Several pigmented healed scars are also present

83. • Sudden onset of several yellow round to
oval lesions, along with significant vitritis
and anterior uveitis is suggestive of a group
of conditions called multifocal choroiditis
with panuveitis/recurrent multifocal
choroiditis
• Common in females in their thirties, it is
bilateral although frequently asymmetrical.
• The lesions range from 50-1000 microns in
size.
• Old pigmented lesions are commonly
present alongside new ones .
• As the inflammation subsides, the lesions
become more punched out and atrophic with
varying degrees of pigmentation.
• The disease tends to be chronic with
recurrent bouts of inflammation.
• Mild edema of disc, CNVM

84. • Similar lesions seen in young myopic patients without evidence of vitreous
inflammation may be a rare variant called punctate inner choroidopathy (PIC). The
lesions are deeper and punched out.
• Multiple cream colored large ‘plaque like’ flat lesions, occurring bilaterally, in a
young-middle-aged patient presenting with sudden onset of visual blurring or
floaters and photopsia is likely to be lesions of acute posterior multifocal placoid
pigment epitheliopathy (APMPPE)

85. PIC

86. APMPPE

87. Bilateral lesions of active APMPPE with multiple foci of plaque like epithelitis and
hyperemic disk edema

88. • Bilateral occurrence of small multiple round to
oval hypopigmented lesions in slightly older
women
• The cream colored lesions are located deep in the
choroid and the larger choroidal vessels can be
seen to traverse over them.
• They begin in the peripapillary area and
disseminate outwards in the pattern of a spray of
pellets from a shotgun.
• This appearance is enhanced by the fact that the
shots tend to be oval with the long axis
perpendicular to the optic nerve.
• one-fourth disk diameter in size.
• The arrangement of the lesions is often
symmetrical in the two eyes.
• The margins can be well defined or slightly fuzzy
but there is usually no associated pigmentation or
changes in the overlying retina.
• As the lesions resolve they flatten out or even
disappear but usually leave small scars
BIRD SHOT CHORIORETINOPATHY

89. Birdshot chorioretinopathy

90. MEWDS

91. • Acute, unilateral appearance of small multiple white dots, 100-200 microns in size
seen in young women is likely to be part of multiple evanescent white-dot syndrome
(MEWDS).
• The lesions are at the level of the RPE and appear at the posterior pole extending to
the mid-periphery.
• They are more concentrated in the perifoveal region though they usually spare
the fovea.
• Characteristically the macula shows a granular appearance due to the presence of
small white dots.
• Blurring of the margins of the optic nerve head may be present
• an enlarged blind spot on visual field testing.
• The lesions resolve over a couple of months leaving fine RPE alterations and fairly
good vision.

92. CHOROIDAL COLOBOMA
A choroidal coloboma appears as a well defined oval defect in the choroid usually in the
inferonasal fundus, that allows the white sclera to show. Atrophic retinal vessels can be seen
traversing over the colobomatous area contrasted against the luminous sclera

93. DEGENERATIVE MYOPIA
Geographical patches of chorioretinal atrophy exposing the underlying sclera in severe
degenerative myopia.

94. Well circumscribed hypopigmented areas of chorioretinal atrophy in the mid-peripheral
retina with posterior scalloped edges is typical of gyrate atrophy. There is associated
pigmentation and the lesions gradually coalesce spreading anteriorly and posteriorly
GYRATE ATROPHY

95. CHOROIDAL RUPTURE
Multiple choroidal ruptures secondary to blunt trauma, seen as thin crescent-
shaped scars, concentric to the disc temporally .

96. Photocoagulation scars appear as multiple,
regularly arranged, circular scars scattered in
a pattern in a part or all over the fundus
sparing the posterior pole
Multiple scars of variable size scattered
randomly anywhere in the retina
following multifocal choroiditis

97. White, cobweb like subretinal fibrosis secondary to long standing choroiditis

98. Acute retinal necrosis
An infection caused by the varicella-zoster or herpes simplex virus which is often bilateral
(A) Peripheral infiltrates with well-defined borders – there is vitreous haze, and a few
perivascular haemorrhages
(B) advanced disease reaching the posterior pole
(C) full-thickness retinal necrosis

99. Progressive outer retinal necrosis
• An infection caused by varicella-zoster virus which is often bilateral and
predominantly affects patients with AIDS.
• Multifocal homogeneous yellow–white deep retinal infiltrates. The macula may be involved
at an early stage
• Established/middle. The signs typically spread rapidly around the retina, with very extensive
full-thickness necrosis
• Late. Scarring is plaque-like and characterized as ‘cracked mud’. Rhegmatogenous retinal
detachment (RRD) is very common, as is optic atrophy.

