Ординатура / Офтальмология / Английские материалы / Handbook of Retinal Screening in Diabetes_Taylor_2006

Figure 10.7 Old pan-retinal laser scars

Disc

A few tiny dilated vessels can be seen on the temporal side of the disc, these being the remnants of previous disc new vessels.

Vessels

The veins are irregular in calibre. This is especially so for the vein running down from the disc.

Retina

Above the disc is a large pale area with sharp edges. This is the scar left by several contiguous laser burns, and the pallor reflects destruction of capillaries in this area. The irregular red areas are haemorrhages which persist many years after laser therapy. Note that the pale scars do not involve the major vessels (unlike areas of old chorioretinitis) but rather fit between the vessels. Towards the upper margin of the image the choroidal circulation can be seen through the thinned retina. The irregular very dark blotches are exposed choroids, and such an appearance is common in association with laser scars. This is particularly so for older laser scars, as the more modern application of laser treatment does not apply such intense burns.

Although the image may look alarming, vision in this eye was 6/06 and the appearances have been stable for many years.

Figure 10.8 Pan-retinal laser scars

Disc

This image corresponds to the disc centred image in Figure 10.6. The tiny dilated vessels on the temporal side of the disc can be seen more clearly. These are the remnants of previous disc new vessels.

Vessels

Venous irregularity can be seen in both larger and smaller veins. One of the small branches of the inferior vein leads to an area of tangled new vessels. If observed as a development since last screening these would trigger referral, but in fact the appearance of this image had been stable for many years.

Retina

The laser burns can be seen to have been positioned along the main vessels of the arcade. The area between fovea and disc is never lasered. The scars are of different size and shape and some are confluent. Black choroids are exposed irregularly. A few superficial retinal haemorrhages can be seen towards the temporal side of the image. Some scattered microaneurysms are present.

Figure 11.1 Early fibrosis

Disc

Several small tortuous vessels are present towards the temporal side.

Vessels

There is some variation in venous calibre. A venous loop arises from the inferior vein and small tangled new vessels can be seen arising from the other branches.

Retina

Arising from the disc there is a pale area of fibrosis. This extends upwards and it can be seen that the nearby veins appear distorted. A few IRMA can be seen in the vicinity of the temporal fibrous band. Above the superior arcade laser scars are present.

Figure 11.2 Fibrosis

This image was taken 1 year later from the eye shown in Figure 11.1. Compare these two images to observe how the vessels have become further distorted.

Disc

The small vessels running temporally on the disc remain tortuous.

Vessels

The traction effect of the fibrotic process is particularly obvious for the vein forming the superior arcade. Now the band of fibrous tissue extending upward is thicker. The small venous loop remains unchanged one disc diameter below the fovea.

Retina

The laser scars are still visible although fine retinal detail is not well seen. Vision in this eye is maintained at 6/09. However, continuing ophthalmological follow-up is required to determine when vitrectomy may be required to remove the fibrous bands and prevent further distortion.

Figure 11.3 Fibro-vascular membrane

Disc

The disc is largely hidden by a fibrous sheet. This gives the appearance of blurring the disc margin, but the fibrous bands which radiate out are characteristic.

Vessels

The major vessels near the disc are obscured by the fibrous change. The main sheet of connective tissue runs diagonally down from the disc and contains two leashes of new vessels, one running diagonally and the other downwards.

Retina

Some laser scars are present below and temporal to the fovea and in the lower part of the image. Blot haemorrhages are present. The vision in this eye was 6/09.

Figure 11.4 Pre-retinal haemorrhage

Disc

The disc is normal with a well-defined optic cup.

Vessels

Venous engorgement is present (ratio 3 : 1). Following the veins leads the eye to two separate tangles of new vessels.

Retina

The obvious haemorrhage is extensive and has relatively clearly defined borders. This has to be pre-retinal. The upper border is relatively horizontal, representing settling of the red blood cells under gravity. There are scattered exudates including in the macula region. The pale stripe with well-defined edges (lower edge of the image) is caused by the flash reflecting from an eyelash.

Figure 11.5 Pre-retinal haemorrhage

Disc

The disc is unremarkable with normal vessels, margins and cup.

Vessels

The veins are engorged, particularly in the upper half of the image where the ratio of vein to artery diameter is greater than 3 : 1 (normal 3 : 2). Near the temporal margin of the image there are some spidery new vessels. There may be some indistinct new vessels arising from the inferior temporal vein just over one disc diameter from the disc. The artery running down from the disc appears to become indistinct and can then seen to replaced by white lines running across the image. This indicates a complete and longstanding blockage of the artery.

Retina

Extensive hard exudates are present across the macula region and beyond. Microaneurysms and blot haemorrhages are seen below the fovea. The most obvious abnormality is a dark shape with a straight upper border across the lower part of the image. This is a pre-retinal haemorrhage. Blood has leaked into the space between the retina and the vitreous. The blood cellssettleundergravity,causingthecharacteristicstraightupperborder.Thereisalsoanextensive haemorrhage near the temporal margin of the image which may represent a very recent pre-retinal haemorrhage as the upper border has not yet become distinct. It is most important that urgent referral to the doctor responsible for the diabetes care is organized to ensure that aggressive blood pressure control is in place. Urgent ophthalmological referral is also required.

Figure 11.6 Severe exudative maculopathy

Disc

The disc is indistinct for much of its area, and it is impossible to exclude the presence of abnormal fine vessels, especially just beyond the margin of the disc at 6 o’clock.

Vessels

The vessels are unremarkable.

Retina

There are extensive sheets of exudates involving most of the retina. In several areas the exudates can be seen to be in an approximate circinate pattern. There is a large plaque of exudates encroaching on the fovea. A few small blot haemorrhages and microaneurysms are also present. Visual acuity was 6/60, reflecting macular oedema. Laser therapy is unlikely to be of benefit at this stage. Referral is still indicated.