2.1 Posterior Segment Examination

Examination Outline

Examination Structure

Attention should be given to the wording of the question which often directs the candidate where to look:

“Examine the”…

  1. Macula
  2. Optic disc
  3. Posterior pole
  4. Fundus
  5. Peripheral fundus
Examiners may direct candidates to specifically use an indirect ophthalmoscope or perform slit-lamp biomicroscopy, but if not, initial use of the indirect ophthalmoscope is often beneficial in providing an overall view of the fundus.

1. Visual Acuity, IOP, Inspection, ± Refraction

(see 2 Posterior Segment General Comments)

  • Always ask for the VA and IOP (may be raised by rubeotic glaucoma, lowered following retinal detachment)
  • Observe the patient’s age / gender / ethnicity:
    • A young patient with bilateral macular changes suggests a retinal dystrophy
    • A young patient with a rhegmatogenous retinal detachment is suspicious for Stickler’s syndrome
    • An Asian or Afro-American with macular haemorrhage is suspicious for Polypoidal Choroidal Vasculopathy (PCV)
    • A Japanese patient with serous retinal detachments and a hyperaemic optic nerve is suspicious for Vogt-Koyanagi-Harada (VKH) disease
    • A Middle Eastern patient with panuveitis is suspicious for Behcet’s disease
  • Look at the patient’s spectacles. Are they a high myope or aphakic?
  • Look for visual aids
    • Is there a white cane by the patient’s chair? Is there a guide dog in the room?
  • Look for hearing aids
    • Sensorineural hearing loss can be associated with various retinal dystrophies (Usher syndrome), VKH and Susac disease
  • Look for dysmorphic facial or body habitus as seen in various retinal dystrophies such as Stickler’s and Bardet-Biedel syndromes
  • Look at the patient’s skin (PXE, Neurofibromatosis type 1, Tuberous Sclerosis)
  • Dim the lights after initial inspection (ask the examiner to assist with this)

2. Anterior Segment & Anterior Vitreous

It is important to focus one’s time on the posterior segment when asked to do this, but a quick glance observing the anterior segment on the way to the posterior segment may yield a few clues to diagnosis:

  • Look at the peripheral aspects of the globe by holding the patient’s eyelids and asking them to look up and down, inspecting for previous glaucoma surgery or a scleral buckle
  • Look at the character of the conjunctiva and also the sclera for thinning. Has the patient had multiple surgeries? Are there globules of silicone oil under the conjunctiva?
  • An Asian patient with crystalline keratopathy and retinopathy is suspicious for Bietti crystalline dystrophy
  • Is there rubeosis or a traumatic mydriasis from previous trauma?
  • Look for previous cataract surgery
  • Are there anterior chamber cells (uveitis)or a shifting hypopyon (Behcet’s disease)?
  • Check the anterior vitreous for cells (uveitis, haemorrhage, pigment / ”tobacco dust”) and optical emptiness (Stickler’s syndrome)

3. Vitreous

  • Is there a posterior vitreous detachment? (Weiss ring)
  • If the view is hazy, there may be:
    • Vitreous haemorrhage (the location of dense haemorrhage may help localise the site of bleeding) or
    • Vitritis (look for a “headlight in a fog” suggesting toxoplasmosis chorioretinitis)

4. Macula

  • Foveal light reflex
  • Macular hole (Watzke Allen test- ask for an OCT if suspicious)
  • Macula oedema (CMO or DMO)
  • Epiretinal membrane / Premacular fibrosis
  • Presence of drusen or hard exudate (the distribution of which tends to follow vasculature - e.g. circinate around microaneurysms)
  • Retinal haemorrhage (AMD, PCV, Diabetic retinopathy)
  • Choroidal “white dots” (PIC / MFC, APMPPE, Serpiginous Choroiditis)


Other changes:

  • Bull’s eye maculopathy
  • RPE pigment migration (Macular Telangiectasia Type II, AZOOR)
  • Lacquer Cracks and Posterior Staphyloma (High Myopia)
  • Choroidal folds
  • Yellow vitelliform deposit (Best vitelliform dystrophy / Adult foveomacularvitelliform dystrophy)
  • Retinal “flecks” (ABCA4 / Stargardt’s disease, familial dominant drusen)
  • Cherry red spot (CRAO)


Label the fovea in your diagram with a cross “+” (rather than an X which could indicate a laser burn at the fovea!)