100. Bilateral diffuse choroiditis resulting in retinal edema, serous retinal detachment and
pigment epithelial detachment in Vogt-Koyanagi-Harada disease
VKH

101. FFA showing multiple pinpoint leaks causing extensive areas of pooling of dye
beneath the neurosensory retina and the pigment epithelium detachment

102. LARGE AREA OF GREYISH
WHITE OPALSCENCE

103. CRAO
Two patients that are mirror images of each other—one with central retinal artery
occlusion with cilioretinal sparing and the other with cilioretinal artery occlusion

104. Emboli at the bifurcation of the retinal arteriole on the optic nerve head causing an
inferior branch arteriolar occlusion. There is another embolus which has lodged
further along the arteriole to lodge at a distal arteriolar bifurcation

105. PIGMENTED LESIONS

106. A welldefined, solitary gray-black flat lesion
surrounded by a hypopigmented halo is likely
to be a patch of congenital hypertrophy of
the retinal pigment epithelium (CHRPE). The
size of these lesions can vary from small to
several disk diameters
CHRPE
Grouped pigmentation (bear tracks) are
seen as clusters of small pigmented
lesions arranged in patterns resembling
animal tracks (‘bear tracks’)

107. Dark pigmented lesion on the optic nerve head
(Melanocytoma)
A choroidal nevus present
inferotemporal to the disk,seen as an ill-
defined, deeply located, pigmented
lesion. The margins of the nevus are
feathery

108. An area of subretinal hemorrhage can
appear as a dark blackish-maroon lesion
of the fundus mimicking pigmented
lesions. The size can vary from small to
large and can be quite elevated
Dark subretinal blood with areas of
white altered blood at the macula

109. A well defined area of blotchy pigmentation involving a sector or a large
segment of the retina with well defined convex margins could also be an area of
spontaneous resolution of retinal detachment. The margins are delineated by a
border of granular pigmentation called demarcation lines or water marks’. The
causative break is often found to be surrounded by relatively heavy
pigmentation.

110. classic ‘bone corpuscle’ shaped
pigmentation in retinitis pigmentosa
Attenuation of the retinal vessels along with
a fine mottling of the RPE in the mid-
peripheral retina but no discernible
pigment clumping referred to as retinitis
pigmentosa sine pigmento

111. Scattered white spots deep in the retina with arteriolar attenuation and an
atrophic macula in retinitis punctata albescens

112. Pigment clumping seen in the posterior pole, bilaterally, with minimal pigment
disturbance in the peripheral retina in inverse RP or pericentral retinitis pigmentosa.
The arterioles are attenuated and the disk shows a waxy pallor. The features are
present bilaterally

113. A diffuse dark red discoloration of the posterior pole where the normal
choroidal vascular pattern due to a diffuse choroidal hemangioma

114. In Oguchi’s disease the fundi have a striking grayish pink metallic color. The retinal vessels
including the finer vessels stand out contrasted against this background and it is difficult
to differentiate the arteries from the veins. The choroidal vessels are less visible

115. Fundi of patient with Oguchi’s disease after staying in a dark room for
one hour. The appearance has changed dramatically and the fundi look
normal

116. HYPOPIGMENTED FUNDUS

117. A total lack of chorioretinal pigment in albinism resulting in a completely
hypopigmented fundus. All levels of the choroidal vessels are visible.
The fovea is indistinct.

118. Almost complete atrophy of the choroid with
only small patches of intact choroid, seen in
an elderly male is likely to be the end stages
of choroideremia
FFA highlights the small island of normal
choroidal tissue remaining at the macula

119. End-stage retinopathy with extensive areas of both pigment clumping and
depigmentation

120. Diffusely hypopigmented fundus (sunset glow) in a patient recovered from
Harada’s disease

121. FUNDUS LESION 3
ABNORMALITIES WITH RETINAL VASCULATURE

122. Normally at an AV crossing the venule
crosses the arteriole obliquely but with
arteriolar sclerosis the venule is seen to be
deflected in such a manner that it crosses
the arteriole at right angles (Salus sign)
Compression of the vein (arrow) results
in an apparent impediment to the flow
of blood in the vein across the crossing
resulting in ‘banking’ and swelling of the
peripheral part of the vein (Gunn’s sign)

