Stereo Atlas of Vitreoretinal Diseases [1st ed. 2020] 978-981-13-8398-4, 978-981-13-8399-1

Table of contents :
Front Matter ....Pages i-vii
Basic Principles of Stereo Fundus Photography (Hanyi Min, Di Chen, Bo Wan)....Pages 1-5
Retinal Diseases (Gensheng Wang, Peipei Xie, Jiayu Wang, Hanyi Min)....Pages 7-110
Macular Diseases (Hanyi Min, Hong Du, Ziyang Liu)....Pages 111-161
Vitreous Diseases (Qinying Ye, Chengxi Zhang, Fei Gao, Hanyi Min)....Pages 163-190
Papillary Diseases (Gangwei Cheng, Zhikun Yang, Rongpin Dai, Hanyi Min)....Pages 191-254
Choroidal Diseases (Donghui Li, Hanyi Min, Weihong Yu)....Pages 255-286
Fundus Changes After Vitreoretinal Surgery (Hanyi Min, Erqian Wang, Huan Chen)....Pages 287-303

Citation preview

Hanyi Min  Editor

Stereo Atlas of Vitreoretinal Diseases

123

Stereo Atlas of Vitreoretinal Diseases

Hanyi Min Editor

Stereo Atlas of Vitreoretinal Diseases

Editor Hanyi Min Department of Ophthalmology Peking Union Medical College Hospital China Academy of Chinese Medical Science Beijing Beijing China

Funding support: Chinese Academy of Medical Sciences Medicine and Health Science and Technology Innovation Project, 2017-I2M-1-012. ISBN 978-981-13-8398-4    ISBN 978-981-13-8399-1 (eBook) https://doi.org/10.1007/978-981-13-8399-1 Jointly published with People’s Medical Publishing House, PR of China The print edition is not for sale in China Mainland. Customers from China Mainland please order the print book from: People’s Medical Publishing House. © Springer Nature Singapore Pte Ltd. and People's Medical Publishing House, PR of China 2020 This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

When I was a junior resident, I was so confused by the retinal layers of different lesions described by the senior doctors, such as the bleeding at the retinal nerve fiber layer, exudates near the outer nuclear layer, and tumor derived from the choroid. Had they got X-ray vision that can penetrate or even dissect the retina nakedly? I had been doubted for my qualification as an ophthalmologist for so long! Finally, I took courage to confirm that my stereovision was normal and even superior by standard stereo examination, and yet, I still perceived the retina as a single plane! The contour, shape, and color of the lesion are certainly easy to determine. As for the optic edema, I can only clarify the diopter by adjusting the turntable of the direct ophthalmoscope and comparing with the macular. But how can human eyes distinguish the different retinal layers? They only exist in the books and biopsy slides! It was not until I started to learn the retina subspecialty that this problem was finally solved with full confidence of ophthalmologist. With the help of double +10D or +5D lens, the stereo pair taken by different shooting angles looked so vivid. I was even tempted to “touch and squeeze” the lesions, just like in the 3D movies! Once the self-doubt was swept away, I regained the dream to become a vitreoretinal specialist. Then, I learned to use the slit lamp ophthalmoscope (+90D, +78D), the indirect ophthalmoscope (+20D), the stereo fundus photography (SFP), and the optical coherence topography (enhanced depth imaging technique). All these techniques were aimed to penetrate the retina, choroid, pigment epithelium, and even sclera. Although the technology of “deciphering” retinal diseases is constantly advancing, the SFP is still indispensable, which not only can reveal the retina stereoscopically and comprehensively but also has been the gold standard for certain diseases, such as glaucoma and retinal angiomatous proliferation (RAP). Meanwhile, the equipment demands for SFP are not so expensive and can be easily promoted in the grassroots hospitals. In this book, we carefully collected and organized more than 300 stereo color fundus images and angiography pictures of various vitreoretinal diseases for colleges to recognized the three-dimensional features at first glance, such as retinal bleeding at different layers, optic disc change of glaucoma, macular diseases, tumors, RAP, and polypoidal choroidal vasculopathy (PCV). All these will interest you in vitreoretinal diseases. As the saying goes, no man is his craft’s master the first day! I sincerely hope this book will clear up the uncertainties of stereo fundus for all the readers and become a stepping stone to learn vitreoretinal diseases for ophthalmologists! Beijing, China 2018/7/28

Hanyi Min

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Contents

1 Basic Principles of Stereo Fundus Photography �������������������������������������������������������   1 Hanyi Min, Di Chen, and Bo Wan 2 Retinal Diseases�������������������������������������������������������������������������������������������������������������   7 Gensheng Wang, Peipei Xie, Jiayu Wang, and Hanyi Min 3 Macular Diseases����������������������������������������������������������������������������������������������������������� 111 Hanyi Min, Hong Du, and Ziyang Liu 4 Vitreous Diseases����������������������������������������������������������������������������������������������������������� 163 Qinying Ye, Chengxi Zhang, Fei Gao, and Hanyi Min 5 Papillary Diseases��������������������������������������������������������������������������������������������������������� 191 Gangwei Cheng, Zhikun Yang, Rongpin Dai, and Hanyi Min 6 Choroidal Diseases ������������������������������������������������������������������������������������������������������� 255 Donghui Li, Hanyi Min, and Weihong Yu 7 Fundus Changes After Vitreoretinal Surgery������������������������������������������������������������� 287 Hanyi Min, Erqian Wang, and Huan Chen

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1

Basic Principles of Stereo Fundus Photography Hanyi Min, Di Chen, and Bo Wan

1.1

Brief History of Stereo Imaging [1–3]

As early as in sixteenth century, filter lens had been used to draw a certain difference in the color of the image for the eyes to produce stereovision. Wheatstone invented the reflecting mirror stereoscope (Fig. 1.1) in 1838, just like the synoptophore, to prove stereovision is based upon the fusion images of both eyes. In 1849, refraction stereoscope (Fig. 1.2) was developed by Brewster, who put two +5D lenses in front of left and right pictures and made these two lenses outwardly eccentric to produce prism effect separately for both eyes. This method can be taken under different vergence distances and the distance between the lens and the pictures can be adjusted to match the accommodation needs. Early 3D movies came out at the end of the nineteenth century. With the emergence of filming, scientists used two cameras to simulate human eyes and projected the film through polarized filters, while the audience watched the movie wearing polarized glasses. Stereoscopic glasses first appeared in the Hollywood movies on May 24, 1953, which marks the beginning of a new era of stereoscopic films. Then, the “stereoscopic TV adopting dual channel polarized imaging technology” and the “complementary color stereoscopic imaging technology” made black & white and color TV three-dimensional, respectively. Currently, the most advanced 3D TV is fractional liquid crystal glasses stereo TV, which can provide vivid stereoscopic color image. When the TV frequency becomes higher, the image is stable without flicker. It is compatible with current color TV system and computer screen, and can easily be transformed to digital TV system.

Fig. 1.1  Reflecting mirror stereoscope invented by Wheatstone

H. Min (*) · D. Chen Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China e-mail: [email protected] B. Wan Department of Ophthalmology, Tongxian Luhe Hospital, Beijing, P.R. China

Fig. 1.2  Refraction stereoscope invented by Brewster

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_1

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Ophthalmic operating microscope is also one form of stereovision. As early as in 1590, the Dutch Hans Jansen invented the first compound microscope composed by multiple prisms. OPMI-1 produced by Zeiss corp. in the 1950s was the first operating microscope of modern sense. The current ophthalmic operating microscope integrates illumiation, suspension, multi-optical path, synchronization, built-in inverter, and HD camera in one, which can greatly improve the quality of ophthalmic surgery and expand the scope of surgical indications.

1.2

Stereopsis

Worth proposed that binocular vision was composed of three levels in 1921, namely, simultaneous perception, fusion function, and stereopsis from low to high, respectively. Simultaneous perception is the basis for binocular vision, which requires that both eyes must have the ability to percept simultaneously, and the images from each eye must have corresponding points on both retinas. Fusion function is a level II binocular vision function, including sensory fusion and motor fusion. Sensory fusion is the ability to integrate two images from two retinas with tiny disparities into one complete image through the analysis of the brain. Stereopsis is a level III binocular vision function. True stereopsis is dependent on disparities between the two images received by each eye, and therefore, a certain number of points must fall on disparate points on the retina, which is the physiological parallax (Fig.  1.3), or the intersection angle of the A

F B

line of sight is different (Fig. 1.4). The brain then analyzes the depth of the image, i.e., the stereopsis. Although one eye can also make a rough judgement of the distance through perspective, shadow, parallax, and shield, it is not accurate enough to make fine judgement and operation. Only the depth perceived through stereopsis is sufficiently accurate [3–5]. Physiological parallax (η) is the distance between the corresponding images on both retinas. The physiological parallax of objects with different distances is not the same, and this disparity then is transmitted to the cerebral cortex center to create the sense of distance. Physiological parallax is the basis of stereopsis.

h a = f1a1 - f 2 a2 h b = f1b1 - f 2 b2

The physiological parallax of fixation point F is zero, for the points further than F, η  0, like point B. The distance of objects is determined by the intersection angle α of the line of sight, the object with larger α is nearer, and the object with smaller α is more far away. The relationship between D and α is below:

tg

a ba a = ba / D = 2 2D

In general, the eye feels most comfortable when D is 25  cm, which is the distance of distinct vision. The eye loses the ability of discerning depth when α is less than 30′, equivalent to the distance of 450 m, which is the observation radius of human stereopsis. The fovea is responsible for fine stereopsis and could detect the parallax ranging from 2″ to 1200″, suitable for high spatial frequency, static and colored objects. The peripheral retina is responsible for coarse stereopsis and could only detect the parallax ranging from 0.1° to 10°, suitable for low spatial frequency, dynamic and colorless objects. F

