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Diagnosis and Management of Red Fundus Lesions

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Diagnosis and Management of Red Fundus Lesions Continuing education CET Diagnosis and management of red fundus lesions Sam Khandhadia and Richard Newsom discuss common red fundus lesions, how to identify them and the most appropriate clinical management. Module C8569, two general CET points suitable for optometrists and dispensing opticians ed fundus lesions are a common cause for anxiety, as they sometimes herald blind- ing eye disease. However, most are relatively benign Rand require little or no active ophthal- mic management. Separating the severe from the benign takes time, experience, and courage of conviction. This article gives pointers on which types of red fundus lesions can be monitored in the primary care setting and which should Figure 1 More prominent subhyaloid Figure 2 Proliferative diabetic retinopathy precipitate referral to the Hospital Eye haemorrhage in front of the macula. Note the with a crescent-shaped sub-hyaloid Service (HES). crescent-shape (solid black arrow), and haemorrhage inferiorly (solid black arrow). This article examines the classic red- horizontal blood level (dashed black arrows) New vessels are present at the optic disc coloured fundus lesions in order of (dashed black arrows). Also note the peripheral their location, starting in the vitreous, laser scars (from previous pan-retinal working backwards to the choroid, and photocoagulation) ending with the optic disc. Pointers will be given on how to identify each lesion type. The pathogenesis, likely causes incurred, so a relatively short macular ● Ruptured retinal artery (common and rare), and suggested examination is recommended. Using macroaneurysm management for each lesion type will the red-free filter on the slit lamp will ● Trauma also be discussed. This article was also help to highlight any abnormal red ● Valsalva retinopathy (enquire written with information referenced lesions. about a previous history of excess from several ophthalmology textbooks, exertion, for example weight lifting, and readers are encouraged to refer to Lesions anterior to the retina blowing up balloons, excessive these for further information.1-5 coughing/straining) Pre-retinal/Sub-hyaloid haemorrhage ● Terson’s syndrome (due to increased Examination of red fundus (Figures 1 and 2) intracranial pressure). lesion The term pre-retinal/sub-hyaloid refers It is best to examine the fundus using to the potential space between the retina A patient with a pre-retinal/sub- stereo-biomicroscopy and a dilated pupil. and the posterior vitreous face, where hyaloid haemorrhage should be referred The authors’ choice is a non-contact blood can collect. Pre-retinal haemor- immediately to the HES. Volk lens – a ‘Superfield’/‘Widefield’ rhage appears as a red, round-shaped lens for extramacular lesions and a lesion, lying anterior to the retina and Neovascularisation (new vessels) 66D/‘High Mag’ lens for the macula. obscuring the retinal vessels. With (Figures 3 and 4) Use of biomicroscopy is essential for time, red blood cells settle and form a New vessels can arise from the retina or accurate assessment as it gives a stere- fluid level, producing the characteris- from the optic disc. Retinal new vessels oscopic 3D view of the retina, essential tic crescent, or ‘boat-shape’ appearance usually begin from veins as a collection to gauge the depth of the lesion within (Figure 1). Occasionally the blood in this of multiple fine vessels on the surface the retina. space may break through the hyaloid of the retina. Initially these vessels are A reasonable level of illumination into the vitreous itself, causing vitreous flat. With time, these new vessels grow should be used, since using the lowest haemorrhage. towards ischaemic retina, and become level on the slit lamp further reduces The most common cause is bleeding elevated, extending into the vitreous. the ability to detect retinal thicken- from retinal/disc neovascularisation. These new vessels often form an intri- ing. Many patients find the full beam In turn, the most common causes of cate network which resembles a carriage uncomfortable, so a smaller slit – 3mm neovascularisation are proliferative wheel – the vessels radiate spoke-like in height and 1mm in width – can be diabetic retinopathy (Figure 2) and from a point on the retina, and are joined used. Care must be taken when assess- ischaemic retinal vein occlusion. by a circumferential vessel. Peripheral ing the macula that photic damage is not Other less common causes include: retinal neovascularisation often takes 34 | Optician | 29.02.08 opticianonline.net Continuing education CET Figure 3 Retinal new vessels (solid black Figure 4 Retinal new vessels (solid black Figure 5 A fibrosed retinal new vessel (solid arrow) in proliferative