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Home , Black Arrow, Fundus (eye), Hypertensive retinopathy, Retinal haemorrhage

Continuing education CET

Diagnosis and management of red 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 . 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 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 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 , 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 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 textbooks, exertion, for example weight lifting, and readers are encouraged to refer to Lesions anterior to the 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 . 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 – 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 (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 (note microaneurysm, in a patient with 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 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 . 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 . beading, tortuosity and looping. The around 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 . 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 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 referred

Intra-retinal lesions ● Associated retinal thickening or hard exudates within one disc diameter of Red Dots and blots (Figures 7 to 10) the macular centre Small, round, bright-red dots (up to 60 ● A group or circinate pattern of exudates microns – about half of the diameter anywhere within the macula. of the retinal artery at the edge of the A patient without these features is optic disc) are typically retinal micro- graded M0 (Figure 7), does not require aneurysms. These are sac-like dilations referral, and can be reviewed annually. of capillaries in the middle layers of If any of these features are present, then the retina. The mechanism for their the patient is graded as M1 (Figure 8) formation is unknown, but is probably and should be referred to the HES. Figure 12 Ischaemic central retinal vein due to basement membrane absorption occlusion. There are extensive dark blotchy (by macrophages) and endothelial cell Other causes of red dots/blots haemorrhages (solid black arrow). Note also proliferation, triggered by the release of include: cotton-wool spots (dashed black arrows) VEGF. If a cluster of microaneurysms ● Retinal vein occlusion form, retinal oedema and exudates can ● Age-related : result from active leakage. The patient will be over 50, and may idiopathic. Other causes include: Red dots may also represent small have reduced central vision with distor- ● Branch retinal vein occlusion intra-retinal haemorrhages from capil- tion. Associated signs include subretinal ● Retinal laser laries in the deeper retinal layers, and and sub-RPE haemorrhages, bilateral ● Retinal cryotherapy may be difficult to separate from micro- drusen, macular pigment changes – ● Chronic intraocular inflammation. aneurysms. However dot haemorrhages including both atrophy and hyperpig- A macular hole is a small full-thick- are generally larger, more irregular, and mentation. The patient needs referral ness hole in the retina formed by excess do not leak. Both single microaneu- to the HES soon to rule out choroidal vitreous traction on the fovea. The main rysms and intraretinal haemorrhage are neovascular membrane – see below cause is idiopathic, usually in older relatively transient phenomena within ● High myopia: The patient will have a females in their 60s or 70s. Other causes the retina, and a single lesion may not red or pigmented spot at the centre of the include high myopia and blunt ocular indicate serious retinal disease. fovea, called a Fuchs’ spot (Figure 10). trauma. The vision is usually reduced, Red blots are larger haemorrhages The patient may have reduced central and the Watzke-Allen test is usually which originate from bleeding from vision with distortion. Associated with positive (the patient will notice a gap the deep retinal capillaries. They are peripapillary myopic crescent, optic disc in the middle of a narrow vertical beam darker than dot haemorrhages since tilt, chorioretinal atrophy. The degree of of light shone over the hole). There may they spread across the whole retina (dot myopia is usually in excess of 8 dioptres. also be a cuff of intraretinal fluid around haemorrhages are more superficial). The patient needs referral to the HES the hole. The commonest cause of red dots/ soon to rule out choroidal neovascular Tips to help differentiate a pseudo- small blots is background diabetic membrane hole from a true macular hole include: retinopathy (Figures 7 to 9). Associated ● Ocular ischaemia syndrome ● Vision – usually 6/6 or better with a features include hard exudates. Diabetes ● Radiation retinopathy pseudohole may or may not have been previously ● HIV retinopathy. This is usually ● Watzke test – will be negative with diagnosed. In a patient with known associated with cotton-wool spots, and a pseudohole. diabetes, referral to the HES is recom- other viral . mended by the National Screening Sometimes, the only way of definitely Committee (NSC)6 if the following In patients with an isolated single dot being to tell the two apart, is with are noted: or small blot haemorrhage and good an optical coherence tomogram. The ● Red dots/blots within one disc vision, referral to the HES is probably patient should be referred to the HES diameter of the centre of the macula in not indicated. The patient needs referral if this is a new finding, or the vision is association with decreased vision (6/12 to their GP for diagnosis and manage- worsening. or worse) ment of any underlying diabetes, hyper- opticianonline.net 29.02.08 | Optician | 37 Continuing education CET

