Ocular fundus. Fundus video Reverse ophthalmoscopy technique video for fundus examination

Department of Eye
diseases
RUDN University
Light reflexes
fundus
Completed by: Boryanova N.V.

VODOVOZOV Alexander Mikhailovich
October 7, 1918 – April 27, 2007
Alexander Mikhailovich was born on October 7, 1918 in
Odessa. A year before the start of the Great Patriotic
war, he graduated from the Odessa Medical Institute
In 1954 he defended his Ph.D. thesis on
"Prolongation of the action of penicillin with local
application in ophthalmology.
In 1962, A. M. Vodovozov was elected to the position
Head of the Department of Eye Diseases
Volgograd Medical Institute. In 1963
defended his doctoral dissertation on
the results of many years of fundus research
light of different spectral composition. Leading
for 30 years the specified department, Professor A. M.
Vodovozov fully revealed his
outstanding abilities and proved to be
talented world-class scientist,
highly qualified ophthalmologist,
brilliant ophthalmic surgeon, excellent lecturer and
experienced teacher.

A. M. Vodovozov developed in detail a method for studying the fundus of the eye,
called ophthalmochromoscopy, summarized and described in detail other
methods for examining the eye in transformed light, conducted
unique work on the study of light reflexes of the fundus.
Numerous scientific works of Alexander Mikhailovich and his students, except
of these problems are devoted to the description of a detailed ophthalmic
symptoms, pathogenesis of myopia, strabismus, issues of ophthalmic surgery. Them
9 monographs have been published, three of which are in the form of atlases. A. M. Vodovozov -
author of 420 scientific papers. Under his leadership, 20 candidate and 4
doctoral dissertations.
A bright page in the life of A. M. Vodovozov was his inventive
activity. It included new methods of diagnosis and treatment, in
in particular surgical, eye diseases, new devices and instruments,
many of which are named after the author. Alexander Mikhailovich had 20
copyright certificates for inventions.
A. M. Vodovozov made a significant contribution to the organization of ophthalmic care in
Volgograd and the region.

Alexander Mikhailovich was one of
initiators of the opening in Volgograd of a branch of the MNTK
"Eye Microsurgery". He was deputy
chairman of the presidium of the board
All-Russian Society of Ophthalmologists,
editor of the section "Ophthalmology" Bolshoi
medical encyclopedia, member of the editorial board
Journal of Ophthalmosurgery. Successful A.
M. Vodovozova was awarded the Order of the Red
Stars and "Badge of Honor", many medals,
Honorary diplomas of the Supreme Council of the Russian Federation. He
was elected an academician of the New York Academy
Sciences, recognized by the American Biographical
institute one of the leaders of the intellectual
influences of the late 20th century.
Since 2000 Professor A. M. Vodovozov lived in Germany.

Causes and conditions for the occurrence of light
reflexes
2 types of reflection
scattered (diffuse) - flat picture
mirror - surface depth
favorable conditions for the emergence
specular reflections are usually created when
moving from an environment with a lower indicator
refraction into a medium with a large index.
On the fundus, such conditions are created at the border
vitreous and retina. (dimmer).

Surface reflective
rays
1. Mesh inner border membrane
shells (Jaeger, 1869, Dimmer 1891, Gorban
1967).
2. in the vitreous (Weiss 1879, Bedell 1955)
3. a thin layer of liquid between the inner
boundary membrane and vitreous
body (Planten 1968)
4. Multiple reflective surfaces
(Vodovozov 1980)

The influence of the shape of the reflective surface on the appearance and
light movement
reflex
Reflex formed by a convex surface
(tumor), will move during the study in direct
view in the same direction as the ophthalmoscope, and in
opposite when examined in reverse.
A reflex formed by a concave surface moves in the opposite direction of the object's movement
direction.
The cylindrical surface forms a reflex in the form
lines, stripes.
Toroidal surface - reflex in the form of a ring
(an example is the macular reflex).
The conical surface is a reflex of a triangular shape.
The ovoid surface is an oval reflex.

Factors affecting registration
light reflections
Type of ophthalmic
research
pupil width
Light intensity

10.

Types of ophthalmoscopy
Straight
ophthalmoscopy
Reverse
ophthalmoscopy

11.

12.

13.

14.

15.

The dependence of reflectivity on age, refraction and
degree of pigmentation of the fundus
Age
Lack of macular reflex (and other reflexes) in newborns.
Explanation:
The region of the central fossa is not formed (flat relief of the surface
retina, all recesses and protrusions are not formed).
Reduced reflectivity of the inner boundary
membranes.
By the end of the 1st year of life, most of the reflexes at the bottom of the eye are already visible.
Full formation of reflexes ends by 4-5 years.
All reflections reach their maximum brightness by 6-7 years and are clearly visible.
up to 25 years, after which they begin to gradually fade and to old age
some reflexes disappear.
If we do not take into account the age-related attenuation of retinal reflection,
then you can suspect a pathology where in reality it
No.

16.

Reasons for the weakening and disappearance of reflexes
at the bottom of the eyes of the elderly
Reduced illumination due to age-related pupil constriction and
turbidity of media, as well as due to possible changes
the ratio of the refractive indices of the vitreous body and
retinas (Sthali, 1919).
Changing the optical properties of the internal border
membranes (Gorban A.I.)
Structural changes occur with age
retina and vitreous associated with tissue involution
organism and, first of all, tissues of the ectodermal
origin (skin, nervous system). border
the membrane loses its usual smoothness, specularity,
its surface becomes rougher. Parallel
This may result in an expansion of the space between
retina and vitreous body or even so often
recorded in the elderly posterior vitreous detachment
body. (Vodovozov A.M.)

17.

The question of age-related extinction of reflexes before
end is not clear, since it is possible that
the presence or absence of reflexes
to be one of the most obvious signs
aging and, in particular, aging of the nervous
systems that, from the point of view of gerontology and
geriatrics may be important for
assessment of the state of the nervous system.

18.

Refraction
The reflections are very bright
farsightedness
The least bright and pronounced are
reflexes in myopia (due to changes in
surface of the inner limiting membrane
with its stretching, depigmentation of the fundus,
and possibly with posterior vitreous detachment
body)
With astigmatism, there are peculiar
changes in the shape of reflexes

19.

Fundus pigmentation
The weaker pigmentation, the worse visible
reflexes and vice versa (Leibreich, 1863; Haab
1895).
Reason: spectral selection of light (large
part of the long-wavelength rays is not reflected, and
absorbed, and specularly reflected rays
begin to dominate, in addition, by virtue of
contrast, light reflections are better seen on
dark background than light background).

20.

Classification of light reflections
fundus
Reflexes of the fundus
normal
pathological

21.

I. Normal fundus reflexes and their
pathological changes
1.
2.
3.
4.
5.
6.
7.
Foveolar reflex: normal, abnormal, false,
no foveolar reflex.
Macular reflex: normal, abnormal, false,
disappearance of the macular reflex.
intramacular, paramacular, perimacular
reflexes.
Planar and perivascular: normal, pathological
(glare reflections).
Frost (Gunn) points.
Vertical-linear reflections.
Reflexes (light stripes) on vessels: normal,
pathological (intensification of brightness, expansion of the strip, reflexes
copper and silver wire, mottled reflex,
transverse and disappearance of the reflex

22.

