seen in this example. The blood vessels are straighter and narrower than those in younger people, and the ^
choroidal vessels can be seen easily. In this person the optic disc is less pink, and pigment may be seen temporal to the disc and in the macular area.
Inspect the fundus. The nasal border of the optic disc is blurred. The light reflexes from the arteries just above and below the disc are increased. Note venous tapering—at the A-V crossing, about 1 disc diameter above the disc. Note tapering and banking at 4:30 o'clock, 2 disc diameters from the disc, also punctate hard exudates and a few deep hemorrhages.
Punctate exudates are readily visible: some are scattered; others radiate from the fovea to form a macular star. Note the two small, soft exudates about 1 disc diameter from the disc. Find the flame-shaped hemorrhages sweeping toward 4 o'clock and 5 o'clock; a few more may be seen toward 2 o'clock. These fundi show changes typical of accelerated (malignant) hypertension and are often accompanied by a papilledema (p. 184).
(Source of illustrations: Normal Fundus of a Fair-Skinned Person, Normal Fundus of a Dark-Skinned Person, Normal Fundus of an Older Person, Hypertensive Retinopathy, Hypertensive Retinopathy With Macular Star—Michaelson IC: Textbook of the Fundus of the Eye [3rd ed.], Edinburgh, Churchill Livingstone, 1980. )
Study carefully the fundi in the series of photographs below. They represent a national standard used by ophthalmologists to assess diabetic retinopathy.
Nonproliferative Retinopathy, Moderately Severe
Note tiny red dots or microaneurysms. Note also the ring of hard exudates (white spots) located supero-temporally. Retinal thickening or edema in the area of the hard exudates can impair visual acuity if it extends into the center of the macula (detection requires specialized stereoscopic examination).
Proliferative Retinopathy, With Neovascularization
Note new preretinal vessels arising on the disc and extending across the disc margins. Visual acuity is still normal, but the risk of visual loss is high (photocoagulation reduces this risk by >50%).
Nonproliferative Retinopathy, Severe
In the superior temporal quadrant, note the large retinal hemorrhage between two cotton-wool patches, beading of the retinal vein just above them, and tiny tortuous retinal vessels above the superior temporal artery.
Proliferative Retinopathy, Advanced
This is the same eye, but 2 years later and without treatment. Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity.
(Source of photos: Nonproliferative Retinopathy, Moderately Severe; Proliferative Retinopathy, With Neovascularization; Nonproliferative Retinopathy, Severe; Proliferative Retinopathy, Advanced—Early Treatment Diabetic Retinopathy Study Research Group. Courtesy of MF Davis, MD, University of Wisconsin, Madison.)
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