Figure 13 The patient has multiple flame Figure 14 Inferotemporal branch retinal vein Figure 15 A patient with preproliferative haemorrhages (solid black arrows) with dilated occlusion. There are extensive flame diabetic retinopathy. There is a large flame veins, , and a macular star, haemorrhages (solid black arrow), as well as haemorrhage at the inferior macula (solid due to cotton wool spots (dashed black arrow) black arrow). Other associated signs include blot haemorrhages (dashed black arrow) and dilated, tortuous veins

Common causes include: Widespread peripheral retinal ● Hypertensive retinopathy (Figure haemorrhages 13): Associated with arteriolar narrow- If widespread peripheral retinal ing, arteriovenous nipping, copper/ haemorrhages are seen, consider the silver wiring of the artery due to arterio- following diagnoses: sclerosis, and cotton-wool spots. Blood ● Diabetic retinopathy pressure will be greater than 140/90 ● Central retinal vein occlusion ● Retinal vein occlusion (Figure 14) ● Hypertensive retinopathy ● Pre-proliferative diabetic retinopathy ● Ocular ischaemia syndrome Figure 16 A macroaneurysm (solid black (Figure 15). ● Radiation retinopathy arrow) originating from the inferotemporal ● Leukaemia (this can be associated retinal artery. Note the centre of the Less common causes include: with cotton-wool spots, Roth’s spots, macroaneurysm here appears yellow – this may ● Retinal vasculitis. vein occlusion, and choroidal/retinal/ be due to coagulation of the macroaneurysm, Flame haemorrhages also form vitreous infiltrates) or reabsorption of red blood cells from a around the optic disc. If a flame haemor- ● (in a child) chronic haemorrhage. There is surrounding rhage is seen, a dilated fundus examina- HES referral is indicated in all cases. haemorrhage and hard exudates (dashed black tion should be carried out looking for arrow) extending to the centre of the macula, any other retinal pathology. If only one Retinal artery macroaneurysm which may affect the patient’s central vision flame haemorrhage is seen with normal (Figure 16) vision, then a GP referral for assessment A retinal artery macroaneurysm tension, and cardiovascular disease. If, of , diabetes and cardiovas- appears as localised dilatation of a however, there are any associated signs cular disease can be made. If more than retinal artery, within the first three (as described above), or the vision is one flame haemorrhage is seen, or if the orders of branching of the arterial tree. reduced, then the patient should be vision is reduced, then referral to the It may be large, even several times referred. HES is indicated as well. larger than the associated retinal artery. There may be associated surrounding Large blotchy intraretinal Localised peripheral retinal hard exudates and haemorrhage due to haemorrhage (Figures 11 and 12) haemorrhage leakage. The vision may be affected if Large blotchy intraretinal haemorrhages Isolated peripheral haemorrhage may leakage of blood or serous fluid occurs usually indicate deep retinal ischaemia. be due to diabetic retinopathy or retinal at the macula – a large haemorrhage The most common causes are: vein occlusion. However other specific may cause a sudden drop in vision. ● Pre-proliferative diabetic retinopathy causes should be considered: Haemorrhage can be subretinal, intra- (Figure 11) ● Posterior vitreous detachment: The retinal, preretinal, or can break into the ● Ischaemic retinal vein occlusion patient will present with sudden onset vitreous; this may mask the view of (Figure 12). of and flashing lights. Associated the macroaneurysm. The condition is Large blotchy haemorrhages should signs include vitreous condensation and uncommon, and usually occurs unilat- be referred to the HES, since they a Weiss ring. The vitreous may pull on a erally in elderly females with systemic indicate more severe retinal ischaemia. , causing localised haemor- hypertension. It usually occurs as an rhage. Occasionally the blood vessel isolated finding, but is occasionally Flame-shaped/splinter haemorrhages may be pulled away from the retina associated with previous retinal artery (Figures 13 to 15) and a retinal tear can form. The patient or vein occlusion. The patient should be These are haemorrhages in the super- should be referred urgently to the HES referred to the HES, and to the GP for ficial retinal nerve-fibre layer, and are to rule out a retinal tear blood pressure control. bright red in colour. They follow the ● CMV retinitis: This is a rare finding, and nerve fibres, the anterior edge being occurs in immunosuppressed patients, for Telangiectasia (Figures 17 and 18) serrated or ‘flame-shaped’. Typically example in AIDS. There will be retinal The word telangiectasia literally means they occur in groups, usually spreading necrosis (death) associated with haemor- dilated end of a vessel. They appear as from the (where the nerve rhages, the so-called ‘pizza’ appearance. irregular dilated flat capillaries within fibre layer is thickest). Urgent HES referral is indicated. the retina.

