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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_103_библиотеки_им_акад_М_И_Перельмана
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25 Fundus Photography
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changes, retro-mode imaging offers several
advantages. It is a quick, easy, and non-invasive
imaging method. The imaging procedure resembles fundus photography. Contrary to FA and
ICG angiography, retro-mode imaging does not
require an extended capture time or intravenous
dye infusion. Owing to the long wavelength of
the infrared laser, the examination can be done
even in the presence of lens opacity or undilated
pupils. Since infrared light is invisible, people are
more comfortable during the examination [19].
25.5 Techniques
The patient should sit comfortably at a wellmatched table height. The table height should be
matched according to each patient so that the
patient leans forward into the fundus camera; this
reduces the chances of the patient pulling the
head back during the procedure. The patient
should be asked to place his/her chin on the chin
rest with the forehead well approximated to the
head bar (Fig. 25.3). The photographer should
align the camera using the joystick to move back
and forth and upward and downward, directing it
toward the patient’s fundus through the pupil
using the fundus camera. The image should be
focused before capturing the picture to eliminate
unwanted reexes or artifacts. The crosshairs
should be kept in sharp focus for good focusing,
and the camera dial can be used for ner focusing. Patients should be asked to blink before capturing the fundus image as this gives a better
lubricated corneal surface, thereby improving
image quality and preventing patients from blinking during fundus image capture.
25.5.1 Stereophotography
Stereophotography gives important diagnostic
information by imparting a sense of depth. It was
used as early as 1909 but was popularized by Lee
Allen in the 1960s, who described a practical
sequential stereo fundus photography technique
[20]. It allows in-depth interpretation of both
eyes’ images simultaneously taken from slightly
different angles. The angiogram is read from
right to left; therefore, this order is important as
a
Fig. 25.3 Fundus photography on the fundus camera. (a) Patient positioning. (b) Optimal position of the head
b
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the photographs are taken and positioned on the
lm accordingly. The lateral shifting of the fundus camera by a few millimeters between two
consecutive photographs causes cornea-induced
parallax as the illuminating beam of the fundus
camera passes through the opposite slopes of the
cornea. This cornea-induced parallax gives a
hyper-stereoscopic effect which is appreciated on
viewing the sequential pair of photographs
together [16]. Specially-made stereo viewers are
available to read the stereo images [21, 22].
25.6 Clinical Application
andInterpretation
25.6.1 Age-Related Macular
Degeneration
Age-related macular degeneration (AMD) is a
common macular condition affecting older persons characterized by the development of drusen
in the macula, followed by geographic atrophy
(GA) or MNV.
Drusen appear differently on FAF according
to the size, composition, and condition of the
ellipsoid and retinal pigment epithelium (RPE)
layer (Figs.25.4 and 25.5b, e). Cuticular drusen
exhibit hypo-autouorescence on FAF.
Geographic atrophy: Depigmented, hypoautouorescent regions corresponding to RPE
loss in dry AMD may indicate early GA
(Fig. 25.6a). Loss of intrinsic uorophores is
seen in RPE atrophy, leading to negligible/nil
FAF signal with clearly dened borders.
Perilesional hyper-autouorescence, which indicates functional disturbances in RPE, is occasionally seen around GA and suggests progression
(Fig.25.6b) [23].
Initially, the FAM (Fundus autouorescence
in age-related macular degeneration) investigation identied eight patterns of FAF in the junction zone of GA [24], which were subsequently
updated to include a ninth pattern [25]. Eyes are
categorized as “none” (when there is no evidence
of enhanced autouorescence signal at the outer
margins of the GA), “localized” (focal, patchy,
and banded autouorescence is detected), and
“diffuse” (branching, ne granular, ne granular
with punctuated spots, trickling, and reticular
autouorescence is detected) in the junction zone
of atrophy [26]. The signicance of these patterns lies in the possibility that they correspond to
various phenotypic forms of the illness. Analysis
of natural history showed that different subtypes
of FAF grow at different rates and that the progression of atrophy in GA and the FAF pattern
are strongly correlated [25, 26].
