The Ocular Fundus

The original German language version was created by Christof Daetwyler MD at the Institute for Medical Education, Department of Instructional Media, University of Berne Medical School. The copyright for the photographs of is at the Augenklinik des Universitätssptials Bern. The US-English translation was done by Kenneth Kronenberg with a grant from "Slice of Life" Development Fund

How to use this program: The pictures in the frame on the left are in didactial order - starting on top and then making way to the bottom will allow the interested student to hopefully gain some understanding of the ocular fundus and the changes caused by some medical conditions.

The program is divided into 4 chapters:
(click a chapter title to see the fundi of that chapter)

Chapter 1: THE OPTICAL DISC
Chapter 2: VASCULATURE
Chapter 3: FUNDUS
Chapter 4: MACULA
Chapter 1 - 4: ALL FUNDI

Show fundi where description contains
(and you'll see only the fundi which are related to the search term)

We thank Prof. Fritz Koerner MD, Prof. Daniel Mojon MD and PD Johannes Fleischhauer MD for their contribution.

We wish you an enjoyable learning experience - and we'd very much enjoy getting feed-back: mailto:christof.daetwyler@drexelmed.edu

Other learning programs for Ophthalmology:

The German Language Version of "The Ocular Fundus"
http://e-learning.studmed.unibe.ch/clinisurf/
Vienna Ophthalmic Case Studies
http://www.meduniwien.ac.at/augen/englisch/steps.htm
The Eye Simulator Version 2.0
http://cim.ucdavis.edu/EyeRelease/Interface/TopFrame.htm

102*TAB*1.  Optic Disc Introduction*TAB**TAB*Anatomically, the rim of the disc corresponds to the zone where the lamina cribrosa turns into solid sclera - in other words, it is bordered by the solid sclera.  The nerve fibers are transparent because they lose their myelin sheaths after passing through the lamina cribrosa. The cup, through which the central artery and central vein of the retina pass into the interior of the eye, is usually situated in the middle of the disc.  Here, the fibers of the optic nerve divide, allowing the lamina cribrosa to be viewed directly.*BR**BR*4 criteria are used to evaluate the disc:*BR**BR*1.  The form of the disc*BR* Is a round or oval?*BR**BR*2.  The margin*BR* Is a clear and visible -*BR* or blurred and indistinct?*BR**BR*3.  The color*BR* Is it well perfused and vital*BR* or pale and transparent?*BR**BR*4.  The diameter and position of the cup*BR* What is the diameter of the cup in comparison to that of the entire disc?*BR* Is the position of the cup central - or does it extend to the disc margin?*TAB**TAB**CRLF*01*TAB*1.  Optic Disc - Case 1*TAB*This picture represents the right eye of a 30-year-old man.*BR**TAB*The disc is round; the rim is sharp.*BR*The color of the disc shows that it is vital.  Only after comparing it to a disc with pathological changes will you be able to see the difference.  Using this example, try to remember the color of a normal disc. *BR*Anatomically, the rim of the disc corresponds to the zone where the lamina cribrosa turns into solid sclera - in other words, it is delineated by the sclera.  The nerve fibers are transparent because they lose their myelin after passing through the cribrous lamina.  The cup, through which the central artery and central vein of the retina pass into the interior of the eye, is usually situated in the middle of the disc.  Here the fibers of the optic nerve divide, allowing the lamina cribrosa to be viewed directly.*BR*The cup appears clear. First, the rim of the disc appears in various red tones through the vascular bed behind it.  The diameter of the cup corresponds to half the diameter of the disc - as in this picture.  We say that the cup:disc ratio is 0.5.*BR*The cup is positioned in the center of the disc and does not touch its rim at any point.*BR**BR*This picture represents a normal fundus.*TAB**CRLF*10*TAB*1.  Optic Disc - Case 2*TAB*This picture represents the right fundus of a 26-year-old man.*TAB*The disc is round to oval.  The disc is sharply delineated.  The color is unremarkable, leading to the conclusion that the disc is vital.  The cup extends over approximately 1/3 of the disc, that is, the cup:disc ratio is 0.3.*TAB*This picture represents an unremarkable, normal fundus.*CRLF*04*TAB*1.  Optic Disc - Case 3*TAB*This picture represents the right eye of a 37-year-old woman with severe myopia.*BR**TAB*The disc is somewhat obliquely oval and is sharply delineated.*BR*One can see from the color that it is vital.  The cup is not definable, as is often the case in severe myopia.*TAB*In myopia, the eye is longer than normal.  In the picture of the fundus, this is often visible as increased elongatedblood vessels.  As far as the disc is concerned, it is often surrounded by a typical scleral cone, the conus myopicus.In addition, the cup is often not definable in the myopic eye.  In the emmetropic eye, the disc’s nasal pole is closer to the eye of the observer then the temporal pole.  In comparison, in the myopic eye, the disc is set even more oblique to the optical axis because, as mentioned earlier, the eye as a whole is longer, and therefore the disc is more or less forced to the margin.  This circumstance is well-visualized in the explanatory illustration.*CRLF*03*TAB*1.  Optic Disc - Case 4*TAB*This picture represents the right eye of a 76-year-old woman.*TAB*The disc is sharply delineated.  Except for a narrow edge around the rim, which shows by its stronger coloration that it is still vital, the color is generally too pale.  The cup is deep, though not overhanging. The relationship between the cup and the disc diameter, the cup:disc ratio, is approximately 0.9, and is therefore considerably outside normal limits.*TAB*This picture represents a disc showing glaucomatous change.*BR*One can understand the visible changes if one considers that the only permeable tructure in the eyeball, namely the lamina cribrosa, has been displaced dorsally as a result of the elevated intraocular pressure.  Nerve fibers and vessels are also subject to this high pressure after they have passed through the cribrous lamina into the eye. They run along the floor of the lamina cribrosa, entering into the eye past the inflexible scleral edge.  In addition, capillary perfusion of the retina is impeded by the elevated intraocular pressure.  This leads to the observable atrophy of nerve fibers.