Optic Nerve Head

CD ratio= ratio of the cup area to the optic nerve head area
o Horizontal ratio (decimal form)/ Vertical ratio (decimal form)

o Record laminar dots (holes in lamina cribrosa) if seen

NFL defects
o Record absent or slit, wedge, or atrophy and location of defect
Seen with the red-free filter

 Color
o Record pink or pallor

Quality of margins
o Record if margins are distinct (MD) or elevated and indistinct
o Note optic nerve swelling and measure
Papilledema=optic nerve swelling from increased intracranial pressure
To measure optic nerve head swelling
Focus on a blood vessel in the center of the nerve; then focus
on a blood vessel just outside the nerve and note how many
diopters of lens change you made
3.00D= 1 mm of elevation
o Papilledema can cause a difference in elevation of 9.00D
o Note optic nerve head drusen (calcium deposits)

o Note choroidal crescents or scleral crescents

Choroidal crescent= pigment crescent at border of nerve (usually
temporal) where retina is pulled away from nerve and choroidal
pigment shows; normal

Scleral crescent= white crescent where retina and choroid are both
pulled away from optic nerve; often seen in myopia

o Record congenital abnormalities

Nerve fiber layer myelination= white myelin on the nerve fiber layer
often at the edge of the disc; no problems

Bergmeisters papillae= embryonic glial tissue remnants over part of

the disc, clear/whitish; no problems

o Note whether a spontaneous venous pulse (SVP) is present or not present

Spontaneous venous pulse= pulse of the central retinal vein
Present in ~80% of normals
Absent in papilledema
If was present before but now absent could also indicate impending
closure of CRV
Pulsation of central retinal artery is abnormal
Only occurs if IOP is very high in a glaucoma attack; CRA
occlusion may occur
Macula
Note whether the foveal reflex is bright (FRB), dim (FRD) or absent (FRA)
o FRA often in older patients
o FRA also in macular disease (central serous retinopathy, macular edema,
macular dystrophy)

 Note pigmentation
o Darker than the surrounding retina is normal
o Pigment clumping and RPE window defects (hypopigmented areas) are seen
in dry ARMD

o Bulls eye maculopathy= pigmented ring at edge of macula; sometimes seen

in patients taking chloroquine (arthritis medication); bad

o Beaten bronze= metallic appearance in Stargardts disease

Note flat or elevation

o Flat is normal
o Elevation indicates disease such as a choroidal neovascular membrane from
wet macular degeneration, central serous choroidopathy, cystoid macular
edema, etc.
Note any lesions
o Drusen= white or yellow, round, or oval deposits in Bruchs membrane that
indicate damage to the RPE
Macular drusen seen in dry ARMD

o Hole=red, circular and may have white edges of fluid under retina
o Hemorrhages= red and can be dot, blot, flame, or boat-shaped depending on
depth/location (easier to see with red-free filter)

Dot/Blot in deep retina

Flame in nerve fiber layer

Pre-retinal hemorrhages b/t retina and vitreous are large, boat-shaped

o Hard exudates=yellow lipid deposits of variable shape, often linear,

associated with hemorrhages and retinal thickening from leakage from
nearby blood vessel

o Cotton wool spot=white puffy circular or oval area that is a localized infarct of
the retina nerve fiber layer from ischemia

Vessels
Note the A/V ratio
o A/V ratio= ratio of arteriole diameter to venule diameter
Go beyond the first bifurcation to assess
Normal A/V ~2/3
In HTN, arteries are attenuated and A/V ratio may be 1/2 or 1/3
Note the arteriolar light reflex
o Arteriolar light reflex (ALR)= ratio of the line of light in the center of the
arteriole to the width of the arteriole
Go beyond the first bifurcation to assess
Normal ALR ~1/2

With arteriolar sclerosis from high cholesterol/hyperlipidemia or HTN,

the light is wider and the fraction larger
If the reflex is very obvious and wide it is called copper wire
Patient likely has serious cholesterol/lipid disease including
plaques in the heart and carotids, HTN
If the reflex takes up almost the entire diameter of the vessel it is
called silver wire
Patient almost assuredly has serious heart and/or carotid
disease from cholesterol and lipid plaque, HTN

Patients with cholesterol and lipid plaques are at increased risk for MI
(myocardial infarction) and stroke because of emboli and thrombi,
HTN
Note the caliber
o Normal
o Attenuated (thinner than normal )
Seen with carotid occlusive disease

o Venous beading (looks like sausages)

Found in diabetics

o Dilation
Blood dyscrasias like sickle cell
Note crossing changes
o Note if present or absent in all hypertensives
Arterioles and veins share the same outer layer (tunica adventita)
where they cross
If an arteriole becomes sclerosed (accompanies HTN) the force
transmitted through the tunica adventitia causes traction on the wall of
the vein
Result is crossing changes: compression, deviation, humping,
tapering, banking

 More obvious the crossing changes, the more serious the sclerosis
o Note if present in non-HTN patients
If present, check blood pressure (be suspicious of HTN)
Note course
o Note any tortuosity and whether it is arterioles or venules or both
Tortuosity in one eye only may be a sign of disease (vascular, tumor)
Tortuosity in both eyes may be a sign of a blood dyscrasia

Background
Note color
o Uniform
o Tigroid=reddish stripes like a tiger from the choroidal vessels visible in
patients with lightly pigmented RPE
Normal variant, myopia, increased age

o No pigment in RPE
Choroidal vessels clearly visible in albinism/ ocular albinism patients
blonde fundus

Note any lesions

o Note any hemorrhages
o RPE hyperplasia= patches of black pigment with well-defined borders
No problems outside of macula

o Choroidal nevus=slate grey or blue gray

Borders hard to tell, flat
Disappears with red-free filter

o Holes
o Tears

o Tumor
Elevated, may have hemorrhages

choroidal melanoma

Media
Note if clear or opacities
o Dark areas in the red reflex are opacities
o If opacities, note location, color, and density
Opacities in front of the iris (cornea, anterior chamber) will move in the
opposite direction from the ophthalmoscope
Against motion
Opacities behind the iris (lens, vitreous) will move in the same
direction as the ophthalmoscope
With motion