123. All caliber changes occurring at arteriovenous
crossings are collectively referred to as ‘AV
nicking’ seen here at multiple sites (arrows)
Grade 4 hypertensive retinopathy with
disc edema,retinal hemorrhages, soft
exudates and vessel caliber changes

124. Dilated veins in papillitis seen along with disk edema
and peripapillary soft exudates

125. Venous reduplication (S shaped looping or winding of vessels) is a sign of
increasing retinal ischemia as seen in severe NPDR along with other signs
such as soft exudates and retinal hemorrhages in multiple quadrants

126. Sheathing of a vessel with an adjacent
patch of retinal hemorrhage due to active
vasculitis
A sheathed occluded vessel as a result of
old vasculitis

127. Resolving vasculitis with decreasing perivascular infiltration,
retinal hemorrhages and retinal edema

128. New vessels initially look like small red bulbs
that grow to spread out as multiple radial
vessels like a fan
Radial arrangement of new vessels also
called ‘sea fan’ neovascularization

129. Vasculitis in Eales’ disease is often associated with
patches of chorioretinal atrophy

130. • Frosted branch angiitis is a severe form of vasculitis that affects almost the entire vasculature.
• The profuse perivascular infiltration causes the blood vessels to look like frosted branches

131. Retinal edema, crystalline deposits and dilated ectatic vessels seen in
the temporal parafoveal region suggestive of idiopathic macular
telangiectasias (formally referred to as idiopathic juxtafoveal
telangiectasias/parafoveal telangiectasias)

132. Extensive malformations of the retinal capillaries
with subretinal and intraretinal exudates in Coats’
disease

133. Presence of a red vascular growth with a pair
of markedly dilated feeder vessels, i.e. an
arteriole and venule extending from the mass
for a variable distance is highly suggestive of
peripheral capillary hemangioma
A vascular malformation that looks like a
cluster of dark grapes (saccular aneurysms)
filled with blood occupying one to two disk
diameters in size is the unmistakable
appearance of a retinal cavernous
hemangioma

134. A pair of dilated and tortuous vessels
emerging from a tumor is likely to be the
efferent and afferent vessels of a
peripheral capillary hemangioma
Highly dilated and tortuous vessels,
secondary to peripheral arteriovenous
communications in Wyburn-Mason
syndrome

135. A network of arborising or broom like vessels
lying superficially on the disk or on the retinal
surface is suggestive of neovascularisation
Neovascularization is initially very subtle
and visible only with high magnification

136. NVE form at the junction of ischemic and non-ischemic retina

137. Retinal edema, crystalline deposits and dilated ectatic vessels seen in the temporal
parafoveal region suggestive of idiopathic macular telangiectasias (formally
referred to as idiopathic juxtafoveal telangiectasias/parafoveal telangiectasias)

138. Extensive malformations of the retinal capillaries with subretinal
and intraretinal exudates in Coats’ disease

139. Retinal macroaneurysm seen along the
inferotemporal arteriole surrounded by
retinal edema and deposition of hard
exudates
The macroaneurysm fills up with dye on FFA
surrounded by a thin rim of blocked
fluorescence due to hemorrhage

140. Avascular retina of a premature neonate where
the vessels are still to reach the retinal periphery
which looks pale
Stage 1 retinopathy of prematurity: Abrupt
cessation of retinal vascularization in a premature
neonate creating a ‘demarcation line’ between
the vascular and avascular retina

141. Stage 2 retinopathy of prematurity: The
demarcation line acquires a three-
dimensional element forming a well defined
‘ridge’ between the vascular and avascular
retina
Stage 3 retinopathy of prematurity: Small tufts of
bright red blood vessels grow behind the ridge.
Later they extend into the vitreous and proliferate
as if trying to grow towards the lens. This is
referred to as ‘extraretinal proliferation’

142. Stage 4 retinopathy of prematurity: A
sub-total retinal involvement with macula
spared
Stage 5 retinopathy of prematurity: Total retinal
detachment assuming a partial or closed funnel
configuration. The detached retina and proliferative
tissue in the vitreous give a white appearance to
the pupil (leukocoria)