*CRLF*02*TAB*1.  Optic Disc - Case 5*TAB*This picture represents the left eye of a 15-year-old boy.*TAB*The disc is sharply delineated.*BR*The color of the disc is vital.*BR*The cup is deep; the cup:disc ratio is 0.5-0.6.*BR*Remarkable is the trace of a pigment cone at the temporal edge of the disc.*TAB*Because the cup:disc ratio is greater than average, the status of this patient must be further clarified, and the intraocular pressure measured.*BR*As a result of the elevated intraocular pressure, the only permeable structure in the eyeball, namely the lamina cribrosa, is displaced dorsally. Nerve fibers and vessels are also subject to this high pressure after they have passed through the cribrous lamina into the eye. They run along the floor of the lamina cribrosa, entering into the eye around the inflexible scleral edge.  In addition, capillary perfusion of the retina is impeded by the elevated intraocular pressure.  This leads to observable atrophy of nerve fibers.  The pigment: at the temporal age of the disc, mentioned earlier, is a normal variation.*CRLF*05*TAB*1.  Optic Disc - Case 6*TAB*This picture represents the right eye of a 14-year-old boy.*TAB*The disc is round and sharply delineated.*BR*It is pale, except for a vital band at the rim.*BR*The cup is deep, and the cup:disc ratio is 0.6-0.7*TAB*Optic nerve tissue and the blood vessels at the edge of the sclera are compressed and damaged by the elevated intraocular pressure.  The changes that occur in glaucoma as a result of this may be explained by a progressive loss of nerve fibers.  In general, this occurs when the clinically visible glaucomatous cup has extended to the disc rim at any point, most often initially in the lower temporal area.*BR*One of the most important criteria for recognizing a glaucomatous cup is therefore whether or not it reaches the board of the optic disc.*BR*Because the cup:disc ratio is greater than 0.6, this patient’s condition must be further clarified, and the intraocular pressure must be measured.*CRLF*09*TAB*1.  Optic Disc - Case 7*TAB*This picture represents the right eye of a 20-year-old, dark-skined woman.*TAB*The disc is round and sharply delineated.*BR*The cup is unremarkable, allowing one to conclude that the disc is vital.*BR*The cup: disc ratio is 0.2*TAB*This fundus is normal in dark-skinned persons.  The blood vessels of the choroidea appear as a marbled red structure around the disc.*CRLF*11*TAB*1.  Optic Disc - Case 8*TAB*This is the left eye of an unknown patient*TAB*The disc is round to oval and sharply delineated.  The color is unremarkable, allowing one to conclude that the disc is vital.  The cup extends over approximately 1/3 of the disc; the cup:disk ratio is therefore 0.3.*TAB*This picture represents an unremarkable, normal fundus.*CRLF*15*TAB*1.  Optic Disc - Case 9*TAB*This picture represents the right eye of a 29-year-old woman*TAB*The disc is round and sharply delineated.  A small sickle-shaped scleral cone borders it temporally.*BR*The color of the disc is unremarkable.  Entry of the vascular trunk shows slight nasal displacement.  The cup:disc ratio is 0.4*TAB*This picture represents a normal fundus in a young woman.  The reflectivity of the vessels should be observed in young people. The nasal displacement of the the vascular trunk may be physiological.*CRLF*14*TAB*1.  Optic Disc - Case 10*TAB*This picture represents the left eye of an 84-year-old man.*TAB*The disc is round and sharply delineated.  It is too pale, except for a narrow vital band around the rim.  The cup extends to the edge of the disc, and continues under it so that it forms a so-called glaucomatous halo. The cup:disc ratio is 0.9-1.0.*BR*The course of the blood vessels is remarkable: The main vessel is displaced nasally, and the vessels are kinked. The disc is surrounded by a light-colored structure, the glaucomatous halo mentioned above.*TAB*This picture represents an advanced marginal glaucomatous disc cup.*CRLF*23*TAB*1.  Optic Disc - Case 11*TAB*This picture represents the left eye of a 24-year-old man.*TAB*The disc is sharply delineated.  The color is very pale, except for a vital band at the rim.  The cup is very deep (this fact that is made visible by the course of the vessels).  The cup:disc ratio is 0.8-0.9.*TAB*This picture represents juvenile glaucoma with a pathological cup. As a result of treatment, intraocular pressure is now compensated.*CRLF*16*TAB*1.  Optic Disc - Case 12*TAB*This picture represents the right eye of a 77-year-old man.*TAB*The disc is around, except for a small temporal outpouching.  It is sharply delineated temporally; signs of a pigment cone can be seen here.  Nasally, it is somewhat indistinct.  The color is vital.  The cup:disc ratio is 0.3*TAB*This picture represents an unremarkable normal disc finding.*CRLF*19*TAB*1.  Optic Disc - Case 13*TAB*This picture represents the left eye of a 43-year-old man*TAB*The disc exhibits a slight lack of sharpness at the rim, most notably lower nasally.  The color is vital; the cup:disc ratio is approximately 0.2*TAB*The lack of sharpness of the disc nasally and its prominence make one suspect an engorged disc.  The nerve fibers are swollen and edematous. Through the ophthalmoscope, it is almost impossible to differentiate between edema of the optic disc that results from an incipient engorged disc, papillitis, or an ischemic disc infarction.*CRLF*20*TAB*1.  Optic Disc - Case 14*TAB*This picture represents the left eye of a 46-year-old man*TAB*The disc is not sharply delineated.  The color is somewhat pale; the cup is not visible.*TAB*The pale color and the lack of sharp delineation of the disc are evidence that the nerve tissue is edematous.  The edematous change in the disc is, in this case, evidence of vascular lesions secondary to hypertension; this interpretation is supported by the presence of constricted arterioles and exudates.*CRLF*21*TAB*1.  Optic Disc - Case 15*TAB*This picture represents the right eye of a 42-year-old woman. Patient states that she suddenly lost vision in her right eye, but that she had no problems with the left eye.*TAB*The delineation of the disc is unsharp because the tissue is edematous.  Under more careful examination, one sees that to some extent the blood vessels disappear into the edematous tissue.  The color of the disc is somewhat pale; no cup is present.