II. Pathological reflexes
1.
2.
3.
4.
5.
fan reflex
Focal reflexes
Peridisk reflexes
Linear reflexes
Stationary reflexes: coin-shaped
reflexes, patchwork, cellophane macula.
6. Metalloid reflections: golden and
silvery.
7. Crystalline reflections

23.

Normal light reflexes of the fundus
Normal foveolar reflex
This reflex, when examined directly with an ophthalmoscope, is more often
everything looks like a bright shiny dot or speck,
moving in the opposite direction from the movement of the direct
ophthalmoscope side (much better visible when
short wave light study).
Pathological foveolar reflex
It occurs with changes in the shape and size of the foveola.
Form of a dull, blurry spot - flattening of the foveola
Ellipsoid, dashed and other irregular shapes change in the normal spherical shape of the foveola as a result of
retinal atrophy or edema.
Stretching of the foveolar reflex - with astigmatism (with
direct astigmatism, it is elongated in the vertical direction,
at the opposite - in horizontal.

24.

False foveolar reflex
A reflex formed not by a concave, but by a convex surface.
It most often occurs on the macular cyst of the retina, can
be formed by a centrally located prominant
foci and less often - delimited hyaloid detachment
vitreous body membranes.
Appearance does not differ from normal or
pathological foveolar reflex.
Differentiation: in the direction of movement - if the displacement
reflex "occurs with the same name as the movement of the direct
ophthalmoscope, then this is a false foveolar reflex.

25.

Maculitis. The macular reflex is deformed
from separate double-circuit strips. Two are visible
foveolar reflex, one of them is false.

26.

No foveolar reflex
This phenomenon indicates a flattening of the central fovea
or that the boundary membrane in a given area
lost the ability to reflect light.
Foveal flattening is most often accompanied by
flattening of the entire central fossa and its ridge-like
thickened edge, and hence the disappearance
macular reflex.
Causes:
High myopia
retinal edema
The transformation of a layered hole in the macula into a through

27.

Normal macular reflex
He was the first to suggest that the macular reflex
formed by a convex ridge-like surface
around the fossa, apparently by Gunn (1887).
However, this point of view was convincingly substantiated by Dimmer
(1891).
Macular reflex - a reflex located along the edge
central fossa.
The normal macular reflex is recumbent.
oval. Like a shiny frame, this reflex surrounds
dark brown spot in the central region of the bottom of the eye.
When examined with a direct ophthalmoscope, this
reflex is shifted in the same direction as
ophthalmoscope.

28.

Normal macular reflex.
When installing the mirror of the ophthalmoscope along the visual axis,
macular and paramacular reflexes.

29.

Pathological macular reflex
Occurs usually with small changes
surface of the retina in the central region.
Causes:
retinal edema
Flattening of the fovea accompanied by
slight wrinkling of the surface
Type of reflex:
The reflex is dilated, appears intermittent, consisting of
individual highlights, its boundaries are blurred.

30.

False macular reflex
Such a clinical picture, in which in place of the true
macular reflex is a reflex,
due to some focal process,
simulating its location normal or
pathological macular reflex.
Causes:
Central focal chorioretinitis (circular reflex
around the central focus coincides in size with
macular reflex).
Differentiation: in the study of direct
ophthalmoscope is shifted in the opposite direction from
ophthalmoscope side.

31.

False macular reflex
central focal chorioretinitis.

32.

No macular reflex
The absence of macular reflex is not less than
valuable diagnostic feature than the presence of
pathological reflex.
Causes:
Central tapetoretinal dystrophies (and a number of
other injuries)
Retinal atrophy of the central region of the fundus

33.

intramacular, paramacular,
perimacular reflexes.
Sometimes a reflex becomes visible inside the large macular reflex.
the form of a ring or a sickle.
Explanation: The slopes of the fossa are not always flat
funnels. In some people, this slope forms a ridge-like
protrusion.
In many cases, there is another one around the macular reflex
circular reflex - paramacular. It is wider and more blurry than
macular reflex.
Explanation: The retina behind the macular shaft forms a circular concavity.
Behind the paramacular reflex is another arc reflex,
moving in the same direction as the ophthalmoscope. Means
the surface of the retina in the central region in the section should have
undulating character with two rises and one depression.

34.

Schematic representation of normal
reflexes in the central region of the bottom of the eye

35.

Paravasal reflexes
Located next to the vessels and especially visible
along larger vessels, repeat their bends.
The paravasal reflex can be transferred to a vessel,
the light bar dims.
De Speyer (1953) first noted the rhythmic movement
paravascular reflexes synchronously with the pulse.
Explanation: transmission of the pulsation of the vessel to
boundary membrane, the vibrations of which
become noticeable by the movement of reflexes.

36.

Planar reflex reflex
This is a reflex observed between vessels and on avascular
areas (except for the macular area), is very polymorphic.
It takes the form of spots, vague figures, stripes that
easily transform or disappear at the slightest displacement
ophthalmoscope or the gaze of the subject.
The reason for the appearance of paravasal and planar reflexes
lies in the fact that the larger trunks of retinal vessels
elevate the inner limiting membrane, separating
retinal surface into numerous concave surfaces,
having various forms. In a place where there are no large vessels,
reflexes are formed due to the spherical concavity of the retina itself, and
the slightest changes that violate this sphericity affect the appearance
planar reflex, which is of diagnostic value.

37.

Pathological planar reflex glare reflex
This reflex occurs most often with retinal edema. He
described in the literature under various names:
swell-type reflex, a reflection of crumpled foil.
With the movements of the ophthalmoscope, the reflexes are so haphazardly
move, giving the impression of reflection from
rippling water surface.
In the central region of the bottom of the eye, they are often found with
blunt trauma, with optic neuritis, including
number with retrobulbar.
With the elimination of edema, as a rule, glare also disappears.
reflexes.

38.

Frost (Gunn) points
Very small, rounded, and when examined in a redless
light rather polygonal point reflections. They are better
most visible around the optic nerve head and away from
it in young people with a darkly pigmented fundus.
The picture resembles a starry sky. Unlike many
other normal fundus reflexes, these reflexes are not
move as the light source moves. At the same time they
they flare up, then they go out.
Frost reflexes, apparently, occur on the border
membrane.
Most likely, the specific places of origin of these
point reflections are funnel-shaped depressions,
formed by the expanded endings of the Mullerian
fibers.

39.

frost points

40.

Vertical Linear Reflections
Mainly observed at the bottom of the eye of people with
hyperopic refraction.
Best seen on a narrow or medium pupil. They look like
thick palisade of very thin light lines,
usually located between the disk
optic nerve and macula. They are most often seen between
vascular bundle and horizontal line,
connects the foveola to the disc.
In the diagnosis of great importance do not play, although
disappear if at their usual location
there is swelling or folding of the retina.

41.

Vertical Linear Reflections
fundus

42.