143. Plus disease is characterized by engorgement and
tortuosity of the blood vessels in the retina. Additional
findings include retinal hemorrhages, poorly dilating pupil,
abnormal dilated vessels on the iris and hazy media

144. Bilateral presence of extensive hemorrhages in several layers of the retina along with
tortuous and dilated veins and white centered Roth’s spots in anemic retinopathy

145. In patients with hyperviscosity syndromes the
hemorrhages are dense and seen adjacent to
the blood vessels
White centered retinal hemorrhages
called Roth’s spots, though thought to be
characteristic of leukemic retinopathy can
be found in many blood dyscrasias

146. Retinal hemorrhages and a partially
absorbed premacular hemorrhage in a
patient with Terson’s syndrome
Multiple cotton-wool spots and ischemic white
retinal patches seen in the central fundus in
Putscher’s retinopathy

147. Large premacular hemorrhage as a
result of Valsalva’s retinopathy
Multiple retinal hemorrhages and retinal
infarcts in HIV retinopathy

148. Central retinal vein occlusion is often
associated with significant macular edema
and deposits of hard exudates
Sheathed retinal veins, macular scar
and laser marks in an old central
retinal vein occlusion

149. Dense retinal hemorrhages limited to one
quadrant of the retina are suggestive of
branch retinal vein occlusion
Dense retinal hemorrhages involving the
superior hemisphere due to hemicentral
retinal vein occlusion

150. A microaneurysm and a retinal
haemorrhage classified as mild NPDR
without CSME
Presence of microaneurysms, retinal
hemorrhages, hard exudates in the posterior
pole but not within 500 microns of the center of
the fovea classified as moderate NPDR without
CSME

151. Multiple retinal hemorrhages and soft
exudates in all quadrants and venous
reduplication (arrow) classified as Very
Severe NPDR with CSME
New vessels elsewhere less than half disk
diameter and no vitreous hemorrhage classified
as non-high risk PDR

152. Neovascularization of the optic disk occupying
more than half the disk area classified as high
risk PDR
Neovascularization elsewhere with
subhyaloid hemorrhage classified as high
risk PDR

153. MACULA

154. Appearance of a normal macula which
has a central dark area with a small
circular yellow light reflex in the centre
FFA of normal macula in which the central
foveal avascular zone appears dark and is
surrounded by a wreath of end
capillaries. All larger vessels terminate
before the FAZ

155. Glassy appearance of an edematous
macula in a patient with small branch
vein occlusion. There are several retinal
hemorrhages and the edematous area is
bordered by deposits of hard exudates
Grayish looking thickened macula (except
the central cherry red spot) due to
ischemic macular edema in a patient with
central retinal artery occlusion—the
patient also had advanced glaucomatous
cupping of the optic nerve

156. Multiple, small, ‘red colored’ cysts arranged in a
rosette around the fovea is the characteristic
appearance of cystoid macular edema

157. A star shaped radial arrangement of linear
yellow hard exudates centered on the
fovea called a ‘macular star’ seen in a
patient with neuroretinitis
A complete macular star along with
retinal hemorrhages, soft exudates and
disk edema in Grade 4 hypertensive
retinopathy

158. A well circumscribed round to oval area of
neurosensory elevation centered at the
fovea in central serous chorioretinopathy
(CSCR)
An area of neurosensory detachment
associated with a small optic disk pit
(arrow) in the temporal edge of the disk

159. A small, well defined area of retinal elevation
looking like an ‘orange blister’ is the characteristic
appearance of a pigment epithelial detachment
A larger pigment epithelium detachment
with multiple drusen in age related
macular degeneration

160. Thickened macula along with
subretinal hemorrhage due to an
underlying choroidal neovascular
membrane
Dirty gray subretinal membrane gives the
macula a thickened appearance. In the absence
of subretinal hemorrhage or exudates, a subtle
membrane may not be noticed

161. Wrinkles (fine retinal folds) across the
macula in a patient with a shallow
retinal detachment
Folds in the retina due to macular edema

162. A better defined ERM causing
tortuosity of the blood vessels and ILM
folds
A contracting epiretinal membrane can cause
the clivus to be drawn towards the center
deepening the foveal depression. This causes
the fovea to look darker red and when seen in
contrast to the whitish membrane it can falsely
look like a macular hole, actually a pseudohole

163. Bilaterally present delicate pleats arranged radially around the fovea of a young male
are likely to be seen in X-linked juvenile retinoschisis

