Dr. K. Subramanian Consultant Neurosurgeon Anuradha Clinic & Sooriya Hospital

Dr. K.
Subramanian
Consultant Neurosurgeon
Anuradha Clinic &
Sooriya Hospital
What is the Fundus of
the eye?
Interior surface of the
eye opposite the lens
– includes retina, optic
disc, macula, fovea
and posterior pole.
Fundus is the window to the brain – increased
intra cranial pressure is reflected on the optic
disc and surrounding structures with no
barriers – interface to the clinician by air,
clear tissue and clear fluid.
Fundus examination can answer most
symptoms caused by eye disease, provide
answers to the most complicated headaches
and help rapid diagnosis of life and vision
threatening conditions.
How – Instruments – Ophthalmoscope
invented
1847 by Charles Babbage
1851 by Herman Von Helmholtz
(independently)
Technique
 Patient sitting, look straight
 Examiner standing approach laterally
 Red reflex
 Approach slowly focus field
 Trace vessel to centre
 Note disc color, edge clarity, cup size
A good video can be seen here about the
procedure:
http://www.youtube.com/watch?feature=playe
r_detailpage&v=PUz2HLromxY
 Is a must during eye exam, nervous
system exam and must be performed
routinely.
 Practice makes perfect.
 Both sides – always.
 Compare – to the other eye, match it to
your memory database.
Optic nerve – developmentally and
histologically optic nerve is a part of the brain
and surrounded by three meninges. Dura
continuous with orbital periosteum, pia and
arachnoid fuse with the sclera.
Subarachnoid space around optic nerve is
continuous with the brain subarachnoid
space.
Rise in cerebral subarachnoid pressure is
transmitted to the optic subarachnoid space.
Rise in ICP results in
1. Compression of central vein of retina as it
crosses the space.
2. Impeding lymphatic drainage from retina.
3. Interference with slow component of
anterograde axoplasmic transport in the
optic nerve head.
Thus swelling of axons in optic disc and
surrounding retina occurs.
1. Congestion of retinal veins – loss of venous pulsation,
2. Hyperemia of disc – filling of physiologic cup,
3. Disc edges blurred – first upper and lower margins,
then nasal margin, finally temporal margin;
4. Elevation of nerve head (3 – 10 Dioptres),
5. Spread of edema to retina – macular fan,
6. Hump of vessels leaving and entering disc more
marked,
7. Vessels appear and disappear as they course near
the disc,
8. Disc swelling reduces – disc becomes yellowish white
– arteries become constricted, veins remain
congested,
9. Edges of disc become indistinct.
 Venous congestion disappears
 Pulsation returns
 Other changes take much longer to
resolve or may remain permanent.
1. Optic subarachnoid space is congenitally
absent.
2. Optic subarachnoid space is occupied by
inflammation.
3. Optic subarachnoid space is obstructed
by neoplasm.
4. Optic nerve fibers are already atrophied.
 Craniocerebral volume disproportional to
bone,
 Obstruction to CSF circulation and
absorption,
 Edema surrounding a pathological lesion,
 Obstruction to venous drainage.
Also can be classified as
Congenital, traumatic, inflammatory,
neoplastic, vascular or benign ICT.
 Inflammation or infarction of optic nerve
head
 Caused by Usually Optic neuritis, multiple
sclerosis
Feature Optic Neuritis Papilloedema
Side Unilateral Bilateral (rare exceptions)
Pain on eye movement Usually present No pain (rare exceptions)
Onset of visual loss Sudden Gradual
Degree of visual loss as Gloss Slight (except PPOA)
compared to degree of disc
swelling
Color vision Impaired (especially red Defective only at late stage

and green)
Field defect Central or centrocecal Enlarged blind spot,
scotoma Peripheral constriction
Pupillary reaction Ill sustained Normal
Degree of disc swelling Less than 3 Dioptres More than 3 Dioptres
Venous engorgement Less marked More marked
Venous pulsation Present Absent
Hemorrhages Uncommon May be present
Slit lamp examination for Positive Negative
cells in vitreous
 Increased ICP
 Optic Neuritis
 Edema associated with disease of retinal
arteries, malignant hypertension, giant cell
arteritis
 Massive increases in CSF protein – Gullian
Barre syndrome, Spinal neurofibroma.
 Changes in composition of blood – Anemia
(acute iron deficiency, sickle cell),
Polycythemia Vera
 Venous obstruction
 Thrombosis of central vein of retina
 Mass lesions of orbit – Hemangioma,
Meningioma, Neurofibroma
 Cavernous Sinus thrombosis
 Carotido Cavernous fistula
 Superior Sagittal and Lateral Sinus thrombosis
 Intra thoracic venous obstruction – mediastinal
tumours, aortic aneurysm, severe emphysema
 Miscellaneous causes
 Eclampsia
 Premenstrual edema
 Vitamin A excess or deficiency
 Tetracycline administration
 Leukemia
 Lead poisoning
 Caused by chronic
edema, infection or
tumors, sometimes
injury.
 Features – pale, moon
like appearance of
optic disc.
 Increased ICP will not
be reflected on
atrophied disc and will
need other imaging
modalities for
diagnosis.

Dr. K. Subramanian Consultant Neurosurgeon Anuradha Clinic & Sooriya Hospital

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Color vision Impaired (especially red Defective only at late stage

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