Fig. 25.4 Drusen seen as (a) a hyper-autouorescent lesion on autouorescence imaging, and a yellowish lesion on (b)
a multi-color fundus image. (Image courtesy: Rajeev K Reddy Pappuru, MD)
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Fig. 25.5 Familial dominant drusen. Color fundus photographs (a and d) showing drusen which are seen as
hyperuorescent lesions on autouorescence imaging (b
and e) and hyper-reective lesions on IR (c and f). (Image
courtesy: Deepika C Parameswarappa, MD)
c
d
e
Fig. 25.6 Geographic atrophy in dry AMD. (a) Multi-
color fundus image. (b) Blue autouorescence (white
arrow shows the perilesional hyper-autouorescence) (c)
Infrared reectance: delineating the extent of GA. (d)
Green reectance image and (e) Blue reectance image.
Central macula and disc details appeared as hazy due to
artifact. (Image courtesy: Mudit Tyagi, MD)
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Multi-color imaging is a good tool for determining the size and extent of GA and assessing
the extent of fovea sparing. IR pictures are best
for visualizing GA (Fig.25.6c). Refractile drusen
are a common complication of AMD and are considered a key predictive biomarker for the emergence of central GA. Soft drusen are seen as
green structures with orange borders in the
multi- color composite image; the reticular drusen
are distinguished as shiny, light-yellow structures. In GR and BR, refractile drusen are
hyper- reectant, but soft drusen only appear
slightly hyper- reectant (Fig.25.4c, f) [27].
Drusen has a pseudo-3D appearance on retromode imaging, consistent with OCT (optical
coherence tomography) imaging. Retro-mode
imaging identies more drusen than conventional
color fundus photography and cSLO. Retromode imaging is most sensitive in identifying
subtle drusen and can efciently distinguish
between various types of drusen. It can accurately determine the extent of GA and detect retinal changes related to exudative AMD, such as
choroidal neovascularization (CNV) and cystoid
macular edema (CME) [19].
RPE tears: Hypo-autouorescence with welldened borders is seen in areas with absent RPE,
and the adjacent rolled-over RPE appears
hyper-autouorescent.
25.6.2 Polypoidal Choroidal
Vasculopathy (PCV)
Massive submacular hemorrhage or orange
subretinal nodules are strong indicators of
PCV and appear hypo-autouorescent due to
the blockage of the underlying uorescence by
the hemorrhage (Fig. 25.7). In most PCV
patients, polypoidal lesions can be found with
multi-color imaging. Since the lesions are
below the RPE, it is best to visualize the polypoidal lesions and branching neovascular network (BNN) using a multi-color composite or
infrared reectance imaging. On multi-color
imaging, polypoidal lesions appear as darkgreen oval lesions, while BNN is seen as a
stippled gray area on IR. Details of pigment
epithelial detachment (PED) and subretinal
hemorrhage are also clearly discernible [27].
The physical characteristics of PCV, such as
polypoidal lesions and branching vascular networks, can be easily seen with retro-mode
imaging [19].
Fig. 25.7 Polypoidal choroidal vasculopathy. (a) Multi-
color image showing oval lesion with greenish hue. (b)
Blue light autouorescent image showing hypo-
autouorescent lesion due to blockage of underlying autouorescence by hemorrhage. (Image courtesy: Mukesh
Jain, MD)
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25.6.3 Central Serous
Chorioretinopathy
it, distinguishing it from SRF on multi-color
imaging. PED is best detected on infrared images
due to its deep location. Infrared imaging proCentral serous chorioretinopathy (CSC) occurs
due to choroidal dysfunction and idiopathic leak
through the RPE leading to serous retinal detach-
vides a superior view of RPE atrophy compared
to BR or GR imaging. On multi-color imaging,
focal leaks are seen as orange spots [27].
ment. Granular hyper-autouorescence is seen on
FAF, corresponding to subretinal precipitates on
OCT.These precipitates occur due to the separa-
25.6.4 Macular Dystrophies
tion of the neurosensory retina from the RPE
layer and are believed to be debris from the photoreceptor layer along with macrophages. In
chronic CSC (longer than 6 months), gravitational tracts are seen as granular hyperautouorescent/hypo-autouorescent areas,
based on the disease duration, due to longstanding subretinal uid (Fig. 25.8). NIRAF
gives better details than BAF in CSC and is preferred for diagnosis and monitoring [27].
