Retina Picture Quiz: Answers (Figs. 1 to 6)
Fig 1.
55 year old man. Open angle glaucoma in left eye. Noticed loss of vision in right eye on waking this morning. VA right eye 2/60.
Fig 6.
28 year old woman. Type 1 diabetic for 13 years. VA right eye 6/12.
Fig. 1: Central retinal vein occlusion
The large number of haemorrhages, the white cotton wool spot, and the poor vision all suggest that this is probably an ischaemic CRVO. There is a high risk that this will progress to rubeotic glaucoma within the next three months. If iris new vessels are detected, then pan-retinal laser can prevent secondary glaucoma. A high IOP greatly increases the risk of CRVO, so it is important to treat the glaucoma in the other eye.
Fig. 2: Papilloedema
Fig 2.
23 year old woman. Headache for two months. Worse on waking. VA 6/6 in both eyes.
There is a swollen optic disc. As the vision is normal it is unlikely to be optic neuritis, so the most likely diagnosis is papilloe-dema. Possible causes include raised blood pressure, and benign intra-cranial hypertension as well as intra-cranial space occupying lesions.
Fig. 3: Age-related macular degeneration
Fig 3.
75 year old man. Noticed distortion of vision in right eye, then loss of central vision. VA right eye 2/60.
There is a sub-retinal scar (retinal blood vessels pass in front of the paler scar tissue) under the macula. The dark area is due to haemorrhage. Fibrous and vascular tissue has grown from the choroid under the retina at the macula, destroying the photoreceptors at the fovea, and causing irreversible blindness. This is the commonest cause of blindness in Europe and North America.
Fig. 4: Diabetic maculopathy
Fig 4.
65 year old man. Gradual loss of vision right eye for one year. Also polydipsia and polyuria. VA right eye 6/18.
Diabetic retinopathy may occur before the patient knows he has diabetes. This patient has multiple haemorrhages and cotton-wool spots, due to capillary closure, as well as hard exudates, which indicate leaking capillaries. Laser treatment at this stage reduces the risk of further loss of vision over the next five years. Diabetes is becoming a problem in developing countries and health education programmes must raise awareness of the loss of vision due to diabetes.
Fig. 5: Retinal detachment
Fig 5.
58 year old woman. Sudden loss of vision in right eye one week ago. Floaters in right eye two weeks previously. VA right eye HM.
The wrinkled surface of the retina, and the loss of the normal red reflex are characteristic of a retinal detachment. The flashes and floaters are caused by a vitreous detachment, which caused the retinal break that led to the retinal detachment. The macula is already detached, but surgery to re-attach the retina will at least restore navigational vision.
Fig. 6: Proliferative diabetic retinopathy
There are active new vessels arising from the optic disc and from the retina. Untreated, there is a high risk of blindness within five years. This can be greatly reduced by urgent pan-retinal laser treatment. Screening for diabetic retinopathy and offering appropriate treatment is essential to reduce loss of vision.