*TAB*Viewed through an ophthalmoscope, it is almost impossible to differentiate papilledema secondary to incipient engorged disc or secondary to papillitis. Papilledema caused by ischemia is paler than that caused by inflammation or engorgement.  The clinical picture is crucial to the diagnosis: inflammation of the optic nerve is characterized by a central scotoma; by contrast, a disc infarction more frequently causes a large sectional scotoma with horizontal delineation.*BR*Visual acuity is not affected in disc engorgement; in addition, this finding is usually bilateral.*BR*In this case, we are presented with a central scotoma, and so we may interpret this finding as papillitis.*CRLF*30*TAB*1.  Optic Disc - Case 16*TAB*This picture represents the right eye other 29-year-old woman.  The findings are bilateral.  No intracranial mass is detected on neuroradiology.*TAB*The discs are not sharply delineated.  The blood vessels have disappeared centrally into edematous material.  The color is vital.  No cup is visible.  The mushroom-shaped disc projects from the vitreous chamber.*TAB*Elevated intracranial pressure has led to a picture of disc engorgement.If neuroradiology shows no evidence of an intracranial tumor process, and no other cause for the elevation in intracranial pressure can be found, the condition is called a ’pseudotumor cerebri’.  In general, vision is normal.*CRLF*06*TAB*1.  Optic Disc - Case 17*TAB*This picture represents the right fundus of a 15-year-old girl.*TAB*The disc is sharply delineated.  The color is unremarkable, allowing one to conclude that the disc is vital.  The cup is situated centrally in the disc and extends halfway across it.  The cup:disc ratio is 0.5.  The dark sickle-shaped structure at the temporal rim of the disc is a so-called ’pigment cone’, a normal finding without pathological significance.*TAB*This picture represents a normal fundus with a pigment cone situated temporally.*CRLF*07*TAB*1.  Optic Disc - Case 18*TAB*This picture represents the right eye of an unknown patient.*TAB*A light-colored radiating structure that covers both the disc and adjacent areas is immediately evident.  These are myelinized nerve fibers, i.e., nerve fibers that contain myelin sheaths, a finding that is clinically innocuous.*BR*Neither the form nor the margins of the disc can be evaluated; nor can the cup.*TAB*Nerve fibers that contain myelin appear only rarely, and they are not clinically significant.  In a case like this (which occur very rarely), a relative scotoma in the visual field can be found.*CRLF*26*TAB*1.  Optic Disc - Case 19*TAB*This picture represents the left eye of a 19-year-old woman.*TAB*Neither the form nor margins may be evaluated because the disc is covered by a whitish glassy nodule. The cup cannot be evaluated either.*TAB*This is an example of an optic disc plaque.*BR*This results when a constricted lamina cribrosa impedes axoplasmatic flow, which leads to a slow degeneration of the axon and eventual axon rupture.  As a result, mitochondria emigrate into the extra-axonal space, leading calcium deposits and visible plaque development..*CRLF*28*TAB*1.  Optic Disc - Case 20*TAB*This picture represents the right eye of a 55-year-old man*TAB*The disc is sharply delineated, insofar as it can be evaluated from the photograph, which is somewhat fuzzy.  The disc is fairly pale, except for the margin, which has vital coloration.  Centrally, the disc is deeply cupped, except for the lamina cribrosa.  The cup:disc ratio is 0.6.*TAB*Because the cup:disc ratio is greater than 0.5, glaucoma must be suspected.  In this case, the cup is deep but flat. Low-tension glaucoma should be considered in the differential diagnosis.  This condition can lead to defects in the visual field at normal ocular tension.*CRLF*103*TAB*2.  Vasculature Introduction*TAB**TAB*The fundus is the only place in the body where the circulatory system can be observed directly and without obstruction.  Because of this, funduscopy can give us important information about the severity and course of many systemic illnesses with vascular involvement.*BR*The retinal arteries are capillaries that are not associated with any collateral vessels.  Because of this, blockage always leads to infarction in the regions supplied by the occluded vessels.*BR**BR*We have 3 criteria for evaluating blood vessels:*BR**BR*1.  Diameter*BR*Arteries are generally narrower than veins, the ratio being approximately 2:3.*BR**BR*2.  Regularity of the vessels*BR*Normal blood vessels taper regularly toward the periphery without local constrictions.*BR**BR*3.  Vascular intersections*BR*Do the veins appear constricted at the intersections, or does the blood column flow freely?*TAB**TAB**CRLF*35*TAB*2.  Vasculature - Case 1*TAB*This picture represents the right eye of a 68-year-old woman with generalized arteriosclerosis.*TAB*Both the arteries and the veins are constricted.  The blood column is segmented in the vessels.  The vascular intersections are unremarkable.  Temporally, disc perfusion appears adequate.*BR*Apart from the pale disc, the light coloration of the entire retina and the intense redness of the fovea are remarkable.*TAB*The picture presented here is consistent with occlusion of the central retinal artery.  All of the observations mentioned in the findings can be explained in that the retina is barely supplied with arterial blood.  This leads to edema in the entire retina.  The cherry-red color of the fovea may be explained by the fact that there is no layer of nerve fiber tissue that could become edematous, so that the choroidea shimmers through from behind.  A small temporal region of the disc continues to be supplied with blood by a cilioretinal blood vessel.*CRLF*39*TAB*2.  Vasculature - Case 2*TAB*This picture represents the right eye of an unknown patient.*TAB*Arteries and veins are configured normally, and they have a diameter ratio of 2:3.  The arteries reflect light in a way that is reminiscent of silver wires.  We therefore speak of the arteries demonstrating a ’silver-wire look’.  There is no Gunn’s sign.*BR*A light-colored structure in the arteries in the area of the disc, which affects all branches, is noticeable.  The retina is edematous above the disc.*TAB*This is a case of central thrombotic arterial occlusion.*BR*The fundus is edematous.  The silver-wire look alerts us to arteriosclerotic changes in the arteries.