α D

o1 +

– b1 f1

a1

+

– b2

f2

a2

Fig. 1.3  Physiological parallax O1, O2, the lens plane for right and left eyes A, F, B, the distant, middle, and near observing points a1, b1, c1, a2, b2, c2, the corresponding points of A, F, B on the retina of two separate eyes

f1

b4

o2

f2

Fig. 1.4  Intersection angle α F the focus O1, O2, the lens plane for right and left eyes B, the basic plane crossing the two lenses D, the vertical distance between the focus and basic plane f1, f2, the corresponding points of F on the retina α, intersection angle

1  Basic Principles of Stereo Fundus Photography

Stereoscopic vision is the resolution of the stereovision, that is, the minimal depth and diameter difference that can be detected. The stereoscopic vision is described in arc seconds. Object method and picture method have been used to measure stereoscopic vision. Picture method uses a pair of stereo images simulating what both eyes would see. Stereo images can be divided into three types. The first type of stereo image is line stereogram, the individual elements seen by each eye such as edges and lines are matched but with horizontal parallax to make stereovision. The second type of stereo image is random-dot stereogram made by black and white dot matrix, which is disordered lattice seen by one eye and parallax image fused by both eyes. The third type is auto stereogram, a single image stereogram with repeated 2D images. The vergence function of eye will match and fuse similar objects with parallax to create stereoscopic (3D phosphenes).

1.3

be reversed; (4) the position of the photograph must be able to make the corresponding line of sight to be in pairs, and the connection of the corresponding point is parallel to the eye base line [2, 6]. During observation, put the stereo glasses in front of the eyes and make the baseline of the glasses parallel to the photos with an appropriate distance. Figure 1.6 shows several common stereo glasses. The glasses can be rotated appropriately to make the two images overlap for clear central stereoscopic imaging. Different photo position will cause different stereoscopic effects, which can be classified as positive, negative, A B C

 rtificial Stereopsis and Its A Observation

The object produces images on the photosensitive materials, which can be observed through human eyes to form physiological parallax to reconstruct stereovision. This kind of stereovision is called artificial stereopsis (Fig. 1.5). Paired stereo images and observation spectacles are necessary for artificial stereopsis. Paired stereo images are two images of the same object shot with some focus by means of photography to simulate the retina images of both eyes. Paired images are just like physiological parallax, which is named as horizontal parallax. When we observe the paired stereo images through both eyes, the horizontal parallax of different images will be transformed to physiological parallax to create the same stereovision as the actual observation. Several conditions should be fulfilled for the stereoscopic observation of paired images: (1) the paired images should be two photographs of the same object shot from different angles; (2) the scale of the two photographs should not exceed 16%; (3) the two photographs should be observed by two eyes correspondingly, that is to say, the left image for the left eye and right image for the right eye, which should not

a

3

b

b2¢ p1

a1¢

b1¢

c2¢

c1¢

p2 a2¢

c1

c2 b2

b1 a 1

a2

Fig. 1.5  Artificial stereopsis O1, O2, the lens plane for right and left eyes A, B, C, the distant, middle, and near observing points P1, P2, the plane of photosensitive material a1′, b1′, c1, the corresponding points of A, B, C on the photosensitive material a1, b1, c1, a2, b2, c2, the corresponding points of A, B, C on the retina of two separate eyes

c

Fig. 1.6  Common stereo glasses. (a) Stereoscopic monitor viewer, (b) aerial mirror stereoscope, (c) stereo glasses

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and zero stereo effects. Positive stereo effect is defined as the establishment of stereo model by moving two images inwardly at the same time. If the images are exchanged or rotated by 180°, the stereo model will be contrary to the object, which is called negative stereo effect. A plane graph will be obtained when the paired images are rotated to the same direction to make them parallel to the baseline of the eyes, which is called zero stereo effect. During stereoscopic observation, the fluctuation of the stereovision image is more obvious than the actual situation, which is called the vertical exaggeration of the stereo model. Exaggeration index is defined as K = d / f, with d the focal length of the stereoscopic lens and F the focal length of the camera. Stereoscopic observation can also be realized without any equipment. Put the paired images in front of both eyes and use the vergence and binocular motion to make the images fusing (free fusion). Right eye is for the right image and left eye for the left image. If the eyes are exchanged, the stereo imaging will be reversed. Anaglyph uses red and green filters to transform the green and red images to the right and left eye, correspondingly. Vectogram adopts vertical polarization filters to transform the vertical polarization images to both eyes. The polarizing plate method is employed by Titmus stereovision scale and Randot stereovision scale.

H. Min et al.

time of human eye. By increasing the fast refreshing time (at least 120 Hz) and keeping the same frames as the 2D video, the audience will see switching images, which cause the stereo illusions in the brain. 4. Nonflash glasses: By separating the images through polarized light, it sends the left and right images to the glasses, and then to both eyes. The brain combines these two images to stereovision. It has high brightness without flicker, so it is comfortable and cost-effective.

1.5

 aking Stereo Images with Fundus T Camera and Development [1, 2, 7–12]

Stereo fundus photography (SFP) can be classified as two types according to its nature: continuous SFP and spontaneous SFP. The former needs to be exposed twice by simulating the different visual angles of both eyes, respectively. The latter is composed of two parallel images, which can only be recognized by stereo glasses. The sequence of the two images cannot be reversed; otherwise, wrong information will be transmitted. Techniques for shooting stereo images: The 4 mm pupil will get a nice stereo image, and the larger the better. The fixation point and the height of the camera cannot be changed during shooting. First, make the edges of two bright spots clear. Move the joystick to the left and the bright spot to 1.4 Observation Glasses of Stereo Image the right to take the first picture (representing the left eye [3, 7] view), then move the joystick to the right and the bright There are mainly four types of stereo glasses: complemen- spot to the left to take the second picture (representing the tary color glasses, polarized light glasses, time division right eye view). When taking the first picture of the paired images, the focus should be far away from the center of the glasses, and nonflash glasses. pupil to the right of the photographer, that is, the left of the 1. Complementary color type, also known as the chromatic patient. The second picture is just the contrary. The shooting aberration glasses or the commonly used red-blue and red-­ should be fast and the focus should be the same. If the target green 3D glasses. It uses color separation stereoscopic moves, the two pictures should be taken one more time. The imaging technology and prints two images with different different brightness of these two images will not affect the colors shot by two-angled cameras into one picture. Only stereo effect. Continuous SFP can be easily influenced by through corresponding stereo glasses, one can see the ste- multiples factors because of the time interval. In 1998, Qu reo image. The different colored images percepted by both Jia et al. invented the Fresnel biprism separator, which can be integrated into the optical pathways of common fundus eyes are fused in the brain to establish the 3D effect. 2. Polarized light. Two cameras are used to take the stereo camera. Spontaneous SFP can take two images with parallax at the image, one left and one right. The left camera is equipped with a horizontal polarized light filter and the right one same time, which is more comfortable, accurate, and repeatwith a vertical polarized light filter. And the both lenses of able but also much more expensive than continuous SFP. Although standard stereoscopic slide film fundus phostereo glasses are also mounted with horizontal and vertical polarized light filter, respectively, so that the tography has been accepted as a golden reference of clinical horizontal and vertical polarized light can only pass practice for so many years, it is not ideal when compared through the corresponding filter. Commercial cinemas with clinical examination. In order to conquer the obvious and other high-end applications commonly adopt shortcomings such as the expensive slide film and its gradual disuse, technically difficult operation and requirement of polarized light 3D technology nowadays. 3. Time division glasses is also known as active shutter 3D experienced photographer to capture subtle retinal detail, glasses. It realizes stereovision through the refreshing digital fundus camera (DFC), nonmydriatic and/or mydriatic

1  Basic Principles of Stereo Fundus Photography

has been widely applied all over the world. Images taken by DFC can not only be reviewed for quality and content at the time of capture, but also be stored in great amount, and transferred electronically. Furthermore, it is easy to integrate stereoscopic photography into a basic teleophthalmology system or telemedicine.

References 1. Allen L.  Ocular fundus photography: suggestions for achieving consistently good pictures and instructions for stereoscopic photography. Am J Ophthalmol. 1964;57:13–28. 2. Tyleer ME. Stereo fundus photography: principles and technique. J Ophthalmic Photogr. 1996;18:68–89. 3. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 4. Rudnisky CJ, Tennant MT, de Leon AR.  Benefits of stereopsis when identifying clinically significant macular edema via teleophthalmology. Can J Ophthalmol. 2006;41:727–32.