164. Fluid that seeps in through a full thickness
macular hole appears as a cuff of subretinal
fluid around the hole
Subtle thinning at the fovea in a
patient with a lamellar macular hole

165. Macular thinning can be mistaken for a
macular hole

166. occlusion of a cilioretinal arteriole causing a
‘cherry red spot’ as the ischemic retina
extends to the fovea
Reddish perfused patch in the papillomacular
area supplied by a cilioretinal artery in a
patient with central retinal artery occlusion

167. Cherry red spot secondary to traumatic macular edema (Berlin’s edema). The trauma
causes diffuse gray white opacification of the retina and often involves large areas . This
type of opacification is usually at a deeper level of the retina and is better defined and
more glistening than the cloudy edema seen with vascular occlusion

168. Bulls eye maculopathy seen in a patient with
advanced cone dystrophy. A pigmented area in
the center is surrounded by a complete or
incomplete parafoveal ring of depigmentation
Bulls eye maculopathy secondary to chloroquine
toxicity—early changes include irregularity (mild
stippling or mottling) in the macular pigmentation
and blunting of the foveal reflex. Later there is
central irregular pigmentation surrounded bya
concentric zone of hypopigmentation

169. Stargardt’s dystrophy associated with
fundus flavimaculatus Early Stargardts disease

170. Patch of pigmentation just temporal to the fovea bilaterally, seen in late stages of
Idiopathic macular telangiectasias (also called parafoveal or juxtafoveal telangiectasias)

171. Angioid streaks (breaks in the Bruch’s membrane) seenas dark red lines
radiating from the optic disk in all directions that lie deep in the retina
and resemble cracks

172. Myopic maculopathy—rounded, sharply
demarcated,yellowish white areas with varying
amounts of pigmentation seen in a myopic eye
are focal areas of chorioretinal atrophy
allowing the sclera to show through
Criss-crossing yellow colored choroidal
vessels at the macula due to choroidal
sclerosis. A ‘laquer crack’ seen as a fine
linear reddish line is also present

173. Sharply demarcated, round to oval area of depigmentation, showing the underlying
choroidal vessels is an area of geographic atrophy

174. A sharply demarcated hypopigmented spot as a result of
exposure to ultraviolet rays called photic retinopathy

175. Areas of linear or serpentine shaped
mottling at or around the macula in healed
geographic helicoid peripapillary
choroidopathy (GHPC)
Polypoidal or serpentine shaped fuzzy, grayish
yellow lesions at the macula in active macular
GHPC (Geographic Helicoid Peripapillary
Choroidopathy)

176. Scar consisting mainly of white retinal gliosis
with no pigmentation
Scar consisting of subretinal gliosis,
pigmentation and chorioretinal anastamoses
secondary to a choroidal neovascular
membrane

177. Characteristic punched out macular scar
of congenital toxoplasmosis
Multiple linear curved scars concentric to the
disk margin are a result of choroidal tears

178. Multiple yellow, pale or white punctate round
deposits of varying size at the posterior pole
(drusen)
Small (less than 63 microns) flat
drusen with well defined margins are
called hard drusen

179. Large drusen (greater than 125 microns) with
less distinct, fuzzy margins that are elevated
or dome shaped are called soft drusen. They
tend to become confluent adopting various
shapes as they coalesce
Still larger confluent, soft drusen (500 microns)
may have a pool of serous fluid around them
and are referred to as drusenoid PEDs
(Drusenoid pigment epithelial defects)

180. Regressing drusen are whiter and refractile
in appearance. Their margins become
irregular and areas of calcification start to
appear. Associated RPE atrophy becomes
prominent.
Drusen in dry age related macular
degeneration in which they are associated
with areas of hyperpigmentation and RPE
changes

181. Subretinal dirty gray membranous lesion
due to a choroidal neovascular membrane
Often a CNVM is associated with
adjacent subretinal hemorrhage

182. A partially scarred CNVM with a ring of
subretinal hard exudates
CNVM along with drusen in age related
macular degeneration

183. CNVM seen adjacent to an old scars Myopic CNVM

184. Bilateral yellow colored cyst like lesion under the macula is the unmistakable
appearance of vitelliform macular dystrophy

185. A subretinal cystic lesion that is translucent white in color along with a
characteristic white dot within the lesion (scolex) is the characteristic
appearance of a subretinal cysticercus