*CRLF*33*TAB*2.  Vasculature - Case 3*TAB*This picture represents the left eye of an unknown patient.*TAB*Blood flow is reduced or even arrested.  The arteries are very narrow and demonstrate fluctuations in diameter.  The diameter of the veins is normal.  The vascular intersections are unremarkable.*BR*The light color of the entire retina, except for the macula, is remarkable.  The macula appears as a cherry-red dot.*TAB*The picture presented here is consistent with occlusion of the central retinal artery.  All of the observations mentioned in the findings can be explained in that the retina is barely supplied with arterial blood.  This leads to swelling of the nerve fibers.  The red color of the macula may be explained by the fact that there are no nerve fibers here, so that the choroidea shimmers through from behind.*CRLF*38*TAB*2.  Vasculature - Case 4*TAB*This picture represents the right eye of a 50-year-old man.*TAB*The ratio of the diameters of the arteries and veins is 2:3; the blood vessels are therefore normally configured.  Neither fluctuations in diameter nor Gunn’s syndrome are visible.*BR*The watery color of the retina in the region supplied by the superior temporal artery is remarkable and alerts one to the possibility of a cholesterol embolus in this vessel at the level of the disc margin.*TAB*This picture represents an occlusion of the superior temporal artery.  The area of the retina that is not supplied with blood is swollen and edematous.  The macula is not damaged, so that clinically, one would expect to find an inferior nasal quadrant deficit, with the exception of central visual acuity in this eye.*CRLF*37*TAB*2.  Vasculature - Case 5*TAB*This picture represents the left eye of an unknown patient.*TAB*The arteries appear partially dilated.  Remarkable is the superior temporal cholesterol embolus. Behind it, the artery is narrow and ischemic, and the retina is edematous.*BR*The veins appear somewhat dilated peripherally.  Neither fluctuations in diameter nor Gunn’s syndrome are visible.*TAB*This picture represents a minor peripheral arterial occlusion of the superior temporal artery.  The unsupplied region of the retina is edematous and swollen.  At its superior pole, the macula still appears to make contact with the edematous region, so that diminution of central visual acuity, as well as an inferior nasal quadrant deficit in this eye, is to be expected.*CRLF*34*TAB*2.  Vasculature - Case 6*TAB*This picture represents the left eye of a 65-year-old woman.*TAB*The arteries are narrow; the veins, on the other hand, are greatly dilated and tortuous.  As far as one can tell, the vascular intersections are normal.  Remarkable are the dark red striped areas of bleeding over the entire fundus, as well as edematous changes in the disc.  A milky cloudy structure that is not sharply delineated may be seen close to the macula.*TAB*This typical picture with panretinal bleeding and severely congested veins is clear evidence of central venous occlusion.  The bleeding is in the nerve fiber layer, whose course is made clearly visible as a result.  Usually, the cause of venous occlusion is hypertension-related sclerosis of an intersecting artery.  Constriction of the vein also results from transit through the lamina cribrosa.  Increased intraocular pressure or changes in blood viscosity also favor venous occlusion.  Tonometry must be carried out bilaterally.  Nerve fiber infarctions occur as a result of inadequate oxygen supply, leading to milky-cloudy structures, so-called ’cotton wool foci’.*CRLF*77*TAB*2.  Vasculature - Case 7*TAB*This picture represents the right eye of a 45-year-old woman.  The finding is unilateral.*TAB*We see striped bleeding along the nerve fibers in the region between the macula and the superior temporal vascular arch. The surrounding area appears watery so that the subretinal pigment structure cannot be discerned. The arteries exhibit especially wide and bright light reflectivity.*TAB*The areas of bleeding, which have a flame-like appearance, are located in the nerve fiber layer and therefore follow the course of the nerve fibers.  The watery surrounding alerts us to local retinal edema.*BR*The cause of the event is seen to be an occlusion of the venous branch at the point where the artery and vein of the superior vascular arch intersect.*BR*The disseminated fatty foci at the inferior margin of the affected area are a sign that the deficit in the venous branch occurred some time ago.*CRLF*43*TAB*2.  Vasculature - Case 8*TAB*This picture represents the left eye of an unknown patient.  Blood pressure was measured at 220 to 120 mm Hg.*TAB*The arterial-venous diameter ratio is 1:2.*BR*The arterial blood column is uniform.*BR*A cotton wool focus is barely visible above the macula.*TAB*The arterial-venous diameter ratio is pathological. The arteries do not appear constricted, so that the anomaly may be interpreted as severe distention of the venous blood column.  A distended venous diameter is consistent with decreased venous blood flow.  The cause of this could be decreased flow from the capillaries or a blockage of flow in the region of the disc or the ophthalmic vein.*CRLF*88*TAB*2.  Vasculature - Case 9*TAB*This picture represents the right eye of a 52-year-old man.*TAB*The arteries and veins are configured normally.  The diameter ratio is 2:3.  Vascular intersections are unremarkable.*BR*The irregular pigmentation of the fundus is remarkable.*TAB*The inferior nasal vascular branch in this fundus is of interest.  If you follow the course of the artery, you will notice that it branches long before the corresponding vein does.  The already branched artery runs parallel to the much thicker vein and therefore creates the false impression of an incongruity in the diameter ratio.*BR*The irregular pigmentation is a normal variation.*CRLF*48*TAB*2.  Vasculature - Case 10*TAB*This picture represents the right eye of an unknown patient.*TAB*The disc is not sharply delineated.  The arteries are constricted and demonstrate a marked copper-wire look.  The veins are slightly dilated.  The diameter ratio is 1:2.  At the intersections, the veins are constricted like a hourglass, and somewhat more dilated peripheral to the intersection. Gunn’s sign is positive.*TAB*It may be assumed that the arteries experienced arteriosclerotic changes due to persistent hypertension.  