5 5. Somani R, Tennan M, Rudnisky C, et  al. Comparison of stereoscopic digital imaging and slide film photography in the identification of macular degeneration. Can J Ophthalmol. 2005;40:293–302. 6. Li HK, Hubbard LD, Danis RP, et al. Monoscopic versus stereoscopic retinal photography for grading diabetic retinopathy severity. Retina. 2010;51:3184–92. 7. Gass JDM.  Stereo atlas of macular diseases: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997. 8. Stone RA, et al. Utility of digital stereo images for optic disc evaluation. Invest Ophthalmol Vis Sci. 2010;51:5667–74. 9. Rudnisky CJ, Tennant MT, Weis E.  Web-based grading of compressed stereoscopic digital photography versus standard slide film photography for the diagnosis of diabetic retinopathy. Ophthalmology. 2007;114:1748–54. 10. Sanborn GE, Wroblewski JJ.  Evaluation of a combination digital retinal camera with spectral-domain optical coherence tomography (SD-OCT) that might be used for the screening of diabetic retinopathy with telemedicine: a pilot study. J Diabetes Complications. 2018;11:1046–50. 11. Hubbard LD, Danis RP, Neider MW. Brightness, contrast, and color balance of digital versus film retinal images in the age-related eye disease study 2. Invest Ophthalmol Vis Sci. 2008;49:3269–82. 12. Agarwal A.  Gass atlas of macular diseases. 5th ed. Edinburgh: Elsevier; 2012. p. 1–16.

2

Retinal Diseases Gensheng Wang, Peipei Xie, Jiayu Wang, and Hanyi Min

Retina is located at the innermost layer of the wall of the eyeball, which surrounds the vitreous together with the nonpigmented ciliary epithelium, suspensory ligament, and posterior capsular of the lens. From the inside out, the retina consists of inner limiting membrane, neural fiber layer, ganglion cell layer, inner plexiform layer, inner nuclear layer, outer plexiform layer, outer nuclear layer, outer limiting membrane, and photoreceptors. The outer segment of photoreceptors is surrounded by the microvilli on top of the pigment epithelium. The pigment epithelium is connected by tight junction, which constitutes the inner barrier of the retina. Figure 2.1a, b show the biopsy section and schematic diagram of the retina. The fovea is located in the center of the posterior retina, 3 mm lateral to the optic disc. The central of the fovea is the avascular foveola, which is the most sensitive part of visual acuity. The optic disc lies 3 mm medial to the macular. This pale pink/whitish area is 1.8 mm in diameter with a slightly raised rim. The central retinal vessels emerge at the center of the optic disc, pass over the rim, and radiate out to supply the retina. The blood supply of the retina mainly comes from central retinal artery and its branches, which runs into the eye within the optic nerve and supplies a sector of the retina as in the superior temporal, superior nasal, inferior temporal, and inferior nasal area. Cilioretinal artery, which mainly supplies macular, can be occasionally seen in some eyes. Central retiG. Wang Department of Ophthalmology, Handan Eye Hospital, Handan, Hebei, P.R. China P. Xie Department of Ophthalmology, The People’s Liberation Army No. 152 Hospital, Pingdingshan, Henan Province, P.R. China J. Wang Department of Ophthalmology, Wangjing Hospital, Beijing, P.R. China H. Min (*) Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China

nal artery mainly supplies inner layers of the retina, i.e., the part inside of the outer nuclear layer. There are two main levels of capillary networks, which are spreading like a vast cobweb throughout the retina. The inner plexus is situated at the level of nerve fiber layer and the ganglion cell layer and the outer plexus at the level of inner nuclear cell (Fig. 2.2a). The capillary plexus between the nerve fiber layer and the inner nuclear layer is distributed three-dimensionally, just like a “hammock”(Fig. 2.2b). There is no anastomosis or short-cuts between the retinal arterioles and venules. The most wide usage of stereo photography is in diabetic retinal study [1–5]. Since 1968, Airlie House Symposium established the first diabetic retinopathy classification system, stereo fundus photography had been a cornerstone of diabetic retinopathy assessment, and the stereo photography protocol and severity classifications were modified during the Diabetic Retinopathy Study and were later expanded in the Early Treatment Diabetic Retinopathy Study (ETDRS). Until now stereo, 30°, seven-field, 35-mm color slides remain the gold standard for clinically evaluating diabetic retinopathy and are widely used in the DR studies such as Diabetic Retinopathy Clinical Research Network studies, the Action to Control Cardiovascular Risk in Diabetes Eye Study, Epidemiology of Diabetes Interventions and Complications, and the Diabetes Control and Complications Trial. Telemedicine programs also include stereo photography. It is generally assumed that depth perception helps in distinguishing subtle extraretinal neovascularization elevated above the plane of the retina from intraretinal microvascular abnormalities (IRMAs) [6]. This discrimination is important on the ETDRS severity scale. Stereopsis may also aid in detecting new vessels elsewhere (NVE), new vessels on the disc (NVD), and vitreous fibrosis and hemorrhages. Confusing these advanced abnormalities with other lesions could result in missed opportunities for timely intervention to prevent vision loss. Correct classification of the diabetic retinopathy severity level is also essential in clinical and epidemiology studies in which diabetic retinopathy progression is observed. It is also believed that stereo photography’s

© Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_2

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a

ILM Nerve fiber layer

b

Ganglion cell layer

Inner plexiform layer Inner nuclear cell layer

Ganglio

n cell

Outer plexiform layer Outer nuclear layer Outer limiting membrane Cone/Rod layer RPE Bruchs membrane Choroid

Amacrin e cell

Horizon tal cell

Bipolar cell

Müller’s fibre (Glia)

Rod Cone

Pigmen

t epithe

lial cell

Fig. 2.1  Schematic diagram of retina. (a) Biopsy section of the retina. (b) Schematic diagram of retina layers

a

b

Fig. 2.2  Schematic diagram of retinal vessels. (a) Schematic diagram of retinal vessels. (b) Framework of retinal arteries and veins, which looks like a hammock

2  Retinal Diseases

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i­llusion of depth is useful for assessing the severity of diabetic macular edema. Detailed classification of macular edema is dependent on identifying and measuring retinal thickening on 90D/78D microscopy or stereo pairs. Due to the improvement of digital camera and the burdens of stereo photography to photographers and the patients, many studies has forgone stereo photography, such as the Liverpool Diabetes Eye Study, the UK Prospective Diabetes Study et  al. [4, 7, 8]. But until 2010, Li HK had reported monoscopic photography was equal to the reliability of stereo photography for full ETDRS DR severity scale grading and a stereo effect may not be critical for accurate classification of ETDRS diabetic retinopathy severity when using current technology and an optimized framework for fundus photography acquisition and reviewing [5].

Besides the colorful stereoscopic photography, FFA also can be captured in stereo [9]. This facilitates the interpretation of stereo FA by visually separating retinal and choroidal circulation. Both of them can deeply explain and differentiate the exact location and m ­ echanism of the diseases. Though not always necessary, ­well-resolved ­stereo images can aid in the interpretation of angiogram with, for instance, choroidal neovascularization associated with age-related macular ­ degeneration. Comparing with OCT images with cross-section scan, SS-OCT, or even en-face OCT, stereoscopic photography takes advantages such as wider field, freely selected angles, dynamic observation, and more vivid discrimination.

Fig. 2.3  Retinal vein occlusion I. The cup of the optic disc is deepening II. Retinal arteries became narrow and straight

III. Retinal veins became tortuous and wider, A/V ratio = 1/2 to 1/3 IV. Multiple retinal hemorrhages

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Fig. 2.4  Retinal vein occlusion I. Retinal arteries became narrow and straight II. Retinal veins became tortuous and wider, A/V ratio = 1/2 III. Arteriovenous nicking, the Gunn sign

G. Wang et al.

IV. The retinal artery deflected the retinal vein and changed the course of the vein, the Salus sign V. Multiple retinal hemorrhages

2  Retinal Diseases

Fig. 2.5  Branch retinal vein occlusion I. Superficial retinal hemorrhage II. Superficial retinal exudates

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III. Deep retinal exudates IV. Macular edema V. Dilated retinal vein

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Fig. 2.6  Inferior hemi central retinal vein occlusion I. Highly elevated retina in the inferior part, with flame-shaped retinal hemorrhage

G. Wang et al.

II. Mild macular edema III. Dilated retinal vein IV. Flame-shaped retinal hemorrhage, less elevated than region I

2  Retinal Diseases

Fig. 2.7  Branch retinal vein occlusion I. Superficial retinal hemorrhage II. Retinal exudates

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III. Ghost vessel in the distal part of the temporal inferior branch retinal vein IV. Deep retinal exudates

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Fig. 2.8  Old branch retinal vein occlusion I.  Ghost vessel of retinal neovascularization, extended as a webbed membrane II. Retinal artery looks like a white line and extended to the peripheral retina

G. Wang et al.

III. Webbed membrane with thin underlying retina, suspected localized retinal detachment IV. Retinal artery looks like a silver wire V. Regressive neovascularization in the peripheral retina

2  Retinal Diseases

Fig. 2.9  Old branch retinal vein occlusion I. The fibrotic membrane originated from the optic disc extended to the peripheral retina as like a tree branch II. Inferior temporal branch was distorted by the membrane

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III. Ghost vessel in the distal part of the retinal vein IV. Extension of membrane V. Laser spot

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Fig. 2.10  Central retinal vein occlusion I. Retinal hemorrhage around the optic disc II. Macular edema (most elevated part)

G. Wang et al.

III. Macular edema (the second layer) IV. Deep retinal hemorrhage

2  Retinal Diseases

Fig. 2.11  Central retinal vein occlusion I. Severe optic disc edema, with massive hemorrhage II. Macular edema

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III. Intermediate retinal exudates IV. The retinal artery looks like a silver wire V. Engorged retinal vein and narrowing of adjacent artery

