NORMAL RETINAL ANATOMY
MAJOR ZONES OF THE RETINA
CENTRAL VS PERIPHERAL FUNDUS
1. Central fundus
– Posterior pole
– Mid-periphery
2. Peripheral fundus
– Equatorial region
– Oral region
OPTOS Images of most of Central
Fundus
OPTOS will often cut-off the superior and inferior
NORMAL RETINAL ANATOMY
CENTRAL FUNDUS
Arbitrary definition denoting that
portion of the fundus posterior to
posterior edges of vortex veins
Imaginary circle between the
posterior edges of the vortex vein
ampullae is used as the
demarcation between the central
and peripheral fundus
NORMAL RETINAL ANATOMY
CENTRAL FUNDUS
1. Posterior pole
•
•
Ill-defined region in most central
fundus
Includes: ONH, macula, vascular
arcades
2. Mid-periphery
•
Ill-defined region just posterior to
an imaginary circle connecting the
posterior edges of the VV ampullae
NORMAL RETINAL ANATOMY
SIGNIFICANCE OF VV AMPULLAE
VV ampullae are the major fundus
landmarks in recognizing the
retinal periphery
NORMAL RETINAL ANATOMY
PERIPHERAL FUNDUS
1. Equatorial region
•
•
Width: 4 dd in width extending anteriorly
from an imaginary circle connecting the
posterior edges of the VV ampullae
Equator: mid-point of the region and
roughly at the anatomical equator of the
globe
2. Oral region
•
~3 dd in width straddling the ora with 1dd
anterior to ora and 2 dd posterior to ora
NORMAL RETINAL ANATOMY
RECOGNITION OF THE EQUATOR
Depends on:
– Good proficiency with BIO
• Often do not get VV ampullae in a static view or
two ! MUST be able to SCAN the peripheral
fundus to localize the vv ampullae
• Good capability in the use of the Basic Principles
of Orientation and Localization in BIO
– Familiarity with peripheral retina
– Recognition of VV ampullae
• Key in finding the VV ampullae is
finding/recognizing the tributary veins – they all
converge to the VV ampullae
NORMAL RETINAL ANATOMY
MAJOR PERIPHERAL RETINAL
LANDMARKS
1.
2.
3.
4.
Vortex vein ampullae
Long ciliary nerves
Short ciliary nerves
Ora serrata
MAJOR PERIPHERAL RETINAL LANDMARKS
VORTEX VEIN AMPULLAE
• The major landmark – posterior edge
marks the posterior edge of retinal
periphery
• Variable in number: at least 1/quadrant
usually
• Variable appearance – usually reddish or
pinkish
• Tributary veins very often much easier to
recognize
– Use them to find the VV ampullae
MAJOR PERIPHERAL FUNDUS
LANDMARKS
How to find the Vortex Vein Ampulla
Localize the tributary veins and follow them to
their convergence point
Where is the inferior temporal VV ampulla?
Medium dark (tigroid) fundus
Ocular albinism
BIO VIEWS OF THE VV AMPULLAE
No retinal/choroidal pigmentation in this case
BIO VIEWS OF THE VV AMPULLAE
MAJOR PERIPHERAL RETINAL LANDMARKS
LONG CILIARY NERVES
• Mark the 3:00 and 9:00 meridians of
the eye; consistent in location
• In suprachoroidal space
• Long, straight white, yellow or tan.
Often outlined by choroidal
pigment
• Usually 3 to 6 dd in length
MAJOR PERIPHERAL FUNDUS LANDMARKS
Left eye
OD long ciliary nerve at 9:00
position
MAJOR PERIPHERAL RETINAL LANDMARKS
SHORT CILIARY NERVES
• Roughly at 6:00 & 12:00 but VERY
variable in location
• Often near VV ampullae
• Variable in number; may be many
• Appearance: shorter (~2 to 3 dd in
length often). Often not straight.
Usually thicker than long ciliary
nerve.