Multi-color imaging detects pigment epithe-
lial detachment (PED) and RPE atrophy; sub reti-
25.6.4.1 Stargardt Disease
The initial stages have increased lipofuscin pro-
duction and a corresponding rise in autouores-
cence. Eventually, chorioretinal atrophy occurs,
causing macular hypo-autouorescence outlined
by hyper-autouorescent ecks (Fig.25.9) [27].
On multi-color imaging, the delineation of the
central area of atrophy is clearer [27]. Any mate-
rial deposition in the retina is seen as a raised area
with various sizes and shapes, uneven borders,
and darker hues on retro-mode imaging [19].
nal uid (SRF) is best demonstrated with
GR.Since PED is located at a deeper level than
SRF, multi- color imaging recognizes it as an elevation of the retinal contour and gives it a greenish hue that is darker than SRF.PED has smaller,
well- circumscribed sizes and pink rings around
25.6.4.2 Best Disease
The vitelliform stage has well-dened, uniform
hyper-autouorescence at the macula. A hyper-
autouorescent layer is seen settled beneath iso-
autouorescent uid due to gravity in the
a
Fig. 25.8 Chronic central serous chorioretinopathy
showing gravitational tract. (a) Color fundus image of the
left eye. (b) Corresponding blue light autouorescence
b
image showing hypo-autouorescent gravitational tract
with hyper-autouorescent border. (Image courtesy:
Vivek Pravin Dave, MD)
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Fig. 25.9 Stargardt’s disease. (a, b). Multi-color image of left and right eye, respectively; (c, d). Autouorescence
image showing distinctly demarcated central macular atrophy in both eyes. (Courtesy: Subhadra Jalali, MD)
b
pseudohypopyon stage. A dark lesion surrounded
by hyper-autouorescent deposits is seen in the
vitelliruptive stage. Chorioretinal atrophy occurs
in the atrophic stage, resulting in hypoautouorescence [27]. Retinal elevation during
the pseudohypopyon stage is dened more clearly
on composite multi-color and blue reectance
imaging. Subretinal lipofuscin is seen better in
GR images. The multi-color image shows several
ring and visual function; the more central the
ring, the smaller the visual eld. Other retinal
dystrophies exhibit similar hyper-autouorescent
rings, such as Best macular dystrophy, Leber
congenital amaurosis (LCA), X-linked retinos-
chisis, bull’s eye maculopathy, and cone dystro-
phy [27]. Multi-color imaging is better at
identifying macular changes and complications
in patients with RP.
orange dots corresponding to yellow lesions and
a greenish hue over the macula, suggesting
increased retinal thickness. Numerous white
hyper-reective spots in the infrared images indicate RPE level changes [27].
25.6.4.3 Retinitis Pigmentosa (RP)
The inner/outer-segment junction disruption
edge seen on OCT corresponds to the hyperautouorescent “Robson-Holder ring”
(Fig.25.10). Also, kinetic and automated perimetry show a correlation between the size of the
25.6.4.4 Fundus Albipunctatus
FAF shows hyper-autouorescence foci correlat-
ing to the white dots; however, not all the lesions
show hyper-uorescence [27].
25.6.4.5 Choroideremia
Multi-color imaging shows the surrounding cho-
rioretinal atrophy and RPE tissue at the macula
signicantly better than the color fundus photo.
In contrast to GR and BR, the remnant RPE tis-
sue is seen in infrared. In individuals with choroi-
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Fig. 25.10 Retinitis pigmentosa. (a and d) Color fundus photograph. (b and e) Blue light autouorescence images
(BAF). (c and f) IR images. (Image courtesy: Deepika C Parameswarappa, MD)
deremia, multi-color imaging can be used to
assess the viability of the retina and monitor disease progression [27].