Reflexes (light stripes) on vessels
Theories of surfaces on which
reflexes occur
1. internal boundary membrane
2. front wall of the vessel
3. front wall of the blood column, i.e. edge layer surface
plasma
4. front surface of the axial flow, consisting
predominantly from erythrocytes
5. posterior surface of the vascular wall
According to the research of Vodovozov A.M. : excluded borderline
membrane, posterior wall of a vessel. Connection confirmed
reflex with blood flow.

43.

Normal light reflections on
vessels
On the arteries of the retina, normal light reflexes are wider and
brighter than veins.
The light reflex on the arteries takes approximately 1/4 - 1/3
the diameter of the vessel, and on the veins 1/10 - 1/12 of the lumen of the vessel.
Dimmer proposed a comparative caliber on which
two red stripes imitating a vessel are applied.
The unshaded band in the center corresponds to the reflex.
Together with a decrease in the caliber of the vessel, respectively
the reflex band also narrows. With a wide pupil
reflexes on the vessels become wider and in particular on the veins
occupy up to 1/6 of the lumen of the vessel. Reflex color on arteries
light red or pink while on normal
vein, it has an almost white color.

44.

Comparative Dimmer Gauge for
determining the relative width of the light
stripes on retinal vessels

45.

Pathological changes in the reflex
stripes on vessels
Increasing the brightness of the light bar
An increase in brightness can occur for two reasons: first, due to the functional narrowing of the arteries,
when the vessel becomes more convex, in connection with which
the image of the light source on it becomes, although
narrower, but brighter, secondly, as a result of sclerosis
vascular wall, which enhances
its reflectivity.
On the veins, the reflex becomes brighter with venous stasis.
The reasons here are the same as with greater blood filling.
arteries, but the difference in color appears sharper.

46.

Light bar extension
On the arteries due to sclerotic changes in the vascular
wall, the light strip expands. Vascular
the wall becomes less transparent and begins not only
transmit but also reflect light.
The expansion of the light strip on the arteries is accompanied by
increased reflection and pronounced unevenness
reflex, which is associated with a nest characteristic of sclerosis,
uneven damage to the vascular wall. On
the affected area, the reflex may be wider and brighter, and higher
or lower - narrower and less bright.
Differentiation: use of compression
ophthalmoscopy. When squeezing the eyeball to a stop
blood flow in the arteries, the normal reflex to them disappears, and
pathological intensifies or becomes nested.

47.

Scheme of expanding the light strip on
sclerosed vessels

48.

Mottled light strip.
This phenomenon lies in the fact that the reflex on
vessels not only expands, but
becomes uneven
consisting of individual shiny dots,
dash, speck. mottle is
consequence of uneven
sclerosis of the vascular wall.

49.

Reflex (symptom) of copper wire
It consists in changing the color of the light strip and
while enhancing reflection. Reflex acquires
golden luster and resembles a red-hot wire.
Explanation: the formation in the vessel wall of individual
lipoid spots, according to the location of which
the reflex strip becomes yellowish.
Friedenwald (1930) proved histologically that the symptom of copper
wire is the result of hyaline regeneration
vascular wall.
Reflex (symptom) of silver wire
It looks like a bright narrow shiny reflex on a red background.
column of blood. Explanation: the entire sclerotic vessel without
signs of the presence of a blood column as a result of a change
density of the arterial wall begins to homogeneously reflect light.

50.

Transverse reflex on vessels
The appearance of a transverse reflex is due to the fact that the vessel is bent
forward and forms a surface that reflects rays in
perpendicular to the normal direction.
This reflex may be of diagnostic value in the initial
congestive nipples, when the transverse reflex on the vein indicates
prominence of the part of the optic disk lying under it
nerve.
The disappearance of the reflex on the vessels
The reflex is visible if the vessel is located in a plane perpendicular to
to the observer's line of sight.
Reasons for disappearance:
Retinal disinsertion
retinal edema

51.

Pathological light reflexes
fundus
Fan reflex (camet-shaped,
parietofoveal, parafoveolar).
Explanation: reflection of rays from the slope of the fossa, which has
funnel shape. It was observed in myopia with morphological
fundus changes.
The reflex appears when the angle of inclination of the walls of the central
pits. This may occur when the fundus is deformed,
for example, layers of the retina shift to one side with myopia,
accompanied by stretching of the posterior pole. funnel axis
the central fossa is located not along the optical axis, but
at an angle to her.
The fan reflex indicates a greater or lesser deformation
area of ​​the central fossa.

52.

The fan reflex is located between
foveolar and macular reflexes. He
has a triangular shape with a apex,
facing the foveolar reflex, and
base - to the macular.
Causes:
Myopia
Congenital changes in the fundus of the eye
Central retinal edema (especially
characterized by the appearance of a fan reflex and
disappearance of the macular)

53.

Focal reflexes
The occurrence of focal reflexes is associated with a change
retinal surface configurations,
due to local edema or proliferative
process that protrudes the retina. This creates
spherical protrusion. As a result, there are 2 types
light reflexes.
reflex at the base of the focus, where the annular concave
surface - ring-shaped reflex (marginal focal
reflex)
the focus itself is a reflex in the form of a dot or spot located
at the top of the focus (apex reflex)

54.

Apex focal reflex
It looks like a spot, less often a dot. Much less often takes the form of an arc
or rings (the top of the hearth has a crater-like shape).
marginal focal reflex
It occurs more often than the apical one (along the edge of the focus, the boundary membrane
remains a smooth reflective surface for a longer time).
In addition to a continuous ring or arc, the edge reflection can have the form
individual highlights arranged in an arc or in a circle.
If there are several lesions at the bottom of the eye, then it is possible to observe
several focal reflexes.
It is important to distinguish between false macular and foveolar reflexes, which
in fact, they are focal reflexes, from true ones.
Differentiation: observation of the movements of the reflex during
displacement of the ophthalmoscope.

55.

Clinical example
Patient A. was observed for
old focal chorioretinitis.
Noticed a decrease in vision
this eye. When researching
fundus: clearly visible two
identical in size and shape
macular and two foveolar
reflex located nearby.
foveolar reflex,
closer to the old
hearth, shifts in the same direction,
that an ophthalmoscope is formed
convex surface - false
foveolar reflex.

56.

Clinical example
Patient G. was hospitalized with complaints of
metamorphopsy. History
symptomatic renal hypertension.
Objectively:
VisusOU: 1.0
At the bottom of the left eye in the central zone are visible
bright unusual reflexes. Below the macula two
different in size marginal focal
reflex connected so that they form
figure eight. In the center of a large regional
focal reflex, the apical focal
reflex moving in the same direction,
as an ophthalmoscope. Above these reflexes
another marginal focal reflex with
apex in the center. Between macula and disc
numerous two-loop reflexes.
Based on clinical presentation and history
diagnosed with cystic
(vacuolar) retinal edema. Carried out
antihypertensive and dehydration therapy
- elimination of edema and metamorphopsia,
normal picture of the fundus.

57.