MAJOR PERIPHERAL FUNDUS
LANDMARKS
Two Short Ciliary Nerves
MAJOR PERIPHERAL RETINAL LANDMARKS
ORA SERRATA
MAJOR PERIPHERAL FUNDUS LANDMARKS
Peripheral limit of the retina
Retinal vessels do not cross the ora
Retina is darker at the ora
Difficult to view in most cases
Not necessary to view in
baseline/periodic DFEs
• Often necessary to view in extended
ophthalmoscopy (92225/92226)
•
•
•
•
•
VITREOUS BASE
• Definition: Area of strongest normal
attachment between vitreous and retina
• Location: Straddling the ora; posterior
border is 1-2 dd posterior to the ora
generally
• Clinical significance: Posterior edge is
common site of retinal breaks. Why?
Vitreous traction causing a strong
shearing force on the retina at the
posterior edge of vitreous base.
VITREOUS BASE
VITREOUS BASE
POSTERIOR VITREOUS DETACHMENT
(PVD)
When must it be viewed?
Any time the patient has symptoms
or signs suggestive of retinal
traction, retinal tear or retinal
detachment i.e. recent or acute
onset flashes, floaters, pigment or
blood in vitreous etc.
• Definition: Separation of the vitreous from the
retina except at the vitreous base
• Very common, age-related occurrence
• Significance: During the evolution of PVD
there is " shearing force at the posterior edge
of vitreous base
• Up to 10% of recent onset PVDs have retinal
tear, many of the tears are at posterior edge
of vitreous base
• Must view vitreous base to rule out retinal
tear in recent, acute PVD
PVD Causing Horseshoe Tear Which
Releases Pigment into Vitreous
Normal or not?
Your responsibilities in
fundus evaluation
• Recognize normal from not normal.
• If not normal describe and localize.
Describe based on your knowledge of
anatomy and physiology
• Localize as specifically as possible
– In peripheral retina use zones/regions of
fundus and clock hour position
– In central fundus use major fundus landmarks
i.e. ONH, macula
• Draw it – “a picture is worth a 1000 words”
- Judy Tong, OD, very wise philosopher
TEST YOUR BIO BRAINS!!
• Which area (superior,
inferior, temporal, nasal
etc.) of the fundus are
you viewing?
• What normal retinal
landmark would
normally be at a
consistent clock hour
position i.e. 1:00, 5:00
etc. in this (your answer
above) area? Do you
see that landmark in the
image?
• Do you see any normal
retinal landmarks in the
image? If so what
landmark(s)?
TEST YOUR BIO BRAINS!!
On the BIO image:
You are viewing the
patient’s left eye
The patient is
reclined with his feet
to your right
You are standing to
the patient’s right
The patient is
looking to his left
TEST YOUR BIO BRAINS
EVEN MORE!!
• If you wanted to see the most anterior edge of
the lesion what should you do?
• If you wanted to view the most superior
(superior in the eye) edge what would you
do?
• How would you document the lesion in your
chart?
• If this lesion were the result of a retinal tear
where would the tear most likely be?
• If a retinal tear were present what would likely
be found when you evaluate the vitreous with
the slit lamp biomicroscope?
OPTOS
Clinical Documentation
• What 2 abnormalities are present?
• Describe and localize on fundus drawing
the abnormality in the posterior pole location (relative to major retinal
landmark), size, shape, color, borders
– Is it in the retina or choroid?
• Describe and localize the one in the
peripheral fundus on fundus drawing location (zone + clock hours), shape,
color etc.
– Is it retinal or choroidal?
• How does your drawing/description
compare to the retinal image, OPTOMAP?
OPTOS
ECC Room 206 in PC Service; ECC Room 319 in CL
Service; ECC Room 501 in Peds
OPTOS
• Scanning laser ophthalmoscope
• Acquires image with green light
(retina down to RPE) and red light
(penetrates RPE into choroid)
• Acquires very wide angle (~200º
lateral extent) retinal image, called
ans “Optomap!
!”
• Dilation not required!!!