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Figure 17 Coat’s disease. There are abnormal Figure 18 IRMA in preproliferative diabetic Figure 19 A prominent -shaped venous dilated retinal vessels (solid black arrows) with retinopathy, present in the peripheral fundus loop (solid black arrow) in the retinal secondary exudation (dashed black arrow) (solid black arrow) peripheries in preproliferative diabetic retinopathy

Figure 20 Raspberry-like abortive neovascular Figure 21 Cherry-red spot (solid black arrow) Figure 22 Subretinal haemorrhage (solid black outgrowths in proliferative diabetic in central retinal artery occlusion. Note also arrow) secondary to exudative age-related retinopathy (solid black arrow) the attenuated retinal arteries and optic disc macular degeneration. Note surrounding haemorrhages yellow-greyish area (dashed black arrow) probably indicating elevated / thickened retina

Commoner causes include: tortuous, irregular, fine small vessels referred for HES assessment. ● Diabetic retinopathy within the retina, within/adjacent to ● Retinal vein occlusion: ‘collateral’/ areas of retinal ischaemia. They develop Roth’s spots ‘shunt’ vessels – these are thought to be as a compensatory response to retinal Roth’s spots are haemorrhages with a dilated pre-existing vessels which help ischaemia, in an effort to try to replen- central white area. They are uncom- drain blood away from the blocked vein ish the reduced blood supply. They have mon, and can occur in diabetic retinop- into another vein. been termed IRMA, since it is uncer- athy, leukaemia, infective endocarditis, tain if they are dilated pre-existing and HIV retinopathy. The cause of the Rarer causes of telangiectasia dilated capillaries, or early intra-retinal white centre varies according to the include: (non-elevated) new vessels.7 Note that condition. In infective endocarditis, ● Radiation retinopathy IRMAs, unlike definite neovascularisa- it may represent a tiny abscess due to ● Coats’ disease (Figure 17): A rare tion, are present within the retina and do septic emboli, given off by diseased condition which occurs in boys/young not cross the major retinal blood vessels. heart valves, which then lodge in retinal men. Dilated retinal vessels are present Sometimes, fluorescein angiogram may arteries. This damages the capillary unilaterally. There is usually secondary be the only way of differentiating the wall, resulting in focal haemorrhage. exudation, which can be severe) two – definite new vessels will leak In leukaemia, the white centre may ● Leber military aneurysm. This is profusely, whereas there will be an be a collection of abnormal leukaemic thought to be a milder form of Coats’ and absence of leakage from IRMA. white blood cells. In other conditions, a is typified by light bulb-shaped dilated Roth’s spot may be a cotton-wool spot vessels in the temporal peripheries Venous looping (Figure 19) or a platelet/fibrin plug (resulting from ● Idiopathic juxtafovealar telangiecta- A retinal vein may form an ‘omega’- damage to a capillary wall), surrounded sia. This rare condition tends to be shaped loop. This is a feature of by haemorrhage. A Roth’s spot can also associated with symmetrical bilateral ischaemic retinal conditions, such as be formed from central reabsorption of telangiectasia temporal to fovea, involv- preproliferative diabetic retinopathy. a previous haemorrhage. The patient ing area less than 1 disc diameter. The needs same-day referral to eye casualty patient is typically 50-60 years old. Abortive neovascular outgrowths and medical work up for infectious A patient with previously undiag- (Figure 20) endocarditis. nosed telangiectatic vessels should be These are small raspberry-like lesions referred to the HES. lying on the retina, typically associated Retinal capillary haemangioma with proliferative diabetic retinopathy This is a rare finding. It is a benign Intra retinal microvascular anomalies/ in the presence of a posterior vitreous tumour of the retinal blood vessels. abnormalities (Figure 18) detachment. The lack of vitreous archi- It appears as a spherical berry-like IRMA are a feature of preproliferative tecture, leads to an abortive outgrowth red lesion, with a prominent, dilated, diabetic retinopathy. They appear as of blood vessels. These should be tortuous feeder artery and draining