Peridisk reflexes
This is a group of reflections, the occurrence of which is due to anomalies
in the anatomical structure of the disc or its pathological condition,
accompanied by the development of congestive nipple.
Weiss strip
Weiss (1885) found that the light arc strip at the inner edge
disc is visible in 69.4% of children with myopia. Moreover, it appears when
small degrees of myopia. Weiss believed that if the strip
occurs in children with hypermetropia or emmetropia, then this
serves as evidence of the beginning increase in the anteroposterior
axes. That is, myopization of this eye. He saw this as a clinical
reflex value.
Cause of the reflex: posterior vitreous detachment,
arising from myopia due to stretching of the posterior pole of the eye.

58.

Peridisk reflex
with myopic refraction
with hyperopic refraction

59.

Peripapillary reflex
It is observed at the bottom of the eye at the edge of the congestive nipple. It was observed
diagnostic value of the reflex and its changes are described in
depending on the dynamics of the congestive nipple.
With an increase in the phenomena of stagnation, the peripapillary reflex moves away from
edges of congested nipple. At the same time, it expands to 1\8-1\6 DD
optic nerve. The length of the arc also increases. Simultaneously with
displacement and expansion of the reflex, it becomes not continuous, but as
fragmented into separate highlights, each of which
is a short strip. The whole reflex is similar to
a kind of palisade of shiny stripes. In some places they may
merge with each other, and then the reflex band seems jagged.
The banding of the reflex is due to the direction
nerve fibres. With further increase in stagnation
the reflex is pushed even further.

60.

Clinical example
Patient K. was admitted for congestive nipples in both eyes. Later in
A neurosurgical institution was diagnosed with a brain tumor.
On the fundus: a congestive nipple and a wide reflex, located in the form of an arc
at a distance of up to 1DD from the edge of the congestive nipple.

61.

The peripapillary reflex disappears during the transition to atrophy and during the formation
retinal folds around an atrophied optic disc. Explanation:
decrease in the reflectivity of the retina due to the resulting
the roughness of its surface.
Depending on the severity of stagnation, various options are observed
reflex, apparently associated with the anatomical features of the disc and
underlying retina.
Circular areola reflex
Almost circular nipple reflex
Peripapillary reflex in the form of a short arc
Peripapillary reflex in the form of a double short arc
The mechanism of formation of the peripapillary reflex:
It occurs due to retinal edema that accompanies a congested nipple. Together,
where the edematous retina becomes normal, a level difference is formed, according to
shape close to a toroid. According to observations, the retina swells more often,
located on the inside of the disk. Therefore, the peripapillary reflex
more common on the nasal side and has the appearance of an arc.

62.

supra-papillary reflex
The supra-papillary reflex is much less common than
peripapillary. As a rule, it is visible with pronounced congestive
and pseudocongestive nipples.
The supra-papillary reflex has the appearance of a light, reflective ring,
located on the most stagnant nipple. Ring diameter
less than the diameter of the congestive nipple. The reflex often consists of
individual highlights arranged along an arc.
The supra-papillary reflex most often turns out to be open, in these
cases, the gap in the ring is always directed to the temporal side.
The mechanism of formation of the reflex: the nipple swells along the periphery, and
the vascular funnel is not only preserved, but also becomes more
expressed. Due to the difference in levels along the edge and in the center, stagnant
the nipple becomes funnel-shaped.

63.

Linear reflexes
Similar reflexes accompany many pathological changes.
eye fundus.
Distinguish:
Paired reflexes
Radiation
Paired reflexes: they look like thin shiny lines. lines,
located side by side, often connected at the ends of a tender, barely
a noticeable arc that combines two reflex arcs into a pair.
Ray reflexes: reflex lines that are located
relatively evenly and do not pair up.
Cause of occurrence:
linear reflexes and retinal folds have the same anatomical
substrate.

64.

In some patients with a fibroplastic process leading to
wrinkle formation ophthalmoscopically and when shooting in redless
light, it is confirmed that the folds take the form of paired or radial
reflexes.
The mechanism of occurrence of reflex-folds is
reflecting each fold as cylindrically reflecting
surfaces. The crest of the fold, like a cylinder, forms a linear reflex.
Folding structures:
Preretinal membranes
Inner retinal layers or all layers
pigment epithelium layer
Bruch membrane
choroid

65.

Congenital folds are the result of intrauterine inflammatory processes that
lead to scarring of the retina and vascular membranes. They may also occur
due to anomalies of the eye, a high degree of farsightedness,
microphthalmos and elastic pseudoxanthoma.
Mechanism of origin of acquired folds:
Traction folds due to cicatricial tension
Wrinkles resulting from wrinkling of the tissues of the eye
(retrobulbar tumor, endocrine exophthalmos, inflammatory
processes in the orbital cell)
retinal edema (eye injury, iridocyclitis, congestive
pseudocongestive nipples)
The clinical significance of fold reflexes is that they
may be one of the early symptoms of retinal edema starting
fibrous process or deformation of the posterior part of the eyeball.
Sometimes it is possible to follow the dynamics of focal processes.

66.

Clinical example
Particularly clear is the difference in
reflexes at various stages
process. How did this happen when
study of the bottom of the eye of the patient K.
with recurrent focal
chorioretinitis tuberculous
etiology. Around the old hearth
linear reflexes of the fold were located, and glare around the fresh one.
In a number of patients, reflexes-folds
were the only
an objective sign of flat
retinal detachments and played a role
both in diagnostics and in selection
treatment tactics.

67.

Stationary reflexes
Reflections that are formed by spherical or toric
surfaces are movable, i.e. they can be moved
moving the light source. In contrast, stationary
reflexes cannot be moved. When moving
ophthalmoscope, they either flash, then go out, without changing either
its position or form.
Cause of occurrence:
A local accumulation of tissue with a sufficiently strong
reflectivity and generating reflexes only
when light falls on it at a small angle.
Types of stationary reflections
fragmentation
Coin-shaped
Patchwork
Solid stationary reflex

68.

Fragmentation reflections are small reflective areas,
resembling sparks or flashes of light on glass fragments.
Coin-shaped stationary reflections have the form of rounded
spots ranging in size from 1 to 3-4 diameters of the vein of the first order.
Patchwork reflexes look like irregularly shaped reflective
plots of various sizes.
Continuous stationary reflex - a reflex that covers the macula
solid arc, ring or covers the entire central area
The most pronounced are those forms of the stationary reflex, which
occupy the entire macular or central area. This form is similar
that clinical picture, which is occasionally mentioned in the literature under
called "cellophane macula" (Allen, Gass 1976).

69.

Metalloid (gold and
silver reflexes)
Diseases in which data occurs
reflex shapes:
Tapetoretinal dystrophies (disease
Stargart, yellow-spotted dystrophy,
lobular atrophy, typical pigmented
dystrophy)
Residual effects of central
focal chorioretinitis inflammatory
or traumatic

70.

Clinical example
Patient B. examined for residual effects of central focal chorioretinitis of the right eye. On
In the fundus of this eye, a large atrophic focus is visible in the central region. At the bottom of the hearth
visible destruction of the pigment epithelium and accumulations of pigment in the form of small clumps and large
conglomerates. In the lower, atrophic, part of the focus, when turning the ophthalmoscope, it flashes brightly
a reflex reminiscent of a reflection from a polished copper plate is a golden reflex.

71.