At this point, the hardened arteries can no longer be displaced by the veins, which are compressed at the junctions, leading to the observed phenomenon.*CRLF*47*TAB*2.  Vasculature - Case 11*TAB*This picture represents the right eye of an unknown patient.*TAB*The arteries show marked fluctuations in diameter as well as areas of constriction.  Light reflectivity of the vessels is clear.  Where the arterial lumen has narrowed, one can discern arteriosclerotic placques. The veins are configured normally.  They are remarkably tortuous.*TAB*After discussion of the previous picture, we can now interpret the segmental constrictions in arterial diameter as a reaction by the vessels to extremely elevated blood pressure.*CRLF*75*TAB*2.  Vasculature - Case 12*TAB*This picture represents the right eye of an unknown patient.  The findings are bilateral.*TAB*The disc is normal.  The arteries are partially constricted.  The reflectivity of the arteries are markedly light and wide. Gunn’s sign is present at numerous points, and even at the periphery.  Nerve fiber structure is accentuated; the macular region appears markedly dark in the gray surroundings.*BR*Disseminated white fringe-like foci that are not sharply delineated and that follow the nerve fibers are found.*BR*Disseminated areas of bleeding are also present.  These are dot-shaped or flame-shaped.*TAB*This is a case of hypertensive retinopathy.  In comparison to the veins, the arteries are too thin; the whitish structures may be interpreted as cotton wool foci at the periphery, i.e., local ischemic nerve fiber edema.*CRLF*45*TAB*2.  Vasculature - Case 13*TAB*This picture represents the left eye of a 40-year-old woman*TAB*The arteries are narrowed.  The bright and wide light reflectivity of the blood vessels gives it the appearance of silver wire.  The veins, on the other hand, are wide and show fluctuations in diameter.  The A-V diameter ratio is 1:2.  At the places where the veins are intersected by arteries, they demonstrate hourglass constrictions.  Therefore, Gunn’s sign is positive.  In the region between the disc and the macula, we see sharply delineated light-colored atoll-like structures that are called ’hard exudates’.*TAB*This case involves changes that can be caused by extreme elevations in blood pressure.  The arteries are constricted, but hardly sclerosed.  This picture represents an ’angioplastic retinopathy’.*BR*Initially, the arteries are narrowed; subsequently fluctuations in the diameter of the arterioles begins to appear.*BR*Later, the disease is no longer restricted to the blood vessels, but affects the entire retina, as can be seen in our picture.  Bleeding and small infarctions in the nerve fiber layer occur as a result of occlusion of the precapillary arterioles.  In addition, lipid deposits that are often star-shaped and atoll-like build up around the macula as a result of fluid leakage.  These light yellow, sharply delineated structures are called ’hard exudates’.  By contrast, the edema caused by infarction appears as watery cloudy structures that are called ’cotton wool foci’.*BR*During the most severe stages of hypertensive retinopathy, papilledema is added to this picture.*CRLF*60*TAB*2.  Vasculature - Case 14*TAB*This picture represents the left eye of a 78-year-old woman.*TAB*This is a somewhat unusual picture, which, however, allows us to analyze various types of bleeding topographically.*BR*Two larger, well delineated areas of bleeding may be seen.*BR*The upper bleeding is roundish with a blackish zone at its center with no sharp delineation, surrounded by a red zone that is sharply delineated.  There is a red area in the center that is not sharply delineated in which the blood vessels are hidden.  There is a light-colored circle in the center itself.*BR*The lower area of bleeding forms a marked level.*BR*We see several blood spots in the field between these large areas of bleeding.*TAB*The large round area of bleeding is a burst arterial aneurysm that has bled posteriorly into the retinochoroidal space, and anteriorly into the vitreoretinal space.  A compact blood clot has formed posterior to the bleeding, from which a sharply delineated band of hemoglobin has been released.*BR*The blood vessels present around the aneurysm have been covered by the anterior bleeding.  A portion of this blood dripped down between the retina and the vitreous body, and formed the second larger level bleeding, as described above.  The sharp margin of the preretinal bleeding shows that the posterior vitreous body has been lifted only at this location.*CRLF*59*TAB*2.  Vasculature - Case 15*TAB*This picture represents the left eye of the 49-year-old man.*TAB*The main finding is a well-delineated area of bleeding in the inferior section of the fundus.  The bleeding forms a mirror.  The lower portion of the bleeding is penetrated by a gray-white cloudy structure.  Apart from this main finding, numerous secondary findings are also present, which we will point out in the interest of understanding diabetic changes in the fundus.*TAB*The picture suggests diabetic retinopathy.*BR*In this picture, microaneurysms are seen primarily temporally.*BR*Intraretinal hemorrhage is seen here nasal to the disc. Revascularizations show a strong tendency to spontaneous bleeding, which often seeps into the space between the retina and the vitreous body.  Mirror formation is typical of bleeding in this space.  Actual proliferations are not discernible in this picture.  The sausage-shaped vascular distention close to the lower edge of the picture at 7 o’clock may be interpreted as evidence of hemodynamic disturbances that are taking place; a larger area of vascular proliferation may also be hidden behind the black-gray zone at the lower edge of the bleeding.*BR*An atypical white layer is notable in this example that may consist of old leached out erythrocytes - or perhaps of leukocytes associated with a leukemia.*CRLF*65*TAB*2.  Vasculature - Case 16*TAB*This picture represents the left eye of a 68-year-old woman.*TAB*Diffusely distributed temporally concentrated intraretinal areas of spot bleeding are present. Hard exudates, which are concentrated around the macula, are visible over the entire photographed area. *TAB**CRLF*69*TAB*2.  Vasculature - Case 17*TAB*This picture represents the left eye of a 57-year-old man.