40 | Optician | 29.02.08 opticianonline.net CET Continuing education

Figure 23 Extensive sub-RPE haemorrhage Figure 24 Dark subchoroidal haemorrhage at the macula (solid black arrow) secondary to trauma. inferior to the macula (solid black arrow), in Underlying choroidal rupture visible after resorption of haemorrhage (dashed black arrow) exudative age-related macular degeneration. Note the brighter adjacent subretinal haemorrhage (dashed black arrow) and subretinal fibrosis at the macula

Figure 25 Prominent optic disc swelling due to Figure 26 A splinter disc haemorrhage (solid central retinal vein occlusion. Note the cotton- black arrow) in . Note the cupped wool spots and splinter haemorrhages optic disc surrounding the optic disc (solid black arrow). Also note the dilated tortuous veins (dashed black arrows), and the peripheral retinal haemorrhages due to the vein occlusion vein. It can also occur at the optic disc. Sub- (Figure 22) ● Presumed ocular histoplasmosis Patients with multiple haemangiomas These large, bright red haemorrhages syndrome (POHS): This is associated in both eyes are likely to have a rare lie under the retina between the neural with round yellow-white punched out genetic condition called Von Hippel- retina and the retinal pigment epithelium spots in the retina, and peripapillary Lindau syndrome, which is associated (RPE) layer. The retinal blood vessels atrophy with kidney tumours. HES referral is can be seen overlying the haemorrhage, ● Angioid streaks: These appear as bilat- indicated. and give a vital clue to its level within eral reddish-brown/grey bands radiat- the retina. They tend to have indistinct ing spoke-like from the optic disc, and Cherry-red spot (Figure 21) borders, since the neural retina is not are associated with rare conditions such A cherry-red spot is essentially a normal tightly bound to the underlying RPE, as . appearing fovea surrounded by abnor- and usually occur at the macula. If blood mally pale retina. As a result the fovea collects, then the area may be elevated. Other causes of sub-retinal haemor- stands out more. The most common The most common cause is choroidal rhage include: cause is acute central retinal artery neovascular membrane (CNV). These ● Ruptured retinal artery occlusion (Figure 21). This is associ- are abnormal fragile blood vessels, macroaneurysm ated with sudden loss of vision, an which originate from the choroid. A ● Coat’s disease RAPD, attenuated retinal arteries, and CNV appears as a grey-green/pink- ● . pale swollen oedematous retina. The yellow, slightly elevated area at the retina becomes pale and swollen from macula, associated with retinal thicken- Sub-retinal pigment epithelium (RPE) sudden ischaemia. However the retina ing, hard exudates, haemorrhagic PED, haemorrhage or haemorrhagic at the fovea is much thinner, so does not and occasionally vitreous haemorrhage. pigment epithelial detachment swell up much. Of course the patient The most common cause of CNV is (Figure 23) should be referred urgently to the eye exudative AMD (Figure 22). These haemorrhages are brown/dark casualty department. Other more rare causes of CNV red, well demarcated and appear Rarer causes of a cherry-red spot include: elevated; retinal blood vessels overlie include the ‘storage diseases’, in which ● High myopia the blood. They appear darker than abnormal material builds up within the ● Trauma: Associated features include sub-retinal haemorrhages (since they lie retinal layers, giving a paler appearance, a previous history of severe ocular under the pigmented RPE), and usually for example Tay-Sachs disease. Again, blunt trauma, and presence of choroi- occur at the macula. A sub-RPE haemor- since the fovea is thinner than the dal rupture – a yellow-white crescent rhage usually originates from CNV. surrounding retina, it tends to retain a at the posterior pole, usually around the relatively normal appearance. optic disc Choroidal haemorrhage (Figure 24) ● Previous macular laser (Look for laser These are dark red haemorrhages Sub-retinal lesions scars) which are frequently extensive. They opticianonline.net 29.02.08 | Optician | 41 Continuing education CET