Crystalline reflexes
By crystalline reflections we mean the reflection of light from
formations with a crystalline structure.
Crystalline reflexes in oxalosis
A picture of the fundus of the eye called "pulverized
clouding", in which mainly in the macular region
tiny foci of grayish or whitish color. Some of these
point formations has a pronounced brilliance. Point
reflexes owe their origin to deposits in the retina
calcium oxalate crystals.
These changes appear to be a manifestation of a violation
metabolic processes in the retina or throughout the body.

72.

Spotlight reflexes
This is a kind of crystalline reflections. At the bottom of the eye with displacements
ophthalmoscope flashed reflexes in the form of thin rays directed to
vitreous body. When illuminated in blue, the bottom of the eye resembles the night
sky. Drawn by the rays of numerous searchlights. One must think that in
In these cases, we are talking about the reflection of light from crystals, the faces of which
more or less ordered in space.
Crystalline reflexes in cholesterol
These reflexes occur on cholesterol crystals and, as a rule, differ from
reflexes in oxalosis. Cholesterol crystals are polygonal,
relatively large, brightly shining formations. The most characteristic feature
their reflectivity is not only golden and silver luster, but also often
observed overflows with rainbow colors. The deposition of cholesterol crystals in
retina are usually associated with the development of degenerative processes in it. However, not
it is excluded that cholesterol crystals in hypercholesterolemia themselves may be
source of pathological changes in the retina, in particular, if they
accumulate in the vessels of the retina and clog them.

Information for specialists

Differential diagnosis of congestive optic disc

• retrobulbar neuritis (more often a unilateral process, deterioration of visual functions, discomfort, pain in the eye, aggravated by movement, swollen optic disc, negative dynamics);
• prethrombosis / thrombosis of the CVS (more often unilateral, vision improvement in the evening, ophthalmohypertension is possible on the diseased eye, the optic disc is edematous, relative scotomas or concentric narrowing are possible with perimetry, negative dynamics);
• anterior ischemic optic neuropathy;
• compression optic neuropathy;
• toxic optic neuropathy;
• Foster-Kennedy syndrome;
• pseudocongestive optic disc (myopia, latent hypermetropia, no changes in perimetry and tonometry, no dynamics);
• Druses of the optic nerve disc;
• atrophy of the optic disc;

Complaints

These complaints are inherently symptoms of intracranial hypertension (ICH) and not symptoms of congestive optic disc (PAD).

Headache

The most common symptom (rarely absent in ICH), may appear at any time of the day, but is more disturbing when waking up, or interrupts sleep in the morning; aggravated by movement, stooping, coughing, or other type of Valsalva maneuver; may be generalized or local; the doctor, as a rule, leads to pain intensifying within 6 weeks; patients who have suffered from headaches before may report a change in their nature.

Nausea and vomiting

Occurs in severe forms. May relieve headache, may appear without pain or before pain. The next step after nausea and vomiting is impaired consciousness.

Disturbance of consciousness

From mild to severe forms; sudden significant disturbances are a symptom of damage to the brain stem with tenitorial or cerebellar herniation and require urgent action.

Pulsating ringing and tinnitus

visual symptoms

More often absent, but possible: transient blurred vision for a few seconds (paleness of colors, usually in both eyes, especially when moving from a horizontal to a vertical position, or flickering, as if the lights are quickly turned on and off). Blurred vision, narrowing of the visual field, and impaired color perception may occur. Sometimes, with paralysis of the sixth cranial nerve or its tension over the pyramid, diplopia occurs. Visual acuity remains good except in later stages of the disease.

Epidemiology

Congestive optic disc does not occur in all patients with intracranial hypertension. It is very rare in children, especially in infancy (this is due to open fontanelles that compensate for the increase in pressure). But in all patients with MD, an intracranial neoplasm should be suspected first and foremost until another cause is proven.

A recurrent increase in intracranial pressure (ICP) may occur without a congested disc due to glial scarring of the disc during the first episode.

Congestive ONH is sometimes found during routine examination of an asymptomatic patient. In these cases, it is necessary to ask about the drugs taken, the presence of a history of traumatic brain injury.

Etiology

The term congestive optic disc is often misused to describe swollen optic nerve due to infection, inflammation, or infiltration of the disc itself. In these cases, the deterioration of visual functions occurs at the very beginning of the disease, and in the case of MDD - in the last stages. The term is appropriate if the intracranial hypertension itself is due to infection, inflammation, or infiltration. The cause of congestive optic disc is intracranial hypertension. In other words, HPD is one of the symptoms of intracranial hypertension, along with headache, nausea, vomiting, and impaired consciousness, which in most cases is bilateral (with the exception of cases of severe hypotension in one eye or Foster-Kennedy syndrome).

Intracranial hypertension is divided into four types:

1. parenchymal - develops as a result of volumetric intracranial processes: tumors, hematomas, brain abscesses, etc., traumatic cerebral edema, general intoxication with neurotoxins of exogenous or endogenous origin;
2. vascular - develops as a result of vascular diseases of the brain: cerebral thrombosis, thrombosis of the superior sagittal sinus, mastoiditis with thrombosis of the transverse or sigmoid sinus; extracerebral vascular diseases: hypertensive encephalopathy in cases of malignant hypertension of any etiology, glomerulonephritis, eclampsia, etc., difficulty in cerebral venous outflow in congestive heart failure, superior vena cava syndrome, volume intrathoracic processes or injuries;
3. caused by a violation of the dynamics of the cerebrospinal fluid - develops as a result of obstruction of the CSF circulation pathways in tumors, hematomas, narrowing of the Sylvian aqueduct, infection; CSF malabsorption in acute meningitis, subarachnoid hemorrhage, carcinomatous meningitis, sarcoidosis;
4. idiopathic - diagnostic criteria are: symptoms of increased intracranial pressure (headache, papilledema, CSF pressure more than 25 cm of water column), but the CSF composition is normal, there are no topical neurological symptoms, there are no suspicions of intracranial venous thrombosis, and computer or magnetic resonance imaging shows normal structure of the skull and brain).

Examination of a patient with congestive optic disc

In addition to clarifying neurological problems (the nature of the headache and the history of the development of the disease, the presence of a history of episodes of fever), the following is necessary:

• assessment of eyeball motility and carrying out a cover-test when looking directly and at the extreme positions of the eyes at eight points (abducens nerve palsy can be combined with ICH), check for pain on movement;
• assessment of pupillary reactions (relative afferent pupillary defect, as a rule, is absent, since visual functions do not suffer before the onset of atrophy of the optic disc, but it is necessary to remember the complaints described above);
• assessment of visual acuity, color sensitivity, refractometry (detection of latent hypermetropia and the difference in refraction above the disc);
• perimetry (look for concentric narrowing, scotomas);
• tonometry (pay attention to the asymmetry of IOP);
• binocular ophthalmoscopy in dynamics with photography of the fundus to objectify dynamic observation;
• Ultrasound of the orbits (detection of orbital causes of edema, optic disc drusen, measurement of the thickness of the optic nerve and prominence of the optic nerve head);

Classification of congestive optic disc by stages

Congestive optic disc can be graded in several stages according to the Friesen scale (the scale is based on a study using fundus photography and showed good reproducibility between different observers; specificity ranged from 88% to 96%, sensitivity between 93% and 100%; results were more accurate when examined in red-free light).

