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.