Figure 27 New vessels growing forwards into Figure 28 Another patient with proliferative Figure 29 Optic disc collateral vessels in old the vitreous from the optic disc (solid black diabetic retinopathy and new vessels from the central retinal vein occlusion arrows) in proliferative diabetic retinopathy disc (solid black arrow), bleeding into the vitreous (dashed black arrow) are rare, and occur due to blunt ocular trauma (look for an associated choroidal rupture – Figure 24), or as a compli- cation of retinal detachment surgery during drainage of subretinal fluid.

Optic disc lesions

Optic disc haemorrhages (Figures 25 and 26) Optic disc haemorrhages usually appear as splinter/flame haemorrhages on/ around the disc due to the thick nerve Figure 31 ‘Seafan’ of new vessels in sickle-cell Figure 32 New vessels at the disc in fibre layer present here. It is important to retinopathy regression after laser treatment rule out optic disc swelling. Associated signs of disc swelling include: blurring of the disc margin, elevation of the disc, obscuration of the retinal blood vessels, peripapillary cotton-wool spots. The more common causes of optic disc swelling include: ● Papilloedema: This is bilateral optic disc swelling due to raised intracranial pressure. Associated features include central visual field defect, reduction in colour vision, and loss of sponta- neous venous pulsation at optic disc. The patient may experience transient visual loss, , and be systemi- cally unwell. Causes include intrac- Figure 33 OCT image of a full-thickness macular hole ranial space-occupying lesions, and meningitis ● Optic nerve ischaemia: Damage occurs ● Glaucoma (Figure 26): There is Optic disc neovascularisation when there is sudden reduction in the usually elevated intraocular pressure, (Figure 27 and 28) optic nerve blood supply. There will be but be aware of low tension glaucoma. New vessels can grow from the optic associated optic disc pallor and an RAPD. The optic disc will be cupped, with disc due to severe retinal ischaemia The patient will present with unilateral a thin neuroretinal rim at the site of – the appearance, pathogenesis and reduction in vision. Causes include giant haemorrhage). If glaucoma has not causes are similar to that for retinal cell arteritis, hypertension been previously diagnosed, then refer neovascularisation. ● Papillitis: This is inflammation of routinely to the HES. A patient with Optic disc neovascularisation usually the optic nerve and is associated with a previously diagnosed glaucoma and indicates significant retinal ischaemia. hyperaemic swollen optic disc, unilat- stable intraocular pressures does not The patient should be referred urgently eral reduction in vision, and pain on need to be referred to the HES. eye movement. Causes include multi- ● Acute posterior vitreous detachment: ple sclerosis, diabetes, and SLE needs urgent referral to the HES to rule Optic disc collaterals (Figure 29) ● Central retinal vein occlusion (Figure out a retinal tear/detachment Optic disc collateral vessels suggest a 25). ● Optic nerve drusen (the optic disc will previous central retinal vein occlusion Optic disc swelling needs urgent refer- appear lumpy). It is important to differ- (CRVO), and appear as dilated, flat ral to the HES. entiate this from optic disc swelling. If vessels that begin and end at the disc. Other causes of optic disc haemor- this is unclear then refer urgently to the HES referral is probably necessary only rhage include: HES to rule out papilloedema. if no previous diagnosis of CRVO has