0 stage

Normal ONH with nasal and temporal borders, blurred overlying bundles of nerve fibers in inverse proportion to the diameter of the disc (slight blurring with a large disc, and vice versa). The location of the near-discal bundles of nerve fibers is strictly radial, without tortuosity of diverging axons. Blurring of the upper and lower boundaries is not taken into account due to the large number of normal options. Rarely, the major vessels may be covered by overlying nerve fibers at the border of the disc, usually at the superior pole.

1 stage

Excessive (in relation to the diameter of the disc) blurring of the nasal border of the optic disc, with a violation of the normal radial arrangement of the bundles of nerve fibers. The temporal part remains normal, at least within the papillomacular sector. These changes lead to the formation of a thin grayish halo around the circumference of the optic disc, the temporal side of the ONH is not affected by edema (C-shaped edema), and the excavation is clearly defined (generally best assessed with low magnification and indirect ophthalmoscopy).

2 stage

There is a prominence of the nasal part of the ONH and blurring of the temporal margin. The halo surrounds the disk completely. Concentric or radial retinochoroidal folds may appear already at this stage. Excavation is still clearly defined.

3 stage

There is a prominence of the temporal border and a clear increase in the diameter of the ONH. Prominent borders overlap one or more segments of large retinal vessels (vessels are buried in edematous tissue), or become invisible in the place where they, bending, leave the disc. The halo has a flared outer fringed edge. Excavation can be smoothed out.

4 stage

Prominence of the entire OD in combination with smoothing of the excavation or its compression to the size of a gap, or with partial immersion of large vessels in the edematous tissue not only on the edge, but also on the surface of the disc.

5 stage

The increase in disc prominence exceeds the expansion of its diameter. The optic disc is a relatively smooth, domed protrusion with a narrow and indistinctly demarcated halo. The vessels bend sharply, climbing a steep slope, partially or completely immersed in the edematous tissue over the entire surface of the disc.

Stages 1 and 2 can be assessed as mild papilledema, stage 3 as moderate, and stages 4 and 5 as severe.

Early symptoms of congestive optic disc that may help in diagnosis

Disc hyperemia, small single hemorrhages in the layer of nerve fibers

The absence in the classification of indications of hyperemia (or pallor), hemorrhages and cotton-like foci is intentional, due to the significant variability of these signs under various pathogenetic conditions, as well as in different patients under the same conditions. However, in each case, it is very appropriate to make a note about the presence or absence of each of these signs. Obviously, the more complete the information, the easier it is to find the root cause, and the more noticeable any changes in appearance over time.

As the stagnation progresses, the number and size of hemorrhages increase, foci of soft exudates, retinal folds and choroids appear.

After a few months, hyperemia is replaced by pallor, excavation is smoothed out - secondary atrophy is formed. Small, shiny, crystalline deposits may appear on the disc surface (disk pseudodruse).

Spontaneous venous pulsation

The symptom is useful and confirming the optic disc in those cases where the pulsation was recorded earlier and when observed in dynamics, it disappears. Here we can talk about negative dynamics. Also, when evaluating the effectiveness of treatment, the restoration of pulsation indicates a positive trend. But it must be remembered that pulsation is absent in 10% of healthy people, and with intracranial hypertension it disappears with an increase in ICP of more than 190 mm of water column.

retinal reflexes

Peripapillary reflex

In the initial stages, the reflex is located closer to the disc, weakly expressed as a fragment of an arc (more often determined from the nasal side), the closer it is to the disc, the thinner and brighter, as the edema increases, the reflex becomes wider, fades and moves away to the periphery, usually upper and lower the edges of the reflex are farther from the disk than the middle, the edges do not close (in severe cases, the edema extends to the temporal part and the reflex is located on both sides - "ON in brackets").

supra-papillary reflex

It is formed if the vascular funnel contours (ring-shaped reflex at the top of the optic disk around the excavation)

Pathological reflexes of the fundus

The foveolar reflex takes the form of a blurred spot, the normal macular reflex becomes pathological, and then they disappear; if the edema increases, glare and linear reflexes appear.

Features of retinal reflexes in other conditions

• pseudocongestive optic disc- peripapillary reflex is located concentrically relative to the disk; the edges can close, forming a ring;
• Druzy ONH- the peripapillary reflex is located on the side of the drusen;
• retrobulbar neuritis- the macular reflex becomes pathological - it expands, loses its clear outline, breaks into separate highlights, then becomes indistinguishable as an annular formation; glare reflexes appear in its place; the foveolar reflex takes the form of a blurred spot, its mobility increases, disappears together with or a little later than the macular reflex, in some patients, especially with a long course, linear reflexes between the disc and the macula become visible;
• primary atrophy of the optic disc- weakening and disappearance of all reflexes (atrophy of the layer of nerve fibers), the reflex on the vessels becomes brighter, and then uneven and mottled as in atherosclerosis;
• secondary atrophy of the optic disc- a distinctive feature is the presence of a peripapillary reflex (the borders of the disc are not always convincing).

Ophthalmochromoscopy for congestive optic disc

• in redless light: The optic disc becomes light green in color, small dilated vessels become visible in large numbers, the disk seems to be covered with a vascular network, lateral accompanying stripes along large vessels are visible better than in ordinary light, the pattern of nerve fibers is clearly visible, they are thickened, the spaces between the fibers are expanded, hemorrhages visible better and in greater numbers, disc prominence looks more prominent, reflexes and perripapillary retinal edema are more distinct;
• in red light: in some patients, the phenomena of stagnation are indistinguishable, the outlines of the disk contour appear, especially well in indirect illumination (the sign is not pathognomonic, since it does not occur in everyone and no dependence on the cause of edema has been identified); deeply located disk drusen are found, indistinguishable in ordinary light (round-shaped light / "luminous" formations with a paradoxical shadow, resembling bubbles, merging into clumps or resembling a mulberry);
• in purple light: disk in the form of a red-purple blurred spot surrounded by a wide blue jagged border.

Tactics

1. Compare current data with previous inspections.
2. Carefully record the current state of the ONH (better if it is a photograph).
3. Re-examination after 1–2 weeks with the same set of examinations.
4. When making a diagnosis of MDD - a consultation with a neurologist to decide on the tactics of management, referral to CT or MRI of the brain, orbits and optic nerve.
5. If, as a result, idiopathic intracranial hypertension is exhibited - the supervision of a therapist (control of blood pressure, body mass index in dynamics).

Forecast

In the natural course, the stagnant disc turns into secondary atrophy with loss of visual functions.

Fundus examination is one of the objective methods used in the clinic of early age neurology. Examination of the fundus in young children is difficult. To dilate the pupil, 1% homatropin is instilled into the conjunctival sac. In newborns and infants, the head is fixed by the mother or nurse. If the child is very restless, closes his eyes, the doctor may use an eyelid lifter. With good contact with a child of 2-3 years old, you can make him fix his eyes on an interesting subject. The fundus is examined using a mirror or electric ophthalmoscope.