186. Bilateral glistening yellow crystals scattered in the retina along
with atrophy of the RPE and choroid is suggestive of Bietti’s
crystalline dystrophy

187. Drug related crystalline deposits in the
paramacular region

188. Polyps of choroidal vasculature in idiopathic polypoidal choroidal vasculopathy
(IPCV) can result in multiple areas of serous and hemorrhagic detachments of the
RPE and the neurosensory retina in the posterior pole along with altered heme

189. PERIPHERAL RETINAL
DEGENERATION

190. LATTICE DEGENERATION
• 8 % population, moderate myopes
• Linear, spindle/cigar shaped lesions parallel to the ora made up of yellow spots
with white lines of sclerotic vessels crisscrossing are likely to be areas of typical
lattice palisade degeneration or dystrophy.
• Radial or circumferential .
• Radial lie along the blood vessel, posteriorly – Stickler and Wagner syndrome

191. • Pathology. There is discontinuity of the internal limiting membrane with variable
atrophy of the underlying NSR. The vitreous overlying an area of lattice is
synchytic but the vitreous attachments around the margins are exaggerated
• Complications
 Tears
 Atrophic holes

192. • Management.
Asymptomatic areas of lattice are generally not treated prophylactically, even if
retinal breaks are seen, unless particular risk factors are present, perhaps including
RD in the fellow eye;
Treatment of the fellow eye when extensive lattice (more than 6 clock hours) is
present, or there is high myopia, or higher risk of detachment.

193. A pigmented lattice with
prominent sclerosed vessels
running across
A radial lattices running along a blood
vessels and relatively posterior in
location

194. Multiple rows of lattices A lattice harboring a retinal hole

195. A large tear present at the edge of a pigmented lattice. Such tears can
sometimes unzip the entire lattice resulting in a giant tear

196. Snail-track degeneration
• Snailtrack degeneration is characterized by sharply demarcated bands of tightly
packed ‘snowflakes’ that give the peripheral retina a white frost-like appearance.
• The vitreous is usually liquefied and retinal holes are common.

197. • Retinal tears are retinal breaks that occur secondary to retinal traction. The traction
creates a ‘v’ shaped retinal flap which may be elevated in the presence of continuing
traction. Sometimes the flap may tear off completely forming an operculum floating
in the vitreous.
• Inferotemporal quadrant
• U-tears (horseshoe) consist of a flap, its apex pulled anteriorly by the
vitreous, the base remaining attached to the retina
RETINAL BREAK

198. Retinal holes :
• Retinal breaks secondary to trophic changes occur in the form of retinal holes. They
have no tractional element in their pathogenesis. They are usually round in shape
with smooth edges. There is no flap or operculum and little pigmentation.
• They can occur in isolation or within lattices. Retinal holes are found in 0.2-0.4% of
adult eyes.
• They can be unilateral and have no predilection for any particular quadrant.

199. A retinal hole appears as a well
demarcated, round, bright red colored
lesion bordered by grayish, slightly
raised margins
The base appears bright red as the choroid
shines through – as seen in this large hole i

200. Horseshoe retinal tear appears as a
red colored ‘V’ shaped break in the
retina
Retinal hole with surrounding
subretinal fluid

201. Difficult to see large horseshoe tear that can easily be missed on cursory
examination. Such tears are better visualized by indentation.

202. GIANT RETINAL TEAR
• Retinal tears greater than 90 degrees circumference are called giant retinal
tears.
• They occur near the ora and a thin piece of retina can be seen between the
posterior edge of the break and the ora differentiating it from a dialysis.
• The flap of the tear hangs back and tends to roll inwards or scroll up and is
prone to develop PVR changes.

203. • Twenty percent of GRTs result from blunt trauma. The force of trauma is
transmitted to the posterior margin of the vitreous base which may also get
avulsed and hang like a thread or clothes line. Sometimes direct trauma to the
temporal side of the globe may cause a giant tear.

204. A giant retinal tear with retinal detachment and a ‘rolled out’edge

205. The edge of an avulsed vitreous base is seen hanging like a rope in the vitreous
cavity

206. • Disinsertion of the retina from the ora results in a retinal dialysis.
• In a retinal dialysis there is no tendency for the flap to roll up.
• Dialyses commonly occur after blunt trauma or are spontaneous.
• Traumatic dialyses most commonly occur in the superonasal and inferotemporal
quadrants.
RETINAL DIALYSIS

207. • Spontaneous retinal dialyses are often asymptomatic and bilateral. They
occur in young males in the second to third decade. There may be a genetic
predisposition.
• The detachment associated with retinal dialyses are usually slowly
progressive as the patients are usually young and the vitreous is well
formed.
• The detachment shows signs of chronicity such as demarcation lines and
retinal cysts.
• The patients are not symptomatic till the macula is involved which takes
some time.