18

Fig. 2.12  Central retinal vein occlusion I. Superficial retinal hemorrhage II. Retinal exudates

G. Wang et al.

III. Arteriovenous crossing change IV. Macular edema

2  Retinal Diseases

Fig. 2.13  Fluorescein fundus angiography of central retinal vein occlusion I. Cystoid macular edema

19

II. The apex of the edema III. Vessels pushed up by edema IV. Blocked fluorescence by hemorrhage

20

Fig. 2.14  High myopia with old branch retinal vein occlusion I. Weiss ring II. Ghost vessel in the temporal inferior retinal vein branch

G. Wang et al.

III. Fuchs spot IV. Atrophy of retinal pigment epithelium and exposure of sclera V. Large choroidal vessels

2  Retinal Diseases

Fig. 2.15  Chronic branch retinal vein occlusion after laser treatment I.  Proliferative membrane extended from the optic disc to peripheral retina II. Venous loop sprouted to the vitreous cavity

21

III. Ghost vessel of retinal vein IV. Atrophic retinal areas V. Retinal pigment proliferation

22

Fig. 2.16  Branch retinal artery occlusion I. Occlusive spot of retinal artery

G. Wang et al.

II. Pale zone corresponding to the occlusive artery III. Partial involvement of macula

2  Retinal Diseases

Fig. 2.17  Central retinal artery occlusion I. Ligulate sparing of retinal area II. Two suspected cilioretinal artery III. Grey-whitish retinal area

23

IV. Cherry-red spot V. Segmentation of the blood column in the arterioles

24

Fig. 2.18  Branch choroidal artery occlusion I. Choroidal atrophy of the choroidal artery occluded area

G. Wang et al.

II. The retina was mildly depressed

2  Retinal Diseases

Fig. 2.19  Coats disease I. Superficial retinal hemorrhage II. Cholesterol crystal

25

III. Suspending retinal vessels IV. Intermediate retinal exudates V. Dilated retinal vessels

26

Fig. 2.20  Coats disease after laser treatment I. Pre-retinal hemorrhage II. Superficial retinal hemorrhage III. Abnormal dilated vessels and yellow-white exudates

G. Wang et al.

IV. Suspending vessels with white sheath V. Laser spots and atrophic retinal area

2  Retinal Diseases

Fig. 2.21  Coat disease after laser treatment I. Dilated superficial retinal vessel II. Dilated deep retinal vessel

27

III. The end of the vessel was dilated and leaked fluorescein, which was near the base of the lesion IV. The area of laser, where the retina was atrophied

28

Fig. 2.22  Von-Hippel retinal capillary hemangiomatosis I. Hemangioma II. Dilated feeder artery

G. Wang et al.

III. Draining vein IV. Deep exudates V. Old vitreous hemorrhages

2  Retinal Diseases

Fig. 2.23  Von-Hippel retinal capillary hemangiomatosis I+II. Two capillary hemangiomas

29

III. Draining vein IV. Peripheral vitreous opacities

30

Fig. 2.24  Retinal pigment epithelium detachment I. Apex of detachment

G. Wang et al.

II. Intermediate retinal exudates III. Boundary of detachment

2  Retinal Diseases

Fig. 2.25  Sensory retinal detachment in the posterior pole I. Highly elevated sensory retinal detachment of the posterior pole

31

II. Yellow-white lipid exudates in the margin of detached retina

32

Fig. 2.26 Sensory retinal detachment with pigment epithelium detachment I. Area of pigment epithelium detachment

G. Wang et al.

II. Area of sensory retinal detachment III+IV. Intermediate retinal exudates

2  Retinal Diseases

Fig. 2.26 (continued)

33

34

Fig. 2.27  Retinal macroaneurysm near the optic disc I. Retinal macroaneurysm near the optic disc II. Superficial retinal hemorrhage III. Deep retinal hemorrhage

G. Wang et al.

IV. Sub-RPE hemorrhage V. Intermediate retinal hard exudates VI. Vitreous hemorrhage

2  Retinal Diseases

Fig. 2.28  Retinal macroaneurysm I. Suspected area of the aneurysm II. Superficial retinal hemorrhage III. Subretinal hemorrhage and arterioles on the top

35

IV. Superficial retinal hemorrhage V. Deep retinal exudates VI Retinal epithelium detachment

36

Fig. 2.29  Retinal macroaneurysm near the optic disc I. Retinal macroaneurysm near the optic disc II. Superficial retinal hemorrhage

G. Wang et al.

III. Deep retinal hemorrhage IV. Sub-RPE hemorrhage

2  Retinal Diseases

Fig. 2.30  Retinal macroaneurysm I. Suspected area of the retinal aneurysm II. Narrowing retinal artery and ghost vessel in the distal part III. Superficial retinal hemorrhage

37

IV. Suspected retinal neovascularization V. Intermediate retinal hard exudates VI. Dilated retinal vein

38

Fig. 2.31  Retinal macroaneurysm I. Suspected area of the aneurysm II. Narrowing retinal artery and dilating distal dilating part

G. Wang et al.

III. Macular edema IV. Intermediate retinal exudates V. Deep retinal exudates

2  Retinal Diseases

Fig. 2. 31 (continued)

39

40

Fig. 2.32  Multiple retinal macroaneurysms I. Superficial retinal macroaneurysm II. Deep retinal macroaneurysm

G. Wang et al.

III. Intermediate retinal annular exudates IV. Retinal artery V. Retinal vein

2  Retinal Diseases

Fig. 2.33  Retinal macroaneurysm I. Superficial retinal hemorrhage II. Suspected area of the aneurysm

41

III. Intermediate retinal annular exudates IV. retinal artery V. Dilated retinal vein and white sheath

42

Fig. 2.34  Subretinal annular exudates in the posterior pole I. Highly elevated sensory retinal detachment in the posterior pole II. Superficial retinal hemorrhage

G. Wang et al.

III. Subretinal hard exudates IV. Sclerosis of deep retinal vessels like a cradle V. Sclerosis of superficial retinal vessels with white sheath

2  Retinal Diseases

Fig. 2.35  Retinal macroaneurysm I. The elevated retina elevated like a dome II. The area with abnormal retinal artery, suspected retinal macroaneurysm

43

III. Ghost vessel of the retinal vein in the detached retina IV. Deep retinal exudates

44

Fig. 2.36  Retinal macroaneurysm I. The depressed area of retinal macroaneurysm after laser treatment

G. Wang et al.

II. Sensory retinal detachment of macula III. Apex of elevated retina

2  Retinal Diseases

Fig. 2. 36 (continued)

45

46

Fig. 2.37  Epiretinal membrane I. Fibrotic membrane originated from the optic disc II. Superior temporal membrane

G. Wang et al.

III. Inferior nasal membrane IV. Inferior temporal membrane and tractional retinal detachment V. Fresh vitreous hemorrhage like an arc

2  Retinal Diseases

Fig. 2.38  Epiretinal membrane in the posterior pole I. White fibrotic membrane originated from the optic disc II. Tractional macular dislocation

47

III. Oxygonal shape of Superior temporal branch of the retinal vein in the elevated retina showed and tractional retinal detachment IV. Subretinal membrane

48

Fig. 2.39  Subretinal membrane I. Shallow retinal detachment in the macula area

G. Wang et al.

II. Subretinal membrane III. Pigmentation

2  Retinal Diseases

Fig. 2.40  Subretinal fibrous membrane I. Subretinal fibrous streak superior to the optic disc II. Ghost vessel in the retinal vein

49

III. Ghost vessel in the retinal artery IV. Neovascularization bud near the retinal vein V. The retinal vein was distorted like a loop

50

Fig. 2.41  Curly retinal edge I. The inferior temporal edge of the retina was curly into the vitreous cavity

G. Wang et al.

II. The impending retinal vein and its shadow III. Exposed choroid

2  Retinal Diseases

Fig. 2.42  Tractional retinal detachment I. The retinal neovascularization extended into the vitreous cavity II. Vitreous fibrous membrane

51

III. Retinal detachment in the peripheral retina IV. Ghost vessel of the retinal vein V. Retinal arterial sclerosis with white sheath

52

Fig. 2.43  Tractional retinal detachment I. Vitreous hemorrhage II. Vitreous proliferative membrane

G. Wang et al.

III. Subretinal proliferative streak IV. Estimated area of proliferative membrane

2  Retinal Diseases

Fig. 2.44  Stellate retinal fold and retinal detachment I. Stellate retinal fold in the lowest part of retinal adhesive area II. Retinal detachment

53

III. Tractional retinal dislocation IV. Subretinal membrane

54

Fig. 2.45  Tractional retinal detachment I. Subretinal streak like a clothesline pole

G. Wang et al.

II. Retinal detachment

2  Retinal Diseases

Fig. 2.46  Retinal detachment I. Discontinuous blood flow in inferior nasal branch of retinal artery and ghost vessel in the distal part

55

II. Subretinal exudates and hemorrhage III. Exudative retinal detachment

56

Fig. 2.47  Stargardt disease I. Boundary of the lesion, irregular with pigmentation

G. Wang et al.

II. Retinal and choroidal atrophy in the lesion like a basin III. Retinal vessels that passed through the lesion went attenuated

2  Retinal Diseases

Fig. 2.48  Rhegmatogenous retinal detachment I. Horse-shoe tear II. Anterior flap with curly edge

