A/V nicking and other hypertensive vascular changes.

This patient's blood pressure was taken in the clinic and found to be 178/100. He had no documented history of hypertension and had not been treated, likely because he had not been to a PMD is so long. His retina shows early vascular changes associated with high blood pressure without more dramatic retinopathic findings such as CWS, hemorrhage or subretinal fluid. A/V nicking occurs where the artery crosses anterior to the vein. The vein is compressed by the hardened artery. These arteries also show the altered light reflex that is often referred to as "copper wiring." The vasculature may be slightly tortuous, though many people with normal vision have tortuous vessels.

Just for a quick frame of reference for those of you who are used to struggling to find these details with a direct ophthalmoscope; you won't see the fundus in the wide-angle glory of the image above. A direct ophthalmoscope only gives a field of view of about 6-10 degrees, or 15X magnification. In comparison to the fundus photo above, it would look more like this:

I have included two views from the original image to simulate what you might see. To the left is the image of the disc, which nearly fills the field of view. If you can trace the vessels to a point where the artery crosses on top of the vein, you will see clear A/V nicking. Obviously an examination with a direct ophthalmoscope requires a lot of diligence and patience, but great physicians in generations-past were able to describe much of the pathology we know today using nothing more than a direct scope. The detailed illustrations of Gonin (First surgeries for retinal detachment), Wilmer and others were all done this way.

What's this?

What do you see? This is a color fundus photo showing the left eye of a 55 year old A.A. male who claims no past medical history. He has not been to a PMD in over 10 years. When looking at the retina during a fundus exam, look systematically. Just like a chest X-ray, a methodical approach to reading the image will help to make sure you don't miss anything. The findings here are very subtle, which makes asking a sequence of questions very helpful.

1) Disc? I always find cup-disc ratio really difficult on a 2-d photo. Is there Neovascularization? Elevation? Are the margins sharp?

2) Macula? Is there any edema (again, hard to tell on a photo), exudate, drusen?

3) Vessels? Any vascular changes? Look closely. This will tell you something about this patient's systemic health.

4) Periphery? Is there any hemorrhage? Any exudates or cotton wool spots (CWS)?

Classic Findings

This set of color fundus images shows the classic triad of a retinal findings in what disease?

(Hint: does the Ohio River Valley sound like a familiar prompt from board prep?)

Choroidal Melanoma Progression

This image shows two color fundus photos taken approximately 1.5 years apart showing the progression of a subretinal pigmented lesion. While subretinal or choroidal hemorrhage is a reasonable guess, this case was selected to demonstrate the differences between choroidal nevus and melanoma. In this pair of images, one may observe the slight increase in size of the lesion (noted most clearly along the edge closest to the optic disc), increase in orange lipofuscin pigment and subretinal fluid. Another important risk factor for melanoma is whether the lesion is over 1mm in thickness.

An important distinguishing characteristic of choroidal nevus is the presence of drusen. This represents retina pigment epithelium (RPE) wear and tear that occurs due to the chronicity of these lesions in contrast to the faster growing melanomas.

For a quick overview:

http://www.aao.org/publications/eyenet/200610/oncology.cfm

Please feel free to post questions, comments, corrections!

First Case!

93 year old caucasian female with no visual complaints. Two images showing 1.5 years of follow-up.

What has changed since the first picture (right)?

(Hint: read about differentiating choroidal nevus from melanoma)

Hey Sinai Ophtho Interest Group and friends,

The purpose of this blog is to provide a running "virtual imaging conference" for medical students interested in ophthalmology in general and retina specifically. I will post regular cases consisting of a fundus photo, angiogram or OCT (or all three!) with a simple one-liner. The goal is to allow visitors to post their thoughts, guesses, observations in the comments section. The following day, I'll post the "answer" to the case. I will be pulling the images from my own personal library. Please let me know what you think. Hopefully, this will be a jumping off point for reading and self-study aimed at gaining pattern recognition skills helpful for diagnosing pathology.

Colin