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Fundoscopy (Fundus Examination) Signs

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Normal Fundus Landmarks

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1. Hypertensive Retinopathy (Scheie's Classification)

Hypertensive Changes (vascular leakage/fundus changes):

Arteriosclerotic Changes (separate grading):

• Copper-wire sign - arteriolar wall thickening, copper-colored reflex
• Silver-wire sign - advanced sclerosis; arteriole appears white/silver
• Gunn's (AV nipping) - venous compression at arteriovenous crossings
• Salus sign - deflection of vein at AV crossing
• Flame-shaped hemorrhages - in the nerve fiber layer
• Cotton-wool spots - ischemic microinfarcts of nerve fiber layer
• Hard exudates - lipid deposits; may form a macular star pattern

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2. Diabetic Retinopathy

Non-Proliferative (NPDR):

• Microaneurysms - earliest sign; dot-like red spots
• Dot and blot hemorrhages - in deeper retinal layers
• Flame-shaped hemorrhages - superficial nerve fiber layer
• Hard exudates (lipid deposits) - yellow, well-defined edges
• Cotton-wool spots (soft exudates) - fluffy white patches from ischemia
• Venous beading / venous loops - severe NPDR sign
• Intraretinal microvascular abnormalities (IRMA)

Proliferative (PDR):

• Neovascularization at disc (NVD) or elsewhere (NVE)
• Vitreous/preretinal hemorrhage
• Fibrovascular proliferation
• Tractional retinal detachment

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3. Papilledema (Raised Intracranial Pressure)

• Disc margins blurred - earliest sign (nasal margin first)
• Loss of venous pulsation (early sign)
• Disc hyperemia / engorgement
• Flame-shaped peripapillary hemorrhages
• Disc elevation (swelling above retinal plane)
• Dilated, tortuous retinal veins
• Paton's lines - retinal folds concentric to disc
• Enlarged blind spot on visual field testing
• Chronic papilledema → atrophic papilledema (disc pallor) → optic atrophy

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4. Glaucoma (Optic Disc Cupping)

• Increased cup-to-disc ratio (>0.5, pathological cupping)
• C/D asymmetry between eyes >0.2 is suspicious
• Loss of neural rim (ISNT rule violated - Inferior > Superior > Nasal > Temporal normally)
• Notching of the rim (especially inferior or superior pole)
• Disc hemorrhages (Drance hemorrhages - splinter shaped at disc margin)
• Nasal shift of vessels ("bayoneting" of vessels)
• Peripapillary atrophy (beta zone atrophy)

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5. Central Retinal Artery Occlusion (CRAO)

• Diffuse retinal whitening / pallor (ischemic edema)
• "Cherry red spot" at the macula - the fovea lacks inner retinal layers and appears red against the pale background
• Attenuated arteries, "box-carring" of blood column
• Afferent pupillary defect (APD)

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6. Central Retinal Vein Occlusion (CRVO)

• "Stormy sunset" / "blood and thunder" appearance
• Flame-shaped hemorrhages in all 4 quadrants
• Disc swelling and hyperemia
• Dilated, tortuous veins
• Cotton-wool spots
• Macular edema

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7. Age-Related Macular Degeneration (AMD)

• Drusen - yellow deposits under retina (early AMD); hard (discrete, small) or soft (larger, confluent)
• Geographic atrophy (dry AMD) - focal loss of RPE
• Choroidal neovascularization / subretinal membrane (wet AMD)
• Subretinal / sub-RPE hemorrhage (wet AMD)
• Disciform scar (end-stage wet AMD)

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8. Optic Atrophy

• Disc pallor (white / chalky disc)
• Loss of small disc vessels (normally 7-10 visible on disc)
• Causes: glaucoma, ischemic optic neuropathy, MS/optic neuritis, compression, post-papilledema

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9. Optic Neuritis (e.g., Multiple Sclerosis)

• Normal disc in retrobulbar neuritis (65% - "patient sees nothing, doctor sees nothing")
• Disc swelling in papillitis form
• Later: disc pallor (temporal pallor in MS)
• Afferent pupillary defect

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10. Other Important Signs

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Quick Reference Summary Table