25.6.5 White Dot Syndromes
25.6.5.1 Multiple Evanescent White
Dot Syndrome (MEWDS)
On FAF, hyperuorescent lesions are seen, as
photoreceptor loss unmasks the autouorescence
of the underlying RPE [27].
25.6.6 Drug Toxicity
A hyper-autouorescent parafoveal ring corre-
sponding to photoreceptor damage is seen on
FAF that diminishes over time due to RPE atro-
phy. Bilateral bull’s eye maculopathy is seen in
the late stage of the disease. An arcuate band of
hypo-reectance surrounds the speckled hyper-
reectance at the macula, best seen on infrared
images. Multi-color imaging detects a greater
extent of retinal involvement than color fundus
photos [27].
25.6.5.2 Punctate Inner
Choroidopathy (PIC)
Active PIC lesions manifest as chorioretinal nodules at the sub-RPE level, which show faint
hyper-autouorescence initially or change into
hypo-autouorescent patches when the nodules
breach through the RPE.A hyper-autouorescent
border that is seen around these hypoautouorescent lesions correlates with photoreceptor loss on SD-OCT [27].
25.6.7 Vascular Retinopathy
25.6.7.1 Diabetic Retinopathy (DR)
Microaneurysms appear as dark red dots on
multi-color imaging, hard exudates as greenish-
yellow, and cotton wool spots appear greenish-
white. Multi-color imaging can rapidly detect
early subtle neovascularization in proliferative
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Fig. 25.11 Ultra-wide eld multi-color image of right
(a) and left (b) eyes of a case of proliferative diabetic retinopathy after panretinal photocoagulation. Regressing
diabetic retinopathy that may be undetected on
color fundus photos. (Fig.25.11) [27].
new vessels can be appreciated in both eyes. (Image cour-
tesy: Brijesh Takkar, MD)
25.6.8.2 Macular Telangiectasia
Type 2
BR imaging reveals a distinctive oval parafoveal
25.6.7.2 Retinal Vascular Occlusion
Multi-color imaging can identify mild retinal
thickening and macular edema. Macular edema
area with enhanced reectance. It is a reliable,
quick, and non-invasive diagnostic method for
detecting macular telangiectasia [27].
appears as a green hue over the affected retina.
Multi-color imaging enables the diagnosis and
monitors the progression of the disease and its
response to treatment. It aids in deciding treatment and prognostication [27].
25.6.8.3 Epiretinal Membrane
The best way to visualize the hyper-reflective
surface folds of the epiretinal membrane are
with GR imaging. The ERM is visible in
multi-color imaging as greenish retinal mem-
branes [27].
25.6.8 Miscellaneous Retinal Lesions
25.6.8.4 Angioid Streaks
25.6.8.1 Macular Hole
The macular hole margin, SRF, and RPE atrophy
are visualized better through multi-color imaging
than in color fundus photos. Multi-color imaging
can also identify inner retinal changes in patients
Angioid streaks are highlighted as dark orange in
multi-color imaging (Fig. 25.12). In contrast to
GR and BR, these are better seen in infrared.
Complications like CNV can be better detected
through multi-color imaging [27].
who had undergone internal limiting membrane
(ILM) peeling. Spectral-domain optical coherence tomography (SD-OCT) is typically used to
diagnose dissociated optic nerve ber layers
resulting from ILM peeling in macular hole
repair. The dissociated optic nerve ber layer
appears as darker arcuate areas on multi-color
imaging. BR is better than GR for assessing the
dissociated optic nerve ber layer [27].
25.6.8.5 Retinochoroidal Colobomas
The neurosensory retina located within the col-
oboma (also known as the intercalary mem-
brane) is the most frequent location for retinal
breaks and retinal detachments (Fig. 25.13)
[28]. Goel et al. have reported the efcacy of
multi color imaging (MCI) in detecting interca-
lary membrane detachment [29].