*TAB*In the upper half of the picture, we see a vascular bed with irregular capillaries, a so-called ’rete mirabile’.  In addition, several small pointy red structures may be seen.  The irregular thin-walled vascular networks are also present at the bottom of the picture.*TAB*The remarkable structure of the vascular bed is consistent with preretinal neovascularization.  The ischemic retina produces an ’angiogenic factor’ that promotes vascular proliferation (e.g., VEGF). *BR*The red pointy structures are diabetic microaneurysms.  Typically with these capillary aneurysms, both an efferent and an afferent vessel are visible.*CRLF*50*TAB*2.  Vasculature - Case 18*TAB*This picture represents the right eye of a 31-year-old man*TAB*The arteries and veins have a normal diameter, the ratio being 2:3.  The distinct tortuousness of the blood vessels is remarkable.  No Gunn’s sign is present.*TAB*Marked tortuousness of the blood vessels is notable at first glance.  There are no other anomalies; in particular, the diameter ratio is normal.  Gunn’s sign as well as retinal changes such as cotton wool foci and areas of bleeding are missing.  In spite of the conspicuousness of the picture, this need not represent a pathological event, but could will be a normal variation.  Long-term observation is required to make a determination.*CRLF*104*TAB*3.  Fundus Introduction*TAB**TAB*Everything that is neither disc, blood vessel, or macula, in other words, the retina, is called the Fundus.  Let us consider the anatomy of the eye.  The top layer that we see consists of retinal blood vessels and nerve fibers.*BR*Below that follow the nerve and supporting cells.  Finally, the cell bodies of the sensory epithelium push their cones and rods through a membrane against the pigment epithelium, separated only by a capillary cleft through which nutritive substances diffuse from the choroidea.*BR**BR*Normally, the retina presents a smooth, regular picture.  Generally, pathological processes will disturb this smooth integrity, thereby immediately calling attention to themselves.*BR*In addition, changes appear either localized or diffused.*BR**BR*When evaluating the Fundus, we should ask whether:*BR**BR*1. integrity is intact or disturbed;*BR**BR*2.  when the integrity is disturbed, the event is focused or diffuse;*BR**BR*3. and finally, ascertain by means of precise observation in which layer of the retina the changes have taken place.*TAB**TAB**CRLF*51*TAB*3.  Fundus - Case 1*TAB*These 4 pictures show the variety of normal fundus pigmentation.*TAB*Each of the 4 pictures shows a normal fundus.*BR*In the upper left, we see a fundus with a markedly irregular pigmentation distribution.*BR*Upper right, we see a normally pigmented fundus, in which the choroidal vessels that lie behind it shine through with a marbled red pattern.*BR*Below left, we see a light-colored, but normally pigmented fundus.  The choroidal vessels are not visible, evidence that it is well covered by the pigment epithelium.  This fundus coloration is typical of people with light skin color.*BR*And finally we see, below right, a very darkly pigmented fundus, which is typical of people with dark skin color.*TAB**CRLF*54*TAB*3.  Fundus - Case 2*TAB*This picture represents the left eye of a 50-year-old woman.*TAB*There is a clearly localized and sharply delineated color change in the region of the superior temporal vascular arch.  The finding does not appear raised.*TAB*A localized brownish non-raised color change is called a ’nevus’.  To all appearances, the change is subretinal.  When making a differential diagnosis of color changes, the following pathologies should be considered: melanoma, metastasis, choroidal nevus, hemangioma, or subchoroidal bleeding.*CRLF*56*TAB*3.  Fundus - Case 3*TAB*There is no further information about this patient’s fundus.*TAB*This picture represents a peripheral section of the fundus.  The normally homogeneous picture of the fundus is disturbed by diffuse changes.  The pigmentation is very irregularly distributed: it condenses out in the lower half of the picture, and is reminiscent of trabeculae in its structure; by contrast, the choroidal vasculature is easily visible in the upper half of the picture, which is consistent with a thinned pigment epithelial layer.*TAB*Clumping of the pigment and adjacent atrophy of the pigment epithelium are typical of the most frequent hereditary retinal disease, retinopathia pigmentosa.  Other characteristics of this disease are waxy yellow atrophy of the disc and thready retinal arteries, neither of which is visible in this picture.*CRLF*58*TAB*3.  Fundus - Case 4*TAB*This picture represents the left eye of a 45-year-old woman.*TAB*The well-delimited change is hyperpigmented at the periphery; at the center, by contrast, it is generally more hypopigmented.  The lack of sharpness at the center of the alterated area shows that it is protruding.*TAB*Melanoma typically appears as a prominent, mostly pigmented raised protrusion with an irregular surface.  Orange lipofuscin deposits are often seen on the tumor.*BR*By contrast, a nevus is often deep black in color, not raised, and it often has plaques on its surface.*BR*A subretinal hemangioma or bleeding could have a similar look; however, these are never more lightly colored centrally than at the periphery.*BR*In all probability, this is a case of melanoma.*CRLF*67*TAB*3.  Fundus - Case 5*TAB*This picture represents the right eye of a 28-year-old woman.*TAB*Remarkable are the light yellow, sharply delineated plaques.  The structures are radial in form, arrayed in the region of the macula, and they converge centrally.  The arteries are approximately three times narrower than the veins.  Gunn’s sign is not discernible.  A clearly visible nerve fiber course is a discernible secondary finding.*TAB*The converging plaques are lipid deposits, so-called ’hard exudates’.  These, in turn, are formed when the vascular walls are abnormally permeable.  Typical diseases leading to hard exudates include hypertensive retinopathy and diabetes.  Because in this case the microaneurysms and point bleeding that is so characteristic of diabetes is not present, we conclude that this is a case of angioplastic retinopathy.*CRLF*68*TAB*3.  Fundus - Case 6*TAB*This picture represents the right eye of an unknown patient.*TAB*Whitish structures that are not sharply delineated, so-called ’cotton wool foci’, are found temporally on the disc.  