diabetic retinopathy arrows) in SLE black arrow) in proliferative diabetic retinopathy. Note also the fibrosed new vessel from the optic disc (dashed black arrow) Figure 6 A macular pseudohole (solid black Figure 7 Single red dot, probably a Figure 8 Red dots (solid black arrows) and arrow) within an epiretinal membrane (note microaneurysm, in a patient with diabetes and blots (dashed black arrow) in background surrounding wrinkled appearance of retina) normal vision. No signs of leakage. This is diabetic retinopathy. Red dots are more likely graded as M0, or not requiring referral, to be microaneurysms when surrounded by on a ‘seafan’ appearance. according to the UK National Screening hard exudates at the macula. Since there are New vessels lack a basement Committee multiple hard exudates at the macula, this membrane and are prone to bleed, patient is graded as M1 according to the UK especially if the blood pressure is elevated. NSC, and should be referred Sub-hyaloid or vitreous haemorrhage can occur, adversely affecting the vision. of the blocked vein. Signs of ischae- Patients with new vessels require There may be greyish fibrous tissue mia include an RAPD, darker blotchy urgent HES referral for retinal laser within the new vessels (fibrovascular haemorrhages and cotton-wool spots treatment. neovascularisation). This fibrous tissue – see below. The vision may be reduced, Premature babies requiring oxygen can contract, pulling the retina away, with a visual field defect. therapy can develop a condition called causing a traction retinal detachment. retinopathy of prematurity, which may This can cause significant visual loss if Rarer causes include: need laser treatment. occurring at the macula ● Sickle-cell retinopathy: The patient New retinal vessels develop in ischae- is usually of Afro Carribean or Regressing new vessels (Figure 5) mic retinal conditions, where there is Mediterranean descent, and has known New vessels can regress, usually follow- reduced blood supply to the retina. This sickle-cell anaemia ing treatment, but can also do so sponta- produces a host of growth factors, vascu- ● Previous retinal artery occlusion: neously. The intricate carriage-wheel lar endothelial growth factor (VEGF), Associated features include narrowing appearance will gradually regress, to which can encourage compensatory of the retinal artery, an RAPD, and a be replaced by fibrous tissue, until a new vessel growth. history of sudden reduction of vision greyish fibrous stump remains. Common causes include: ● Ocular ischaemic syndrome: ● Proliferative diabetic retinopathy Associated features include dilated Pseudohole (Figure 6) (Figure 3): New vessels are associ- veins (not tortuous, as in retinal vein A pseudohole is a hole in a membrane ated with features of preproliferative occlusion), narrowed retinal arteries, growing on the surface of the retina, diabetic retinopathy, which include and cotton- wool spots. The vision may and not within the retina itself. This dot/blot/flame haemorrhages, intra- be reduced, associated with pain epiretinal membrane is also called retinal microvascular abnormalities ● Radiation retinopathy: There will preretinal macular fibrosis, macular (IRMA), venous changes including be a previous history of radiotherapy pucker or cellophane maculopathy. beading, tortuosity and looping. The around orbit Look for a sheen over the macula, patient usually has a known diagnosis ● Retinal vasculitis: There will be white wrinkling of the retina, and straighten- of diabetes, but occasionally this may inflammatory areas lining the retinal ing of the surrounding retinal vessels. be undiagnosed vessel walls, associated with uveitis. The The pseudohole appears redder than the ● Ischaemic retinal vein occlusion: patient may already have a diagnosis of surrounding retina, since there is less Features of retinal vein occlusion a systemic inflammatory condition, for obscuration of the underlying retina at include a dilated tortuous retinal vein, example systemic lupus erythematosus this point by the epiretinal membrane. and haemorrhages in the distribution (SLE) (Figure 4). An epiretinal membrane is often 36 | Optician | 29.02.08 opticianonline.net CET Continuing education Figure 9 A patient with diabetic maculopathy. Figure 10 A myopic patient with a single red Figure 11 Preproliferative diabetic There are clusters of microaneurysms (solid dot at the centre of the fovea – a Fuch’s spot. retinopathy. There are large darker blotchy black arrows) with secondary hard exudates Note the peripapillary atrophy, which is haemorrhages (solid black arrows). In addition (dashed black arrow) resulting from leakage. associated with high myopia there are dot and smaller blot haemorrhages, This is potentially more sight-threatening. with hard exudates Again the patient is graded as M1 and should be
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