Clinical Advantages of Optomap Images
• Very wide field of view ! easier to
detect color lesions of retina & choroid
• Very wide field of view ! shows
relationships and locations very well
• Digital image ! excellent method of
documentation
– Much better documentation than just writing
– Image can be brought up in any ECC exam
room
– Can be magnified for greater detail
– Can be viewed in either red or green to
localize anomalies to retina or to choroid
Comparison of Fields of View
Optomap – 200 degrees
Slit lamp with 90
diopter lens
Fundus camera – about 45 - 60 degrees
Indirect ophthalmoscope – about 35 40 degrees
Direct ophthalmoscope – ~ 10 degrees
• Dilation is not required
Direct
ophthalm
oscope =
>400
Linked
fields
M or e
realistical
ly 70 is
typical
exam
BIO (or
f u n du s
ph ot o
graphy)
= 50
linked
Fields
OPTOS AT ECC
Clinical Applications
• Screening retinal exam
– Part of all of our comprehensive exams
– Replaces periodic dilated exam in some
cases
• Medical photography (CPT 92250
which is $110 at ECC)
– Superior to other imaging for some
peripheral retinal disorders i.e. lattice,
retinal breaks, retinoschisis etc.
OPTOS IN the PRIMARY CARE EXAM
Patient ed on the value & benefit of OPTOS
• Advise that OPTOS acquires digital images
which are excellent quality and may allow us
to detect very subtle changes over time.
• Advise that it is much better than writing and
an excellent adjunct to DFE. “That is why we
use it as a part of all of our comprehensive
exams at ECC.”
• Advise that we recommend it at the first exam
along with the dilation. We may perform
dilations less often and replace the periodic
dilations with OPTOMAPs. OPTOMAPS allow
us to see areas of the retina that we cannot
see with any other instrument when not
dilated
OPTOS AT ECC
How should it be used in a PC Exam?
• Provide for all new patients as baseline
documentation (digital image)
– Note: Does NOT replace the baseline DFE but
does supplement it by providing much better
documentation than written notes and gives an
additional, unique wide angle view of the fundus.
Written notes should still be made in the chart.
• Use it rather than periodic DFE (in many
cases) or in addition to periodic DFE
– Note: it can be used to replace the periodic DFE in
a patient who has no suspicious findings on the
prior DFE and no reasons for suspicion in the
case history
– Patients love having no dilation!!
OPTOS AT ECC
How are we using it to document eye health
conditions (92250)?
May be used as medical photography (92250
$110) to photodocument a health condition
so we can follow the condition in the future.
MUST indicate the health diagnosis on the fee
sheet to justify the charge.
Examples of health conditions that may be
documented with OPTOS: choroidal nevi,
macular degeneration, diabetic retinopathy,
lattice degeneration, atrophic retinal hole, etc.
Caution with Medicare patients – only a few
conditions are reimbursable for medical
photography
2nd Year Interns & OPTOS
• Should know how to provide patient ed on
OPTOS – what are we doing and why (the
benefit to the patient)
• Should know how to efficiently acquire good
OPTOS images for fundus documentation
during a PC exam
• Should know how to link the OPTOMAP to the
patients record
• Should know how to bring up patients’ OPTOS
images (OPTOMAPs) in exam rooms
• Should be able to review OPTOS images and
determine if normal or not, describe/localize in
anatomic terms & use knowledge of anatomy to
evaluate
High axial myope OS
OPTOS “tilted” the ONH in the past, tilt now corrected
This is your first patient and you
shot this OPTOS. Decision time!
• Normal or not?
• If not what is
not?
• Localize &
describe as you
should record in
Examwriter
12 year diabetic OS
OPTOMAP of lattice degeneration (retinal thinning) &
"choroidal melanocytes)
choroidal nevus ("
Use of red – green separation on OPTOS
Green (retina is enhanced)
Lattice degeneration inferior temporal
Normal or not??
Red (choroid is enhanced)
Choroidal nevus inf to ONH
Normal or not??
Normal or not??
OPTOS AT ECC
What should OPTOS NOT be used for?
• To replace a baseline DFE
– OPTOS should be used to supplement the
baseline DFE with baseline photodocumentation
at the initial exam of all new patients. Do not delay
OPTOS to the DFE; get it at the intial exam.
– OPTOS does NOT replace of the baseline DFE
even though some practices use it that way
• To replace the yearly DFE that diabetics
should have
– OPTOS can/should be used to supplement the
DFE with photodocumentation
• To replace any DFE where there were
questionable findings in the prior exam or
new symptoms/signs suggesting a need for
an periodic BIO or extended ophthalmoscopy