Striped areas of bleeding are visible over the course of the inferior temporal vascular arch.  The veins are configured normally; the arteries, by contrast, demonstrate a silver wire look and are only half as wide as the veins.*TAB*The whitish cloudy structures are localized ischemic edema.  The striped areas of bleeding are intraretinal.  The silver wire look of the arteries is evidence of hypertensive retinopathy.*CRLF*70*TAB*3.  Fundus - Case 7*TAB*This picture represents the left eye of a 48-year-old man.*TAB*In the upper half of the picture we see sharply delineated hyperpigmented foci.  The blood vessels appear to run regularly in this region.  By contrast, the irregular vascular outpouchings are a remarkable feature of the lower half of the picture.  Whitish watery foci that are not sharply delineated are the main finding in the lower half of the picture.  These foci are of notable regularity in terms of arrangement and size.*TAB*The regularity of the arrangement of the light-colored watery foci in the lower half of the picture is grounds for suspecting that they may be the result of artificially produced lesions.  Localized retinal edema brought about by laser coagulation has this look.*BR*Laser coagulation is the therapy of choice in proliferative diabetic retinopathy.  The development of further neovascularizations, and the danger of bleeding that results from them, are thereby decreased.*BR*The hyperpigmented foci in the upper half of the picture also show a certain regularity.  These are older laser scars.*CRLF*71*TAB*3.  Fundus - Case 8*TAB*This picture represents the left eye of an unknown, but almost certainly older, patient. The findings are bilateral.*TAB*In the region around the macula, we see well delineated white foci.*TAB*These are plaques, which are collections of hyaline material in the region of Bruch’s membrane.  The hyaline material amass when the pigment epithelium can no longer process metabolic products from*BR*the photoreceptor outer segments. One pigment epithelial cell must metabolize approximately 200,000 desquamated discs from the outer segments per day.*CRLF*72*TAB*3.  Fundus - Case 9*TAB*This picture represents the right eye of a 30-year-old woman.  The findings are bilateral.*TAB*The diffuse change in the temporal fundus is remarkable.  These are sharply delineated whitish foci that appear particularly in the region of the macula.*TAB*The observed changes in a young woman are evidence of a hereditary degenerative maculopathy.*CRLF*73*TAB*3.  Fundus - Case 10*TAB*This picture represents the left eye of a 60-year-old man.  The finding is unilateral.*TAB*The entire visible retina is diffusely arranged in small folds as a result of inclusion of the blood vessels.  The picture lacks sharpness in the area of the disc and in the superior and inferior region.  The macula has a remarkable yellowish coloration.*TAB*This is the typical picture of retinal detachment.  The focus of the picture is on the detached retina, which is why the disc is fuzzy.*BR*The most common form of detachment results from a tear in the retina, which allows vitreous fluid to seep between the sensory retina and the pigment epithelium.  When examining such a patient, always look for a retinal tear.*BR*Usually, retinal tears occur at the point where the vitreous body attaches to the retina peripherally.  Mechanical pull results at the attachment points as a result of age-related liquification and restructuring of the vitreous body, or after cataract surgery.*BR*Rarer causes of detachment include contusion or perforation of the eye.  In retinal ischemia and inflammation, both preretinal and intraretinal structures may shrink, which can lead to traction detachment.  Failed retinal surgery can also end in such detachment.*CRLF*74*TAB*3.  Fundus - Case 11*TAB*This picture represents the right eye of a 61-year-old man.  The finding is unilateral.*TAB*The greater part of the picture is fuzzy.  The picture is focused upper left on a whitish fold.  No retinal tear is discernible*TAB*This picture is typical of a retinal tear.  The picture is focused on the detached retina.  The most common form of detachment results from a tear in the retina, which allows vitreous fluid to seep between the sensory retina and the pigment epithelium.  When examining such a patient, always look for a retinal tear.*CRLF*76*TAB*3.  Fundus - Case 12*TAB*This picture represents the right eye of a 28-year-old man suffering from AIDS.  The finding is unilateral.*TAB*The normal structure of the fundus is destroyed, except for the superior temporal part.  The disc cannot be evaluated and is surrounded by areas of bleeding.  The retina is darker than normal in the lower half of the picture; in this region, the arteries are bloodless and the veins thready.  There are unsharply delineated wave-like whitish confluent foci on the line that leads temporally from the disc.  These white structures are also found temporal and superior to the disc.  Below the disc, one can make out an area of bleeding with mirror formation.*TAB*This is a case of cytomegalic retinitis secondary to AIDS.  The acute retinal necrosis proceeds like wildfire over the retina, leaving holes in the retina that can lead to detachment of the retina. Cytomegalic retinitis can occur in persons with compromised immune systems, and it usually leads to bilateral blindness.*CRLF*105*TAB*4.  Macula Introduction*TAB**TAB*The macula lies at the optical axis and corresponds to the region of central vision.  The fovea is situated at its center;it is the region of the greatest visual acuity, yet its diameter is no more than 1/5 mm!  Each foveal cone is connected to a corresponding bipolar cell and ganglial cell; by contrast, many receptors converge on one ganglial cell at the periphery.  The cones that are responsible for color vision are located in the fovea.  The rods that are responsible for night vision are located more peripherally.*BR**BR*The anatomy of the macula is somewhat different from that of the rest of the retina.*BR**BR*Because the original vasculature only extends to the rim of the fovea, it is nourished by the choroidea.  In the sectional view, the fovea appears as dimple from which the axons of the sensory epithelium emanate, and only somewhat more peripherally do we get to the regions containing the cell nuclei of bipolar and ganglial cells.