208. In a retinal dialysis the retina appears to be disinserted from the ora and there is no
retinal tissue between the break and the ora

209. • Rows of multiple small cysts arranged as a band running along the ora is likely to
be peripheral microcystoid degeneration.
• These are the most common degenerations of the peripheral retina and are
seen in all adult eyes. The cysts look like tiny, often red colored vesicles on a
grayish white background, which makes the retina, look thickened and opaque

210. A cystic retinal tuft (CRT)
• Also known as a granular patch or retinal rosette
• congenital abnormality consisting of a small, round or oval, discrete elevated
whitish lesion
• typically in the equatorial or peripheral retina, more commonly temporally ;
there may be associated pigmentation at its base.
• It is comprised principally of glial tissue; strong vitreoretinal adhesion is
commonly present and both small round holes and horseshoe tears can occur.
• though the risk of RD in a given eye with CRT is probably well under 1%.

211. • They sometimes give a nodular appearance due to altered retinal and glial cells .
• Often the base of the lesion is whitish, although occasionally there may be some
retinal pigment epithelial hypertrophy at the base.
• Vitreous strands are attached to the tip and avulsion of the tip by these strands
can cause a retinal tear to occur

212. A ‘white without pressure’ area appears as a well defined region of opalescent white
retina in the periphery (like the retina does when indented) tears, occasionally develop
along the posterior border of white without pressure
White without pressure

213. • Sharply demarcated, oval, white patches of
chorioretinal atrophy called Paving stone
degeneration scattered in the peripheral
retina.
• Some of these lesions can coalesce forming
larger ones with convex scalloped margins.
• As the retinal and choroidal layers are
atrophic the underlying white sclera shines
through with mild pigmentation of the
margins.
Pavement stone degeneration

214. Snowflake degeneration appears as tightly packed small white specks looking like
snowflakes scattered in the peripheral retina
SNOW FLAKE DEGENERATION

215. • Degenerative retinoschisis (RS) is present in about 5% of the population over the age
of 20 years
• hypermetropia.
• RS is believed to develop from microcystoid degeneration by a process of gradual
coalescence of degenerative cavities , resulting in separation or splitting of the NSR
into inner and outer layers , with severing of neurones and complete loss of visual
function in the affected area.
• In typical retinoschisis the split occurs in the outer plexiform layer, and in the less
common reticular retinoschisis at the level of the nerve fibre layer.
Retinoschisis :

216. • Early retinoschisis usually involves the extreme inferotemporal periphery of
both fundi, appearing as an exaggeration of microcystoid degeneration with a
smooth immobile dome-shaped elevation of the retina.
• The elevation is convex, smooth, thin and relatively immobile , unlike the
opaque and corrugated appearance of a rhegmatogenous RD.

217. • The thin inner leaf of the schisis cavity may be mistaken, on cursory
examination, for an atrophic long-standing rhegmatogenous RD but
demarcation lines and secondary cysts in the inner leaf are absent.
• The lesion may progress circumferentially until it has involved the entire
periphery. The typical form usually remains anterior to the equator; the
reticular type is more likely to spread posteriorly.

218. Gray dome like elevation of the retina in the peripheral retina commonly in the
inferotemporal quadrant and bilateral is likely to be peripheral retinoschisis

219. • Diffuse choroidal/chorioretinal
atrophy in myopia is characterized
by diffuse or circumscribed
choroidal depigmentation,
commonly associated with thinning
of the overlying retina
• occurs typically in the posterior
pole and equatorial area of highly
myopic eyes.
• Retinal holes developing in the
atrophic retina may occasionally lead
to RD.
• Because of lack of contrast, small
holes may be very difficult to visualize.
CHORIORETINAL ATROPHY

220. Pars plana cysts appear as small translucent cysts in the pars plana region
PARS PLANA CYST

221. RETICULAR (HONEYCOMB) DEGENERATION:
It is an age-related change consisting of a fine network of perivascular
pigmentation that sometimes extends posterior to the
equator