57

III.  Extensive retinal detachment and the lowest area of retinal detachment IV. Apex of retinal detachment

58

Fig. 2.49  Rhegmatogenous retinal detachment I. U-tear and the floating flap II. Strong adhesion with the vitreous

G. Wang et al.

III. Base of the flap IV. RPE exposed V. Apex of the detached retina

2  Retinal Diseases

Fig. 2.50  Rhegmatogenous retinal detachment I. Anterior flap of the retinal tear II. Retinal tear with exposed underlying choroid

59

III. Posterior flap of retinal tear IV. Retinal fold

60

Fig. 2.51  Tractional retinal detachment I. Embedded and tortuous retina vein

G. Wang et al.

II. Epiretinal membrane III. Macular detachment duo to fibrous tissue

2  Retinal Diseases

Fig. 2.52  Funnel retinal detachment I. Optic disc

61

II. Detached macula III. Detached retina

62

Fig. 2.53  Funnel retinal detachment I. Extensive subretinal membrane

G. Wang et al.

II. Detached retina in the macula and dislocation of macula

2  Retinal Diseases

Fig. 2.54  Retinal cyst due to long-term retinal detachment I. Retinal cyst and its border

63

II. Retinal tear III. Retinal detachment

64

Fig. 2.55  Hypertensive retinopathy complicated with enlarged cup/ disc ratio I. The retinal artery was attenuated and straight II. Engorged retinal vein, the A/V ratio was 1:3 to 1:2

G. Wang et al.

III. Deep retinal hemorrhage IV. C/D ratio ≈ 0.9 V. The vessel around the optic disc was tortuous and dilated

2  Retinal Diseases

Fig. 2.56  Acute hypertensive retinopathy I. Superficial hemorrhage and cotton wool spots in the macula II. The retinal vein is engorged and tortuous, the A/V ratio is 1:3

65

III. Superficial retinal cotton wool spot IV. Deep retinal cotton wool spot

66

Fig. 2.57  Diabetic retinopathy I. Deep microaneurysm II. Superficial exudates III. Dilated retinal vein

G. Wang et al.

IV. Pigmentation of the laser spot V. Intra-retinal microvascular abnormality (IRMA)

2  Retinal Diseases

Fig. 2.58  Non-proliferative diabetic retinopathy I. Vitreous hemorrhage

67

II. Intra-retinal microaneurysm III. Hard exudates

68

Fig. 2.59  Non-proliferative diabetic retinopathy I. Microaneurysm

G. Wang et al.

II. Circular exudates III. Macular edema

2  Retinal Diseases

Fig. 2.60  Non-proliferative diabetic retinopathy I. Retinal microaneurysm

69

II. Intermediate retinal exudates III. Multiple drusen

70

Fig. 2.61  Severe non-proliferative diabetic retinopathy I. Macular edema II. Microaneurysm

G. Wang et al.

III. Non-perfusion area (NPA) IV. Intra-retinal microvascular abnormality (IRMA) V. Neovascularization of the optic disc (NVD)

2  Retinal Diseases

Fig. 2.62  Diabetic retinopathy I. Localized edema of the optic disc II. Flame-shaped superficial retinal hemorrhage III. Freckle deep retinal hemorrhage

71

IV. Hard exudates V. Cotton wool spot VI. Microaneurysm

72

Fig. 2.63  Fluorescein fundus angiography of diabetic retinopathy (early phase) I. Optic disc

G. Wang et al.

II. Edematous retina and elevated retinal vein III. Retinal microaneurysm IV. Intra-retinal microvascular abnormality (IRMA)

2  Retinal Diseases

Fig. 2.64  Fluorescein fundus angiography of diabetic retinopathy (middle phase) I. Blocked fluorescence by the hemorrhage inferior to the optic disc II. Edematous retina and elevated retinal vein

73

III. Retinal microaneurysm IV. Intra-retinal microvascular abnormality (IRMA) V. Non-perfusion area (NPA)

74

Fig. 2.65  Diabetic retinopathy I. Thread-like superficial retinal hemorrhage superior to the optic disc II. Spotted deep retinal hemorrhage

G. Wang et al.

III. Retinal microaneurysm IV. Soft exudates

2  Retinal Diseases

Fig. 2.66  Fluorescein fundus angiography of diabetic retinopathy (middle phase) I. Thread-like superficial retinal hemorrhage superior to the optic disc and showed blocked fluorescence

75

II. Deep retinal hemorrhage and blocked fluorescence III. Retinal microaneurysm IV. Soft exudates and non-perfusion area

76

Fig. 2.67  Fluorescein fundus angiography of diabetic retinopathy (late phase) I. Thread-like superficial retinal hemorrhage superior to the optic disc and showed blocked fluorescence

G. Wang et al.

II. Deep retinal hemorrhage and blocked fluorescence III. Retinal microaneurysm IV. Soft exudates and non-perfusion area

2  Retinal Diseases

Fig. 2.68  Non-proliferative diabetic retinopathy I. Macular edema and massive hard exudates II. Flame-shaped superficial retinal hemorrhage

77

III. Retinal microaneurysm IV. Sectional white sheath of retinal artery V. Deep retinal exudates

78

Fig. 2.69  Proliferative diabetic retinopathy I. Venous beading II. IRMA III. NVD

G. Wang et al.

IV. NVE V. Microaneurysm VI. Epiretinal membrane

2  Retinal Diseases

Fig. 2.70  Proliferative diabetic retinopathy I. NVD II. NVE III. Proliferative membrane of the vitreous

79

IV. IRMA V. Hemorrhage adhesive to the vitreous filaments VI. Sub-hyaloid hemorrhage

80

Fig. 2.71  Proliferative diabetic retinopathy I. NVD II. NVE

G. Wang et al.

III. Proliferative membrane in the posterior pole along the vascular arc IV. Retinal detachment V. Vitreous hemorrhage

2  Retinal Diseases

Fig. 2.72  Proliferative diabetic retinopathy I. Abnormal retinal vessels II. Superficial retinal hemorrhage

81

III. Subretinal hemorrhage IV. Neovascularization showed by FFA V. Irregular retinal vessels

82

Fig. 2. 72 (continued)

G. Wang et al.

2  Retinal Diseases

Fig. 2.73  NVE on FFA I. NVE extending into vitreous cavity II. Dilated vein

83

III. Laser spots IV. Microaneurysm

84

Fig. 2.74  Proliferative diabetic retinopathy I. NVD II. Cystoid macular edema

G. Wang et al.

III. NVE IV. Deep NVD

2  Retinal Diseases

Fig. 2. 74 (continued)

85

86

Fig. 2.75  Proliferative diabetic retinopathy after anti-VEGF injection I. Fibrosis of NVD after VEGF injection II. Residual NVE

G. Wang et al.

III. Intra-retinal hemorrhage IV. Bean-like vein

2  Retinal Diseases

Fig. 2.76  Diabetic retinopathy after pan-retinal photocoagulation I. Atrophied lesion of retinal pigment epithelium II. Pigmentation

87

III. Retinal vessels IV. Choroidal vessels V. Vitreous opacities

88

Fig. 2.77  Diabetic retinopathy after pan-retinal photocoagulation I. Proliferative streak of the vitreous II. Pigmentation

G. Wang et al.

III. Subretinal membrane IV. A/V crossing

2  Retinal Diseases

Fig. 2.78  Myopic fundus changes I. The optic disc artery over the retinal vein II. Optic cup

89

III.  Choroidal atrophy temporal to the optic disc and exposed large vessels IV. Pigmentation around the area of choroidal atrophy

90

Fig. 2.79  Myopic fundus changes I. Leopard fundus changes and large choroidal vessels

G. Wang et al.

II. Myopic crescent

2  Retinal Diseases

Fig. 2.80  Myopic fundus changes I. Estimated boundary of the posterior scleral staphyloma II. Fuchs spot III. Pigmentation and elevation

91

IV. Choroidal neovascularization V. Coloboma of choroid and exposed sclera

92

Fig. 2.81  Myopic fundus changes I.  Choroidal atrophy temporal to the optic disc and exposed large vessels

G. Wang et al.

II. Retinal hemorrhage III. Choroidal neovascularization

2  Retinal Diseases

Fig. 2.82  Myopic fundus changes I. Massive choroidal atrophy around the optic disc II. Sub-macular choroidal neovascularization

93

III. Choroidal atrophic area

94

Fig. 2.83  Myopic fundus changes I. Posterior scleral staphyloma like a basin II. Exposure of large choroidal vessels

G. Wang et al.

III. Macular atrophy IV. Disappearance of choroidal vessels

2  Retinal Diseases

Fig. 2.84  Myopic fundus changes I. Estimated boundary of the posterior scleral staphyloma II. Multiple choroidal atrophy

95

III. Pigmentation in front of the retinal vessels IV. Pigmentation of retinal pigment epithelium V. Exposed choroidal vessels

96

Fig. 2.85  Myopic fundus changes I. Reflections of silicone oil II. Pigmentation of retinal pigment epithelium

G. Wang et al.

III. Pigment proliferation and atrophy IV. Leopard fundus changes

2  Retinal Diseases

Fig. 2.86  Myopic fundus changes I. Stair-step shaped staphyloma II. Boundary of staphyloma

97

III. Retinal and choroidal atrophy and impending retinal vessels, cavity change underneath and exposed large choroidal vessels

98

Fig. 2.87  Myopic fundus changes I. Estimated boundary of the posterior scleral staphyloma II. Multiple choroidal atrophy and impending retinal vessels III.  Choroidal atrophy temporal to the optic disc and exposed large vessels