*BR**BR*We evaluate the macula according to:*BR**BR*1.  whether the changes only affect the macula, or whether other fundus structures are also involved; *BR**BR*2.  what coloration that change demonstrates; and*BR**BR*3.  whether the margin of the change is sharp or fuzzy.*TAB**TAB**CRLF*80*TAB*4.  Macula - Case 1*TAB*This picture represents the left eye of an 81-year-old woman.*TAB*A large centrally located dark red structure, which does not extend to the fovea, is notable.  In addition, sharply delineated whitish perimacular structures that are distributed in a star pattern may be seen.  The fundus is penetrated by a reddish net-like pattern.*TAB*The dark red structure could be an area of bleeding, a hemangioma, or a bleeding choroid melanoma.  Because the fovea centralis is unaffected, the process must be taking place below the retina, but above Bruch’s membrane.  Therefore, it is most probably an area of bleeding because both hemangioma and bleeding choroid melanoma occur within the choroidea,  i.e., beneath Bruch’s membrane.*BR*The whitish perimacular structures may be interpreted as hard exudates.*BR*The choroidea shimmers through the retina; therefore, the pigment epithelium is only barely present.*CRLF*71*TAB*4.  Macula - Case 2*TAB*This picture represents the left eye of an unknown, but almost certainly older, patient.  The findings are bilateral.*TAB*In the region around the macula, we see well-delineated white foci.*TAB*These are plaques, which are collections of hyaline material in the region of Bruch’s membrane.  The hyaline material amass when the pigment epithelium can no longer process metabolic products from the photoreceptor outer segments. One pigment epithelial cell must metabolize approximately 200,000 desquamated discs from the outer segments per day.*CRLF*82*TAB*4.  Macula - Case 3*TAB*This picture represents the right eye of a 25-year-old man.*TAB*The macula has been lifted and replaced by a dark sharply delineated structure.*TAB*This is a macular hole.*CRLF*83*TAB*4.  Macula - Case 4*TAB*This picture represents the right eye of a 52-year-old woman.*TAB*The normal structure of the macular is disturbed.  Ring-shaped foci of a lighter color that are not sharply delineated are found around the fovea.  The choroidea appears through the lighter region.  In the outer regions, this ring-shaped focus is bordered by normally pigmented portions of the peripheral macula.  As a result, the macula itself has the appearance of an eye.*TAB*This typical picture is also called ’bull’s-eye maculopathy’.  The ring-like zone around the fovea is the result of local pigment epithelial atrophy, something that may be observed with long-term ingestion of the antimalarial medication chloroquinine.*CRLF*63*TAB*4.  Macula - Case 5*TAB*This picture represents the macular region of the left eye of a 57-year-old man.*TAB*The normal structure of the fundus is severely disturbed.  We see many diffusely distributed red points; at the same time, our attention is drawn nasal inferior to capillary proliferation.  No blood column is visible in the artery supplying the inferior temporal region.*TAB*This is a detail picture of a diabetic retinopathy with point-shaped intraretinal areas of bleeding, microaneurysms, a neovascularization Segel, and occlusion of a small vessel.*CRLF*52*TAB*4.  Macula - Case 6*TAB*This picture represents the right eye of an 11-year-old girl.*TAB*Retinal morphology is broken down in the region of the macula.  It has been replaced by a very turbulent ring-shaped structure that consists of dark brown and yellow parts.  Only a light area of reflectivity is visible at the center of the ring.  A small hyperpigmented change that looks like a daughter growth of the above-mentioned structure may be seen nasal inferior.*TAB*This is a central hyperpigmented scar.  The retina and the choroidea are completely destroyed in the center of the scar so that light is reflected directly from the sclera.  The focal type of the change and the age of the patient are evidence of congenital toxoplasmosis.  This was probably the result of a diaplacental infection.  Toxoplasmotic retinochoroiditis is a focal inflammation of the retina and choroidea.  It often affects the macula or the region surrounding the disc and leads to severe visual disturbances.*CRLF*84*TAB*4.  Macula - Case 7*TAB*This picture represents the right eye of a 13-year-old boy who looked directly into a laser beam.*TAB*There is a raised sharply delineated area of bleeding in the foveal region, with a flat offshoot running in the direction of the disc.*TAB*The laser beam caused bleeding in the region of the fovea.  The flat offshoot that runs in the direction of the disc is evidence of lifting of the vitreous body, which allowed blood to seap in.*CRLF*85*TAB*4.  Macula - Case 8*TAB*This picture represents the right eye of a 14-year-old girl.*TAB*There is an irregularly shaped hyperpigmented focus in the region of the fovea that is not sharply delineated, which is surrounded by a pale zone.  The rest of the macular region is well pigmented and dark red.*BR*The tissue around the inferior vascular arch is cloudy and lighter colored.  There is a cloudy light structure near the disc just above the inferior vascular arch.*BR*The disc is very unsharply delineated nasally.*TAB*This is a case of fresh chorioretinitis.  The cloudy white structure above the inferior vascular arch is a fresh retinal edematous focus, the result of inflammation.  The lack of sharpness nasally in the disc is also caused by edema.  In addition to the fresh findings, old macular scars may be seen as well.*CRLF*86*TAB*4.  Macula - Case 9*TAB*This picture represents the right eye of a 69-year-old woman.*TAB*The retinal architecture has been destroyed in the region of the macula and adjacent areas up to the vascular arch.  There are convergent whitish-yellow foci that are not sharply delineated; in addition, several small areas of bleeding may be seen.*TAB*A number of causes for the light yellow structures are possible: these could be areas where both the pigment epithelium and the underlying choroidea have degenerated, causing us to see the light-colored sclera; on the other hand, this picture could also be explained by changes in the connective tissue of the retina.*BR*In this case, we are dealing with a macular scar; in other words, there were connective tissue changes.