Ocular fundus The newborn is distinguished by a number of features. It is dyed light yellow. The optic disc is pale pink with a grayish tint, the boundaries are clear, there is no macular reflex. In adults, such a fundus occurs with atrophy of the optic nerve. The grayish color of the macular area and depigmentation of the rest of the fundus persists until the age of 2 years. The retinal arteries of newborns are of normal size, and the veins are wider than usual.

At newborns born in asphyxia, on the fundus, you can find small-point hemorrhages along the arterioles in the form of flames, blots, strokes, spots, puddles. These hemorrhages resolve on the 6-7th day of life. Hemorrhages in the macular region and periretinal hemorrhages persist longer. Sometimes they reappear on the 12-14th day of life.

In premature babies, which were in an atmosphere with a high oxygen content, retrolental fibroplasia is found in the fundus - proliferation of capillary endothelium, hemorrhages, and swelling of nerve fibers. In the future, the nerve fibers thicken, the newly formed capillaries grow into the vitreous body. Starting at the periphery, the process captures the entire retina and vitreous body.

With an increase intracranial pressure, decompensated hydrocephalus, volumetric processes in the fundus, there are varicose veins, narrowing of the arteries, obscuration of the optic nerve head due to retinal edema. Edema also spreads along the vessels. With an increase in hypertension, the disk increases in size and protrudes into the vitreous body, the vessels sink in the edematous retina, and hemorrhages from dilated veins appear. Prolonged intracranial hyperthepsia leads to subatrophy, and then to secondary atrophy of the optic nerve head. The disk becomes pale gray with indistinct borders. Vessels are narrowed, especially arteries.

congenital atrophy of the optic nerve characterized by a sharp blanching of the optic disc, especially the temporal halves. Disc borders are clear, in contrast to secondary optic nerve atrophy. The arteries are constricted.

For cerebral lipoidosis(gangliosidoses, sphingolipidoses) and some mucolipidoses are characterized by the presence of a cherry-red spot in the macular region, which does not change throughout the course of the disease. These changes in the fundus are associated with retinal atrophy and translucence of the choroid. They can be detected already in the first months of life, which is important for the differential diagnosis. Chorioretinitis, microphthalmos are observed in congenital toxoplasmosis.

Video of the technique of reverse ophthalmoscopy for the study of the fundus

In case of problems with viewing, download the video from the page Table of contents of the subject "Development of the child. Researches at children in neurology":

anonymously

Hello! I am 20 years old. Vision 1/09. 2 years ago, when looking at the sky or another light surface, I began to notice floating round transparent bubbles and compounds from them. She was seen by an ophthalmologist. After examining the fundus, the doctor said the following: the discs are pale, the boundaries are clear, the veins are dense, tortuous, the arteries are narrow, there is swelling in the MZ, dystrophic changes. Diagnosis - macular degeneration of both eyes. What can you say about the above symptoms and diagnosis? What is the treatment?

Hello! It is most likely that the complaints correspond to the destruction of the vitreous body. In most cases, this is not treated, but it does not affect vision either. Requires examination to exclude diseases that could lead to this. Macular degeneration is not completely cured, the "dry form" - multivitamins are prescribed, drugs to maintain the functions of the eye. In the "wet form" the introduction of a special drug into the eye is indicated, the courses require repetition. To determine the shape, optical coherence tomography of the retina is performed. It is possible to give exact recommendations only after internal inspection.

anonymously

She was on an additional examination at the regional ophthalmological clinical hospital. After examination by an ophthalmologist, the diagnosis "Macular degeneration of both eyes" was not confirmed. An advisory opinion was issued: OU - calm. Media are transparent. The fundus of the eye: ONH is pale pink, the boundaries are clear. arteries are slightly narrowed, veins are not changed. The retina is pink. The reflex in the macula is good. Tell me, please, how is macular degeneration determined - during a routine examination of the fundus of the eye or only by tomography? What is a reflex in the macula? What would you recommend for the treatment of the destruction of the vitreous body? What drops can be used for treatment?

anonymously

Hello! Addressed already to you in occasion of a macular degeneration. She was on an additional examination at the regional ophthalmological clinical hospital. After examination by an ophthalmologist, the diagnosis "Macular degeneration of both eyes" was not confirmed. An advisory opinion was issued: OU - calm. Media are transparent. The fundus of the eye: ONH is pale pink, the boundaries are clear. arteries are slightly narrowed, veins are not changed. The retina is pink. The reflex in the macula is good. No eye diseases have been identified, and at the expense of floating particles, I was told that almost everyone has them now and that this may be due to low blood pressure (90/60). No treatment was prescribed. Tell me, please, how is macular degeneration determined - during a routine examination of the fundus of the eye or only by tomography? What is a reflex in the macula? What would you recommend for the treatment of the destruction of the vitreous body? What drops can be used for treatment?

Age-related macular degeneration (AMD: Age-related macula degeneration) is a disease of the central retina that occurs in old age and leads to a decrease in central vision.
The job of the retina is to absorb and convert light into nerve impulses. The structure and functions of the retina in its various zones are not the same.

When looking at a distant object, such as the moon, the eyes are in such a position that the image of the moon is projected directly onto the center of the retina. This center, which appears slightly yellow due to xanthophyll pigment, is called the lutea macula or "yellow spot" (Lat. Macula: spot / Lat. Lutea: yellow). While the periphery of the retina is specialized in the perception of movements (mainly large objects), the center is responsible for spatial vision. This means that the center of the retina perceives even tiny objects, and two points extremely close to each other are identified by it as separate. The resolving power of the retina is expressed by visual acuity. A healthy person (with corrective lenses if necessary) has a visual acuity of 100%, or, as defined by ophthalmologists, 1.0 or 20/20.

The high resolution is the result of a denser arrangement of visual receptors in the macula than in any other area of ​​the retina. In addition, in this area, the ratio of cone cells to ganglion cells is almost 161. Therefore, macula receptors are connected directly to the brain through retinal nerve cells.

If the quality of the image on the retina is not perfect, such as in nearsighted people without glasses, visual acuity will be less than 100%. What is 100% visual acuity, or equal to 1.0? This means that two different points that are very close to each other must be perceived separately by the eye. If visual acuity is 0.5, or, in other words, 50% visual acuity, then in order for two points to be distinguished as separate objects, they must be twice as far apart as compared to the visible points at visual acuity 1.0. This distance should be four times greater at 25% visual acuity, etc. On a vision chart examination, a patient with 0.5 vision only identifies letters or numbers twice as large as a person with 1.0 vision can see. If a myopic patient is examined with correct spectacles (or contact lenses), the results become normal again. However, if the retina itself is changed, which may be associated with the death of receptor cells or their partial damage, a decrease in visual acuity occurs, which cannot be corrected with glasses. This problem is especially important for the macular area.

Like all organs, the retina also undergoes the aging process during life. Even in a healthy person, there is a slow decrease in the number of receptor and nerve cells. The pigment epithelium, located directly behind the retina and continuously absorbing the remnants of parts of the receptor cells, gradually forms deposits of waste substances that are difficult to process. The blood supply to the next layer, the choroid, also decreases with age.