G. Wang et al.

IV. Elevated retina V. Deep retinal hemorrhage (CNV suspected)

2  Retinal Diseases

Fig. 2.88  Retinitis pigmentosa I. The thickness of the macula is within normal range II. Severe thinning of retina outside the vascular arc

99

III. Attenuated retinal arteries IV. Bone spicule formation

100

Fig. 2.89  Subretinal yellow-white exudates I. The lesion locates under the sensory retina and above the RPE

G. Wang et al.

2  Retinal Diseases

Fig. 2.90  Multiple dotted choroidopathy I+II. The lesion locates under the retina and different degrees of pigment proliferation

101

III. Exposure of large choroidal vessels and sclera IV. Pigment proliferation under the retina showed livid color V. Subretinal pigment proliferation showed black color

102

Fig. 2.91  Familial exudates vitreoretinopathy I+II. The superior and inferior temporal retinal vessels are straight III. Vitreous opacities and their shadows on the retina IV. Vessels of different layers

G. Wang et al.

V.  Leakage of fluorescence of neovascularization in the peripheral retina

2  Retinal Diseases

Fig. 2. 91 (continued)

103

104

Fig. 2.92  Dry age-related macular degeneration I. Intermediate retinal exudates II+III. Confluent drusen under the retina

G. Wang et al.

IV. Confluent drusen between the optic disc and macula V. Fovea

2  Retinal Diseases

Fig. 2.93  Familial exudates vitreoretinopathy I+II. The superior and inferior temporal retinal vessels go straightly

105

III. Macular dislocated far away from the papilla

106

Fig. 2.94  Familial exudates vitreoretinopathy I+II. Dendritic retinal vascular endings III. Bulged endings of retinal vessels

G. Wang et al.

IV. Communicative ending among veins/arteries V.  Leakage of fluorescence of neovascularization in the peripheral retina

2  Retinal Diseases

Fig. 2.95  Congenital retinal folds I. Temporal dislocation of papilla and vessels

107

II. Macula dislocation III. Partially dilated veins around papilla

108

Fig. 2.96  Roth dot I. White-gray spot due to bacterial accumulation and inflammation II. Bleeding around the white-gray spot

G. Wang et al.

III. Vitreous exudates

2  Retinal Diseases

Fig. 2.97  Subretinal abscess I. Superior-temporal white-gray abscess under retina II. Retinal bleeding spots

109

III. Dilated retinal vein

110

Fig. 2.98  Syphilis masquerade by retinal vasculitis I. Vitreous opacities or PVR II. Sheathed retinal arteries and veins

References

G. Wang et al.

III. Laser spots IV. Syphilis spot

5. Li HK, Hubbard LD, Danis RP, et  al. Monoscopic versus stereoscopic retinal photography for grading diabetic retinopathy severity. Retina. 2010;51:3184–92. 1. Tyleer ME. Stereo fundus photography: principles and techniques. 6. Lawrence MG.  The accuracy of digital-video retinal imaging to In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal screen for diabetic retinopathy: an analysis of two digital-video retiphotography, angiography, and electronic imaging. 2nd ed. Boston: nal imaging systems using standard stereoscopic seven-field phoButterworth-Heinemann; 2002. p. 118–35. tography and dilated clinical examination as reference standards. 2. Allen L. Ocular fundus photography: suggestions for achieving conTrans Am Ophthalmol Soc. 2004;102:321–40. sistently good pictures and instructions for stereoscopic photogra 7. Hubbard LD, Danis RP, Neider MW. Brightness, contrast, and color phy. Am J Ophthalmol. 1964;57:13–28. balance of digital versus film retinal images in the age-related eye 3. Early Treatment Diabetic Retinopathy Study Research Group. disease study 2. Invest Ophthalmol Vis Sci. 2008;49:3269–82. Grading diabetic retinopathy from stereoscopic color fundus pho 8. Rudnisky CJ, Hinz BJ, Tennat MTS, et al. High-resolution stereotographs: an extension of the modified Airlie House classification. scopic digital fundus photography versus contact lens biomicrosETDRS report 10. Ophthalmology. 1991;98:786–806. copy for the detection of clinically significant macular edema. Am J 4. The Age-Related Eye Disease Study Research Group. The age-­ Ophthalmol. 2002;109:267–74. related eye disease study system for classifying age-related macu 9. Haug S, Arthur DF, Robert NJ, et al. Fulorescein angiography: basic lar degeneration from stereoscopic color fudus photography: the principles and interpretation. In: Schachat AP, editor. Ryan’s retina. age-related eye disease study report number 6. Arch Ophthalmol. 6th ed. Edinburgh: Elsevier; 2018. p. 1–45. 2001;31:167–75.

3

Macular Diseases Hanyi Min, Hong Du, and Ziyang Liu

The macula (anatomically fovea), situated 3  mm lateral to the optic disc, is the most sensitive part of visual acuity. The foveola is a central 0.35 mm wide zone in the macula. The inner retinal layers in the margins of the pit are displaced laterally. Figure 3.1 displays the anatomical schematic diagram of the macula. The macular diseases mainly involve congenital anomaly (congenital macular coloboma), central serous chorioretinopathy, vitreomacular traction syndrome, vitreous hemorrhage beneath the inner limiting membrane, macular edema, macular hole, macular atrophy and proliferative diseases of the macula, such as retinal angiomatous proliferation (RAP), choroidal neovascularization (CNV), and polypoidal choroidal vasculopathy (PCV). Stereoscopic photography plays an important role in macular diseases [1–3]. In the past, stereoscopic slide film photography of the retina is the standard with which other imaging modalities have been compared when identifying age-related macular degeneration (AMD). The Age-Related Eye Disease Study, a multicenter prospective cohort study of 4757 participants designed to access the clinical course, prognosis, and risk factor for age-related macular degeneration and cataract, uses stereoscopic color fundus photographs in a standardized fashion by certified photographers [4, 5]. In ETDRS, besides the grading diabetic retinopathy severity by stereoscopic retinal photography, the clinically significant macular edema (CSME), which is one of the key factors affecting the visual acuity, is also diagnosed correctly by stereoscopic digital fundus photography. The kappa (ƙ) values

among contact lens biomicroscopy (CLBM), slit-lamp biomicroscopy with 90D/78D or by stereoscopic pairs are more than 0.6. So, in most cases, the stereoscopic photography can be used as a diagnosis tool, especially for screening and telemedicine [4–6]. Abnormalities in macular diseases are various [3, 7, 8]. Drusen are yellow-white deposits within Bruch’s membrane underlying the RPE and vary greatly in appearance, ranging from small round, flat spots in size and shape to large deposits even confluent with adjacent drusen. Geographic atrophy may show a sharply demarcated, usually circular zone of partial or complete depigmentation of RPE and exposure of underlying large choroidal blood vessels. The three kinds of choroidal neovascularization (type I, II, and III), which are correspondent with occult CNV, classic CNV, and retinal angiomatous proliferation (RAP), are more vividly and comprehensively shown on stereoscopic pairs than monoscopic and even OCT scans. The retina will be dome-shaped with intra-retinal exudates and cyst, accompanying by intra-­ retinal, sub-retinal and sub-RPE hemorrhages, sub-retinal and sub-RPE neovascularies, etc. The anastomosis between retina and choroid will be shown clearly on stereoscopic FFA pairs [7]. Macular holes are well-defined defects in the middle of the macula in various sizes. Sometimes, there is a thin membrane above the posterior retina called epi-retinal membrane (ERM). Generally speaking, with the combination of stereoscopic photography and other high-tech tools such as OCT, more and more macular signs and characteristics will be explored.

H. Min (*) · H. Du Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China e-mail: [email protected] Z. Liu Department of Ophthalmology, Beijing Youyi Hospital, Beijing, P.R. China © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_3

111

112

H. Min et al.

Inner plexiform layer Muller Fibers of Muller Outer limiting membrane

Retinal pigment cell

Bruch membrane

Nerve fiber layer

Ganglion cell layer

Inner nuclear layer

Fovea centralis

Foveola

Outer nuclear layer

Rods and cones

Fig. 3.1  Anatomical schematic diagram of the macula

Fig. 3.2  Central serous chorioretinopathy I. The central reflex was disappeared

II.    The apex of sensory retinal detachment III. Fold of ILM

Choroid

3  Macular Diseases

Fig. 3.3  Central serous chorioretinopathy I. Leakage from venules inferior-nasal to the macula

113

II. The area of sensory retinal detachment

114

Fig. 3.4  Sensory retinal detachment I.    Apex of detachment II. Fold of epiretinal tissue (ILM)

H. Min et al.

III. Intermediate retinal exudates IV. Vessels located in the depressed area, which was lower than the area I

3  Macular Diseases

Fig. 3.5  Central serous chorioretinopathy I.    Retinal detachment in the posterior pole II. One of the apexes of detachment

115

III. Bottom of detachment IV. The other one of apexes of detachment V.    Retinal fold

116

Fig. 3.6  Pouch-shaped retinal pigment epithelium detachment I.    The area of RPE detachment, which was larger in the color photograph than in the fluorescein angiography II. Apex of detachment

H. Min et al.

III. Sub-RPE fluid IV.  Blocked fluorescence hyperfluorescence

by

hemorrhage

and

intermediate

3  Macular Diseases

Fig. 3.7  Idiopathic macular hole I.    Full thickness macular hole II. Shallow retinal detachment in the adjacent area