42 | Optician | 29.02.08 opticianonline.net CET Continuing education

Multiple-choice questions

Which of the following would be Which of the following would be 1most useful for examination of early 7gradeable as M0? maculopathy? A Multiple dot and blot haemorrhages in the A Superfield lens mid-periphery B 90D lens B Cotton-wool spots C 66D lens C Exudates within 1 disc diameter of the fovea D Widefield lens D Red dot haemorrhage 1 disc diameter from fovea with 6/6 acuity Figure 30 A rare capillary haemangioma Which of the following is the commonest growing at the optic disc (solid black arrow), 2cause of pre-retinal haemorrhage? Of what is a Weiss ring indicative? with surrounding hard exudates from chronic A Retinal artery macroaneurysm rupture 8 leakage (dashed black arrows) B Trauma A Posterior vitreous detachment C Proliferative retinopathy B CMV retinitis been made, or if there is difficulty in D Terson’s syndrome C Hypertensive retinopathy ruling out disc new vessels. D Leukaemia From where do new vessels grow? Optico-ciliary shunts 3 Which of the following is true about Rarely seen, these appear as dilated A Arterioles 9Coats’ disease? vessels which extend from the centre B IRMA A It is mainly found in females of the optic disc, to the edge of the optic C Venous system B Bilateral vessel dilation is found disc. They suggest an optic nerve sheath D Capillaries C Secondary exudation is rare meningioma, but can occur in chronic D Telangiectasia are charateristic papilloedema. Which of the following is most likely to 4indicate ischaemia in a central retinal In which of the following might one Optic disc capillary haemangioma vein occlusion? 10see Roth’s spots? (Figure 30) A Flame haemorrhages A Papilloedema See retinal capillary haemangioma, B Obscuration of the macula B above. C Paler haemorrhage colouration C HIV retinopathy D Cotton-wool spots D Coats’ disease Conclusion Red-coloured lesions are among the Which of the following is indicative of a Which systemic condition has a more common forms of pathology 5macular hole rather than a pseudohole? 11strong association with angioid seen in the fundus. It is important to A Acuity of 6/6 streaks? be able to ascertain the pathology of B Positive Watzke test A AIDS the lesion, at what level of the retina C Patient age of 20 years B Hypertension it exists, any associated findings, and D No apparent elevation or cuff around lesion C Leukaemia consider a differential diagnosis. This D Pseudoxanthoma elasticum will then help the examiner to decide What is the typical diameter of when and how urgently to refer the 6microaneurysms? A patient has a unilateral vision patient to the local eye unit, and also A Up to 30 microns 12loss,unilateral disc swelling, request appropriate investigations from B The same as the retinal artery at the disc altitudinal field defect and an RAPD. Which of the patient’s GP. C The same as the retinal vein at the disc the following is most likely? Typically, routine referral is reason- D Up to 60 microns A Papillitis able for lesions that are few in number B Anterior ischaemic and peripheral to the macula. However C Papilloedema those with multiple or complex lesions D Disc drusen affecting the macular area, especially if associated with visual loss or metamor- To take part in this module go to opticianonline.net and click on the Continuing Education phopsia, demand more urgent atten- section. Successful participation in each module of this series counts as two credits towards tion. ● the GOC CET scheme administered by Vantage and one towards the Association of Optometrists Ireland’s scheme. The deadline for responses is March 27 Acknowledgements The authors thank Dr Ann Clover and Dr Shabeeba Hannan from Southampton Eye 3 Kunimoto DY, Kanitkar KD, Makar M, 6 UK National Screening Committee. Unit for their help in providing images. Friedberg MA, Rapuano CJ. The Wills Eye Essential Elements in Developing a Diabetic Manual:Office and Emergency Room Retinopathy Screening Programme. References Diagnosis and Treatment of Eye Disease. Workbook 4. 2007. 1 Kanski JJ, Nischal KK, Milewski SA. 4th ed Philadelphia : Lippincott Williams & 7 Richard G, Soubrane Gl, Lieb WA. . 2nd Ophthalmology : Clinical Signs and Wilkins, 2004. rev. and expanded ed. Stuttgart ; New York: Differential Diagnosis. Philadelphia: Mosby, 4 Ryan SJ. Retina. 4th ed. Philadelphia, Pa: Thieme, 1998. 1999. Elsevier/Mosby, 2006. 2 Kanski JJ. Clinical Ophthalmology : A 5 Yanoff M, Duker JS, Augsburger JJ. ● Sam Khandhadia is research registrar and Systematic Approach. 6th ed. Edinburgh : Ophthalmology. 2nd ed. : Mosby, Richard Newsom consultant ophthalmologist Butterworth-Heinemann Elsevier, 2007. 2003. at the Southampton Eye Unit opticianonline.net 29.02.08 | Optician | 43