The ability of the choroid to transport heat and regulate the required volume of blood usually decreases with age, which is reflected in the nutrition of the retina. In addition, deposits of unprocessed products, mainly fat deposits, increasingly impede the transport of substances from the retina to the choroid, and vice versa.

Normally, the macula receives a relatively small amount of oxygen from the vessels of the retina, mainly it enters the macular region from the choroid. This is the reason why the macula especially suffers from age-related disorders caused by the deposition of fatty deposits from the choroid adjacent to it. Another important factor is that the macula is more exposed to light and its damaging effects than other areas of the retina.

The difference between the normal aging of the macular area and some of the pathological processes occurring in it is sometimes subtle. Many older people develop overt changes in the macula, which can lead to severe vision loss. The precursor to such defects is the visual entrainment of a number of deposits in the retina, called drusen. Drusen are small, lump-like formations primarily composed of fat; they are located between the pigment epithelium and the choroid. When examining the eyes, they can be identified as small yellowish spots located behind the retina.

If the aforementioned drusen are relatively large, without clear boundaries and tend to shine (become confluent), then the risk of developing macular degeneration (Lat. Degeneratio: degeneration) increases. Degeneration is defined as the reorganization of tissue from a more complex form to a simpler one, as well as the transition from a properly functioning state to an incapacitated level. The first stage of AMD is changes in the structure of the pigment epithelium, determined by ophthalmoscopy.

It can be seen that instead of the usual homogeneous pink fundus reflex, dark and light foci are detected in the macular region. A patient with such changes no longer has 100% vision, and, depending on the severity of these changes, it ranges between 20 and 80%.
The lowest visual acuity that can be "adequate" for reading a newspaper (perhaps with reading glasses) is approximately 30%. AMD may stop at this first stage (changes in the pigment epithelium) and not develop further. Otherwise, there may be further deterioration, and the subsequent development of an atrophic form or progression of the process contributes to the emergence of a "wet" form of the disease (Gr. atrophein: without food). The development of atrophic degeneration may be associated with the risk of severe tissue loss and a significant deterioration in visual functions. The macular changes just described are otherwise known as dry AMD.

The dry form of AMD can go into the wet form. Nature, whenever possible, always strives to restore the body's own failures. Therefore, blood vessels can grow from the choroid into the degeneratively altered macula under the pigment epithelium. They can even break through the pigment epithelium and continue to grow between this layer and the retina. Such compensatory processes actually do more harm than good. Unlike healthy capillaries, newly formed blood vessels are not watertight. Fluid, sometimes even blood, can leak out and enter both under and into the retina, thus causing the wet form of AMD.

These blood vessels and exudate lead to local detachments and displacements of retinal receptor cells. As a result, the rods and cones are no longer where they should be, while the blood supply to the retina becomes even more inefficient. If an image is projected onto a detached part of the retina, the brain receives information that is topographically (spatially) incorrect. This is the reason why the wet AMD patient does not see the doorway as a rectangle, but rather as a twisted or undulating structure. This phenomenon, called metamorphopsia (Gr.metamorphopsein: to see something tilted), is pathognomonic (obligatory manifestation) for lesions of the macular zone.

We list the most important symptoms of AMD: in the dry form of AMD there is a decrease in visual acuity of one degree or another, in the wet form of AMD there is a significant decrease in vision associated with metamorphopsia.

Loss of vision is a heavy burden for the elderly. It is reassuring to know that AMD will not completely blind the patient. He may have difficulty reading or seeing details, but complete blindness will not occur unless there are other eye conditions (such as glaucoma) because other areas of the retina remain intact.
A patient with AMD has a fairly good orientation in space and can move freely, as the disease does not affect the peripheral areas of the retina.

How common is AMD?
There are some very rare hereditary forms of macular degeneration that appear in childhood or at a young age. These forms of macular degeneration should not be confused with AMD, which is a problem in the elderly. AMD is rare in middle age, but the likelihood of developing AMD is greatly increased in the elderly. Approximately 1.5% of people aged 52-64 have AMD, while this figure rises to 10-20% among those aged 65-75 and approximately 35% of people aged 75-84 have it pathology. It's safe to say that anyone who lives long enough will almost certainly develop AMD. As life expectancy increases, a corresponding increase in the number of patients with AMD can be expected in the future.

Pathogenesis and prevention of AMD.
The pathogenesis of AMD is not fully known, so attempts to treat this pathology are still at a very early stage.

Without a doubt, there is some genetic predisposition to the disease: children of parents suffering from AMD are at greater risk of developing the disease in the future. People with pale skin and those who complain of increased sensitivity to bright light are more likely to suffer from this disease. Other risk factors are similar to those that cause arteriosclerosis: AMD is more commonly seen in association with smoking and elevated blood lipids. There is also evidence that vitamin deficiencies, especially vitamins E and C, as well as vitamin A, may hasten the development of AMD. The general rules that have been established to prevent arteriosclerosis can also be regarded as preventive measures for AMD: smoking abstinence, a vitamin-rich and low-calorie diet, exercise, etc. Since light appears to play a significant role in the pathogenesis of AMD, high-quality UV-absorbing sunglasses are recommended, especially at sea, in the snow, and in the mountains.

There is no specific therapy for the dry form of AMD. A diet rich in vitamins is usually recommended, sometimes nutritional supplements of gingko preparations.

With the wet form of AMD, the destruction of newly formed pathological blood vessels (neovascularization) is carried out with a laser. These vessels are indeed destroyed after laser treatment. However, we must not forget that a) during laser treatment, healthy tissue also suffers; b) the main cause of AMD is not affected.

Recently, laser therapy has been complemented by photodynamic therapy. To perform this therapeutic measure, intravenous administration of a photosensitive chemical preparation is performed. This substance is mainly deposited on the walls of newly formed and pathologically altered blood vessels. The interaction of this substance with a non-thermal laser leads to a biochemical reaction, which ends with the closure and, in the future, the destruction of the “marked” newly formed blood vessels. In most cases, after this therapy, it is necessary to conduct frequent and rather extensive examinations and re-treatment, since the main cause of the disease is not eliminated. There are great hopes for photodynamic therapy, but it remains to be determined how significant the benefits of long-term results of this type of treatment are.

In other therapeutic approaches, the newly formed blood vessels are removed surgically, or the retina is completely separated, rotated, and fixed in position so that the macula is in contact with an area of ​​still healthy pigment epithelium. However, such treatment is possible only in very few cases, and some of its results are still unclear.

So far, the best recommendation for patients with AMD is a thorough and complete consultation with an ophthalmologist, as well as an optician who works with patients with low vision. The use of magnifying devices is recommended, which may allow patients with severe forms of AMD to regain some ability to read at least selected documents and texts.

AMD and glaucoma.
Glaucoma does not increase the risk of AMD, however, if the degeneration develops in patients with glaucoma, it is especially dangerous. Glaucomatous lesions are characterized by the development of visual defects in the periphery, while central vision remains normal for a long time. If a patient has both glaucomatous visual field defects and AMD-related visual acuity loss, his vision is doubly affected. This once again emphasizes the need to treat glaucoma, even if no subjective changes are detected. The glaucoma patient should be aware of the possibility of developing AMD in the future and understand that the preservation of visual fields is especially important in this case.