5. Optic Disc

(see Section 3.1 “Glaucoma Examination” for Further Details)

  • Glaucoma assessment (Vertical cup / disc ratio, assess the neuroretinal rim)
  • Disc swelling with a macular star (neuroretinitis / malignant hypertension)
  • Neovascularisation at the disc (NVD)

Other changes:

  • Tilted disc and peripapillary atrophy (myopic degeneration)
  • Dragged disc (FEVR)
  • Angioid streaks and peau d’orange (PXE)

6. Retinal Vessels

  • Dilated / tortuous
  • Arteriolar narrowing, arteriovenous nipping, copper / silver wiring (hypertensive retinopathy)
  • Emboli (e.g. Hollenhorst plaques)
  • Retinal artery macroaneurysm
  • Cotton wool spots
  • Vascular sheathing (periphlebitis / arteritis)
  • In a diabetic patient remember to look carefully for neovascularisation elsewhere (NVE)

7. Retinal Periphery

If candidates are only allowed to use their indirect ophthalmoscope, the likelihood is that the pathology will be peripheral. Common lesions found in examinations would include chronic lesions such as a choroidal tumour or retinoschisis.

Signs that may be found:

  • Retinal detachment
    • Differentiate between: rhegmatogenous, exudative and tractional
    • Locate retinal tears
    • Identify the presence of a PVD and / or proliferative vitreoretinopathy (PVR)
  • Retinoschisis
  • Haemorrhage, hard exudates (peripheral CNV) and telangiectasias (Coat’s disease, vascular tumours, peripheral CNV)
  • Retinal flecks (ABCA4, fundus flavimaculatus, CSNB - fundus albipunctatis, familial dominant drusen)
  • Retinal pigmentation / degeneration (retinitis pigmentosa, PRP laser, lattice degeneration)
  • Retinitis (CMV, HSV / VSV-ARN, toxoplasmosis, syphilis etc.)
  • Vascular dilatation / tortuosity (CRVO)
  • Retinal periphlebitis (tuberculosis, Eales disease, retinitis, retinal vascular occlusion)
  • RPE lesions (CHRPE, leopard spotting in lymphoma)
  • Choroidal masses (naevus, melanoma, metastasis, granulomas - TB / sarcoid)
  • Choroidal white lesions (birdshot chorioretinopathy, MFC, osteoma)
  • Vascular tumours (retinal capillary haemangioblastoma, choroidal haemangioma, vasoproliferative tumour)

Haemorrhages

Determine the level of haemorrhages by its relation to retinal vessels, colour and shape:

  1. Sub-RPE (able to see retinal vasculature but darker than subretinal haemorrhage)
  2. Subretinal (able to see retinal vasculature)
  3. Intraretinal (dot / blot haemorrhages)
  4. Nerve fibre layer (flame haemorrhages)
  5. Preretinal (boat shaped haemorrhages, obscures underlying retinal vasculature)
  6. Vitreous (hazy fundus view)

Signs of a Serous Retinal Detachment (vs. Rhegmatogenous)

  1. No photopsiae (no traction)
  2. No tobacco dust (no RPE cells)
  3. Often inferior (gravitates)
  4. Smooth, convex, may have shifting fluid and / or leopard spots (if chronic)
  5. No tear or PVR
  6. Signs of cause (signs of inflammation, short eye / hyperopia in uveal effusion syndrome)

Differentiating Retinoschisis (vs. Retinal detachment)

  1. Hyperopes (70%)
  2. Often asymptomatic (No flashes or floaters, may get absolute VF defect)
  3. No tobacco dust (no RPE cells)
  4. Tends to be Bilateral, inferotemporal, anterior to the equator
  5. Has a convex, smooth, thin, immobile elevation
  6. No tear, PVR or highwater mark

General Comments

Record important positives and negatives e.g. presence / absence of:

  1. Subretinal fluid or haemorrhage in age-related macular degeneration (AMD) suggestive of choroidal neovascularisation (CNV)
  2. Diabetic macular oedema or NVD / NVE in diabetic retinopathy
  3. Emboli in retinal artery occlusion
  4. Features of hypertensive retinopathy in retinal vascular diseases
  5. Proliferative vitreoretinopathy (PVR) and / or posterior vitreous detachment (PVD) in retinal detachment

Think about the eye / person as a whole. Look for systemic manifestations of retinal disease:

          

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