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Fig. 25.12 Multi-color fundus image in the right (a) and left eye (b) in a case of angioid streaks. (Image courtesy:
Vivek Pravin Dave, MD)
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Fig. 25.13 Multi-color image of right (a) and left (b) eye in a case of retinochoroidal coloboma. (Image courtesy:
Mukesh Jain, MD)
25.6.8.6 Myelinated Nerve Fibers
25.6.9 Optic Nerve Head Disorders
(MNF)
The MNF appears greenish or greenish-orange
on a multi-color image according to the retinal
thickness. Infrared is best for detecting retinal
thickening due to the high melanin content of
MNF. Multi-color images and infrared
images demarcate disc margins better than
CFP [27].
25.6.8.7 Choroidal Disorders
The characteristics of choroidal and retinal pigmentary lesions, such as choroidal nevus, choroidal melanoma, and choroidal hemangioma,
including margin, extent, and halo, can be
detected using multi-color imaging, especially
when combined with infrared imaging.
Retinal nerve ber layer (RNFL) defects are high-
lighted by multi-color imaging as wedge defects
without a greenish hue in glaucoma, as opposed to
the greenish hue apparent in healthy RNFL.Due
to the wide, shallow, and slanted disc, myopic
crescent, and macular degeneration in myopic
eyes, it can be challenging to interpret the cupping
of the optic disc and the health of the neuroretinal
rim. Unlike color and red-free optic disc photog-
raphy, multi-color imaging can distinguish
between the neuroretinal rim and optic cup. The
use of multi-color imaging helps diagnose the
optic disc pit [30]. Retinoschisis, serous macular
detachment, and retinal atrophy are some of the
signs of optic disc pit maculopathy [27].
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25.6.10 Pathologic Myopia
grayish subretinal lesion underneath or near the
fovea, with or without hemorrhage [31]. Lacquer
Myopic maculopathy lesions are categorized
into ve categories, ranging from 0 to 4, according to the META-PM (meta-analysis of pathological myopia) classication system
(Table 25.3), developed using fundus photographs. Lacquer cracks, myopic CNV, and
Fuchs’ spots were added as plus signs since they
can arise from or coexist in the eyes with any of
the myopic maculopathy categories and cause
central vision loss. Myopic CNV (Fig.25.14a)
usually appears on fundoscopy as a small, at,
Table 25.3 Classication of Myopic Maculopathy according to META-PM study [32]
META-PM classication Myopic retinal changes Fundus appearance
Category 0 No myopic retinal changes
Category 1 Tessellated fundus Well-dened choroidal vessels can be observed
Category 2 Diffuse chorioretinal atrophy The posterior pole appears yellowish- white, the
Category 3 Patchy chorioretinal atrophy Well-dened, grayish-white lesions of variable
Category 4 Macular atrophy Well-dened, round chorioretinal atrophic lesion is
+Lc Lacquer cracks Yellowish thick linear pattern
+CNV Choroidal neovascularization Active CNV should be accompanied by exudative
+Fs Fuchs spot Pigmented spot representing the dry brovascular
– Posterior staphyloma Local bulging of the sclera at the posterior pole that
cracks may often be difcult to identify due to a
lack of contrast in the myopic fundus. Fundus
autouorescence imaging only detects 12.5% of
lacquer cracks, which appear as linear hypo-
autouorescence, whereas infrared has a com-
paratively high sensitivity (92.9%); lacquer
cracks are seen as hyper- reective lines
(Fig. 25.14b) [32]. UWF fundus imaging can
help identify peripheral retinal lesions like lat-
tice degeneration, which is common in high
myopia (Fig.25.14c).
clearly around the fovea and arcade vessels
extent of which is variable
size; between one and several choroidal lobules
grayish-white or whitish around a regressed
brovascular membrane that enlarges with time.
Generally, macular atrophy is centered on the
central fovea and has a round shape
activity or hemorrhage. Serous retinal detachments
can be present
scar of myopic CNV
has a radius that is less than the surrounding
curvature of the wall of the eye
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