117

118

Fig. 3.8  Secondary macular hole I.       Full thickness macular hole II.    Proliferative membrane in the vitreous III. Retinal detachment IV.  Ghost vessels

H. Min et al.

V.       Segmented sheath in the retinal arteries VI.    Artery-Vein crossing of the superficial retinal artery and deep ­retinal vein VII. ILM fold

3  Macular Diseases

Fig. 3.9  Macular hole secondary to optic disc pit I.       Full thickness macular hole II.    Shallow retinal detachment in the adjacent area III. Fold of posterior hyaloids and ILM, the retinal vessels were obscure

119

IV. Choroidal coloboma V.    Optic disc pit

120

Fig. 3.10  Retinal detachment secondary to macular hole I.    Full thickness macular hole, approximately 1/4 PD in diameter II. Retinal detachment and fold

H. Min et al.

III. Proliferation under the retina like a streak IV. Peripapillary atrophy

3  Macular Diseases

Fig. 3.11  Retinal detachment secondary to juxta foveal hole I. Suspected para-macular hole, approximately 1/4 PD in diameter, which was confirmed by OCT

121

II.    Detached macula III. Vitreous band IV. Peripapillary atrophy

122

Fig. 3.12  Dry age-related macular degeneration I. Diffused hard drusen

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II.    Confused soft drusen III. Macula uninvolved

3  Macular Diseases

Fig. 3.13  Juxtafoveal choroidal neovascularization I.    Juxtafoveal choroidal neovascularization II. RPE detachment and exudates

123

III. The area of sensory retinal detachment IV. Macular edema

124

Fig. 3.13 (continued)

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3  Macular Diseases

Fig. 3.14  Choroidal neovascularization I.    Subfoveal CNV II. Superficial retinal exudates

125

III. Exudates in the inner retina IV. Deep retinal hemorrhage V.    Suspected area of CNV

126

Fig. 3.15  Choroidal neovascularization I. Subfoveal choroidal neovascularization

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II. Intra-retinal hemorrhage around the lesion

3  Macular Diseases

Fig. 3.16  Juxtafoveal CNV I.    Suspected area of CNV II. Sensory retinal detachment

127

III. Sub-RPE hemorrhage IV. Sub-retinal hemorrhage

128

Fig. 3.17  Sub-macular choroidal neovascularization I.    Sub-macular choroidal neovascularization II. Small thread-like hemorrhage

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III. Dotted exudates IV. Localized narrowing of retinal vessels and drusen

3  Macular Diseases

Fig. 3.18  Polypoidal choroidal vasculopathy I.    Multiple suspected polypoidal lesions II. Deep retinal hemorrhage

129

III. Superficial retinal exudates IV. Sub-retinal hemorrhage V.    Sub-RPE hemorrhage

130

Fig. 3.19  Retinal angiomatous proliferation (RAP) I.    Intra-retinal neovascularization II. Sub-retinal choroidal neovascularization

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III. Deep retinal exudates IV. White-dotted sub-retinal exudates

3  Macular Diseases

Fig. 3.20  Retinal angiomatous proliferation (RAP) on FFA I. Intra-retinal neovascularization

131

II.    Sub-retinal choroidal neovascularization III. Elevated fovea and scattered exudates

132

Fig. 3.21  Retinal angiomatous proliferation (RAP) on FFA I. Intra-retinal neovascularization on early FFA

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II.    Intra-retinal neovascularization on mid-stage FFA III. Fluorescent leakage of neovascular of neovascular

3  Macular Diseases

Fig. 3.22  Polypoidal choroidal vasculopathy I.    Orange elevation II. Vitreous hemorrhage

133

III. Sub-retinal hemorrhage IV. Chronic sub-RPE hemorrhage V.    Intermediate retinal exudates

134

Fig. 3.23  RPE tear I. Folded RPE in triangle shape

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II.    Exposed sclera III. Intra-retinal exudates

3  Macular Diseases

Fig. 3.24  RPE tear I.    Folded RPE or RPE tear II. Exposed sclera

135

III. Normal RPE area IV. Geographic atrophy of macula

136

Fig. 3.25  Silicone oil tamponade of PCV I.    Chronic choroidal lesion II. The retinal artery went over the retinal vein

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III. The reflex of silicone oil IV. Deep retinal hemorrhage

3  Macular Diseases

Fig. 3.26  Macular hemorrhage I. Thickened posterior hyaloid and strong reflex

137

II.    Yellow-white epiretinal hemorrhage III. Sub-retinal hemorrhage

138

Fig. 3.27  Sub-macular choroidal neovascularization membrane I.    Apex of elevation and appeared white II. The second layer of exudates

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III. The third layer of exudates and appeared yellow-white IV. Pigment proliferation and small sub-retinal membrane

3  Macular Diseases

Fig. 3.28  Juxtafoveal sub-retinal mixed choroidal neovascularization I.       Sub-retinal grey scar II.    Sub-retinal choroidal neovascularization III. Sub-retinal pigment proliferation

139

IV. Sub-retinal hemorrhage V.    Epiretinal hemorrhage VI. Scattered sub-retinal dotted exudates

140

Fig. 3.29  Sub-macular fibrous membrane I.    Apex of sub-retinal membrane II. Suspending retinal vessels

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III. Pigment proliferation IV. Retinal artery sheath V.    The retinal artery went over the membrane

3  Macular Diseases

Fig. 3.30  Macular edema I. Elevation of macula and loss of central reflex

141

II. The retinal artery went beneath the retinal vein

142

Fig. 3.31  Macular edema I. Cystoid macular edema

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II.    Distorted veins on the optic disc III. Vitreous opacities

3  Macular Diseases

Fig. 3.32  Macular edema after grid laser treatment I.    The macula was flat II. Laser spot

143

III. The end of retinal vein was dilated IV. Neovascularization of the optic disc

144

Fig. 3.33  Macular radial hard exudates I.    The end of retinal artery was dilated II. Superficial retinal exudates

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III. Deep retinal exudates IV. Grey-whitish exudates

3  Macular Diseases

Fig. 3.34  Juxtafoveal telangiectasis I. The area of macular edema

145

II.    The deep retinal vessels were dilated III. Intermediate retinal exudates

146

Fig. 3.35  Adult Coats’ disease I.    The lesion was elevated like three layers of cake II. The blood supply of the retinal artery was insufficient than the other retinal branches

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III. Suspected abnormal vessels

3  Macular Diseases

Fig. 3.36  Adult Coats’ disease of the macula I. Superficial retinal exudates

147

II.    Large amount of yellow-white exudates and crystal in the deep retina III. Deep retinal hemorrhage

148

Fig. 3.37  Coats’ disease I.    Yellow-whitish sub-retinal exudates II. Exudates of the retinal artery

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III. Irregular diameter and exudates of retinal veins IV. The end of the retinal vessels was dilated

3  Macular Diseases

Fig. 3.38  Macular hemorrhage in various layers I.    Pre-retinal hemorrhage looked alike a boat II. Sub-retinal hemorrhage

149

III. Sub-RPE hemorrhage IV. The retinal vessels were distorted and dilated

150

Fig. 3.39  Boat-like epiretinal hemorrhage I.    The serum II. The platelets

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III. The white blood cells IV. The deoxygenated hemoglobin V.    The oxygenated red blood cells

3  Macular Diseases

Fig. 3.40  Epiretinal hemorrhage I.    The boat-like epiretinal hemorrhage like a dome II. After dissection of posterior limiting membrane by Nd:YAG laser, the hemorrhage was disseminated and absorbed

151

III. Thickened posterior hyaloids and folds

152

Fig. 3.41  Proliferative vitreoretinopathy I.    Proliferative membrane and streaks II. Pseudo hole

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III. Atherosclerosis of superior temporal retinal artery

3  Macular Diseases

Fig. 3.42  Epi-retinal membrane I.    Epi-retinal membrane extended from the optic disc to the periphery II. Distorted retinal veins

153

III. Irregular diameter of the retinal vein

154

Fig. 3.43  Retinal hemorrhage of different retinal layers I.    Sub-RPE hemorrhage, the lesion was highly elevated II. Deep retinal hemorrhage

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III. Sub-retinal hemorrhage IV. The central reflex was lost

3  Macular Diseases

Fig. 3.44  Chronic retinal hemorrhage I.    Pre-retinal hemorrhage II. Suspected location of retinal macroaneurysm

155

III. Intermediate retinal hemorrhage IV. Artery-Vein nicking (Salus Sign)

156

Fig. 3.45  Sub-retinal parasitic infection I.    Suspected scolex of the parasite II. Intra-retinal reaction of multiple retinal layers

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III. Exudative retinal detachment IV. Dotted yellow-whitish exudates V.    Ghost vessel of retinal vein

3  Macular Diseases

Fig. 3.46  Coloboma of macula I.    Exposed sclera II. Choroidal vessels

157

III. Boundary of coloboma IV. Impending retinal vessels

158

Fig. 3.47  Congenital coloboma of macula I.    The sclera was exposed in the area of coloboma II. Suspending choroidal vessels

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III. Mottled epithelial pigment proliferation IV. The boundary of coloboma

3  Macular Diseases

Fig. 3.48  Stargardt disease I.    Bull-eye shaped lesion, irregular with pigmentation II. Retinal and choroidal atrophy like a basin

159

III. Retinal vessels that passed through the lesion went attenuated

160

Fig. 3.49  Macular atrophy I. Fovea

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II.    Irregular diameter of retinal veins III. RPE atrophy

3  Macular Diseases

161

Fig. 3.50  Macular atrophy after branch retinal artery occlusion I. Macular atrophy and thinning

II.    Thinning of inferior temporal retinal artery III. Pigment proliferation

References

5. The Age-Related Eye Disease Study Research Group. The age-­ related eye disease study system for classifying age-related macular degeneration from stereoscopic color fudus photography: the age-related eye disease study report number 6. Arch Ophthalmol. 2001;31:167–75. 6. Rudnisky CJ, Hinz BJ, Tennat MTS, et al. High-resolution stereoscopic digital fundus photography versus contact lens biomicroscopy for the detection of clinically significant macular edema. Am J Ophthalmol. 2002;109:267–74. 7. Slakter JS, Yannuzzi LA.  Schneider U. et5 al. retinal choroidal anastomoses and occult choroidal neovascularization in age-related macular degeneration. Ophthamology. 2000;107:742–53. 8. Agarwal A.  Gass atlas of macular diseases. 5th ed. Edinburgh: Elsevier; 2012. p. 1–16.

1. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 2. Rudnisky CJ, Tennant MT, de Leon AR. Benefits of stereopsis when identifying clinically significant macular edema via teleophthalmology. Can J Ophthalmol. 2006;41:727–32. 3. Gass JDM.  Stereo atlas of macular diseases: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997. 4. Hubbard LD, Danis RP, Neider MW. Brightness, contrast, and color balance of digital versus film retinal images in the age-related eye disease study 2. Invest Ophthalmol Vis Sci. 2008;49:3269–82.

4

Vitreous Diseases Qinying Ye, Chengxi Zhang, Fei Gao, and Hanyi Min

The vitreous cavity occupies four-fifth the volume of the eyeball and contains the vitreous humor or vitreous, the natural clearance of vitreous cavity or space make the stereo examination possible [1–3]. The vitreous is attached with the retina tightly in the area of optic disc, macula and vitreous base. The vitreous is shaped like a sphere with an anterior depression and attached with the lens peripherally with Wieger ligament. It is traversed by a central fluid-filled canal, called Cloquet’s canal, which represents the remnants of the course taken by the hyaloids artery that supplied the vitreous and lens in the fetal eye. The anterior end of Cloquet’s canal is condensed at the posterior pole of the lens with a width of 1–2  mm, called Mittendorf point. The posterior end is attached with the rim of optic cup, which can be seen as a translucent residual, called Bergmeister papilla, if not fully degenerated (Fig. 4.1). During the development of vitreous (Fig. 4.2A), the primary vitreous is compressed by secondary vitreous to the center; it goes nasally and forward to the center of the cavity from the posterior lens, then it goes temporally and backward to the optic disc until it is surrounded by Cloquet’s canal and connected with Erggelet’s canal. Primary vitreous is only the condensation of the membranes, which separates the primary and secondary vitreous. Secondary vitreous occupies the largest part of the vitreous cavity. Tertiary vitreous derives from the nonpigmented ciliary epithelial cells, extends to the lens and fuses with capsule, which forms the zonular fibers (Fig. 4.2).

Petit canal

Berger space

Hyaloideocapsular interface

Erggelet space

SPM

IPM

Wieger ligament

Fig. 4.1  Structure of interface between lens and vitreous

Q. Ye Department of Ophthalmology, The 2nd Affiliated Hospital, Guangdong Medical University, Zhanjiang, P.R. China C. Zhang · F. Gao · H. Min (*) Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_4

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Lesions of the vitreous include congenital dysplasia, age-­ related opacities, liquefaction, posterior vitreous detachment, neovascularization, proliferation, etc. Most of the vitreous changes are complications of adjacent diseases [4]. For example, vitreous hemorrhage is the most common complication due to retinal tears, proliferative diabetic retinopathy, retinal vein occlusion, posterior vitreous detach-

Q. Ye et al.

ment, etc. What’s more, the hemorrhage will show various manifestations. If it is confined to the inner limiting membrane, the border will be well-defined and like a boat. Sometimes, the different layers of the blood will be discriminated carefully. If the hemorrhage breaks into the vitreous cavity, the amount, the time, and the course of the primary disease will decide its appearance. If the hemorrhage is secondary to the retina tear, the retina tear, the traction of the vitreous on the apex of the retinal valve, the crossing blood between the two points of the break will be seen most temporarily and superiorly. Of course, the blood will precipitate on the lower half of the vitreous cavity with red or pale color according to its course. In some cases, the blood will become fibrous and make the retina contract, and tractional retinal detachment will be seen. When we observe the vitreous changes, the primary cause will be considered in mind. Due to the filamentous collagen of vitreous body, the various appearances of opacity, hemorrhage, and fibrous tissue can be detected (Fig.  4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, 4.22, 4.23, 4.24, 4.25, 4.26, 4.27, 4.28 and 4.29).

Fig. 4.2  Schematic diagram of three grades of vitreous. A, B, and C represent primary, secondary and tertiary vitreous respectively

Fig. 4.3  Vitreous opacities I. Location of occlusion of the inferior retinal vein branch, the diameter of the vein is increased sharply

II. Elevated and dilated retinal vessel, within it a grey column could be seen in the center and two blood streams on both sides. Suspected neovascularization is on it

4  Vitreous Diseases

165

Fig. 4.3 (continued)

Fig. 4.4  Vitreous opacities I.    Ghost vessels of retinal vein II. Dilated retinal veins (communicating branch)

III. Thinning and straight retinal artery IV. Vitreous opacities of different layers

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Fig. 4.5  Vitreous opacities I.    Chronic vitreous hemorrhage II. Subretinal hemorrhage

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III. Deep retinal hemorrhage IV. Chronic vitreous hemorrhage

4  Vitreous Diseases

Fig. 4.6  Vitreous opacities I.    Neovascularization of the optic disc II. Hemorrhage in the anterior vitreous

167

III. Hemorrhage in the middle vitreous IV. Hemorrhage near the posterior hyaloids V.    Deep retinal exudates

168

Fig. 4.7  Boat-like pre-retinal hemorrhage I.    The layer of serum II. The layer of platelets

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III. The layer of white blood cells IV. The layer of deoxygenerated hemoglobin V.    The layer of oxygenated red blood cells

4  Vitreous Diseases

Fig. 4.8  Sub-ILM hemorrhage I. Sub-ILM hemorrhage in the macula

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II. Flame-shaped retinal hemorrhage

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Fig. 4.9  Vitreous hemorrhage I. Vitreous hemorrhage located anterior to the retina and posterior to the posterior hyaloids

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II.    Optic disc III. Subretinal hemorrhage

4  Vitreous Diseases

Fig. 4.10  Vitreous opacities I.    Cup-like neovascularization in the posterior pole II. Branch of neovascularization

171

III. Deep exudates IV. Vitreous hemorrhage V.    Superficial retinal hemorrhage

172

Fig. 4.11  Vitreous opacities I.    Dense vitreous hemorrhage in the inferior cavity II. Superficial retinal hemorrhage

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III. Dilated retinal veins IV. Retinal neovascularization V.    Artery-Vein nicking

4  Vitreous Diseases

Fig. 4.12  Vitreous hemorrhage (Anemia) I. Dense vitreous hemorrhage in the posterior pole

173

II.    Dilated retinal veins and retinal beading III. Retinal ischemia, with pale color

174

Fig. 4.13  Vitreous hemorrhage I.    Apex of vitreous hemorrhage II. Fresh hemorrhage in the surface

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III. Retinal vessels IV. Choroidal atrophy

4  Vitreous Diseases

Fig. 4.14  Streaks in the vitreous I.    Streak inferior to the optic disc II. The inferior end of streaks adhesive to the retinal vessel to form a right angle to the vessel

175

III. Projection of the membrane onto the retina IV. Abnormal inferior temporal branch and went upward

176

Fig. 4.15  Proliferative vitreoretinopathy I.    Abnormal neovascularization originated from the optic disc and extended to the periphery II. Massive hemorrhage into the vitreous

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III. Reflex of the retinal artery like a copper wire IV. Distorted retinal veins V.    Vitreous hemorrhage

4  Vitreous Diseases

Fig. 4.16  Vitreous hemorrhage I. Hemorrhage like a streak

177

II.    Fan-like sector membrane in the vitreous III. Obscured optic disc

178

Fig. 4.17  Fibrovascular organization in the vitreous I.    Branch-like membrane between the optic disc and macula II. Stretched retinal veins and insufficient blood supply in segmental vessels

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III. Areas of tractional retinal detachment

4  Vitreous Diseases

Fig. 4.18  Parasitic infection I.    Subretinal lesion of parasitic infection II. Vitreous streak

179

III. Subretinal pigment proliferation IV. Distorted retinal veins in the macula

180

Fig. 4.19  Fibrovascular organization in the vitreous I. Dense white membrane anterior to the macula, and the tentacles extending to its neighbor

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II.    Subretinal reactive change III. RPE reactive change IV. Distorted retinal vessels

4  Vitreous Diseases

Fig. 4.20  Fibrovascular organization in the vitreous I. Streak superior to the optic disc like a jug to stretch the retinal vessels II. Ghost vessel of the retinal vein

181

III. Retinal fold IV. Dilated retinal veins V.    Distorted superior branch like a loop

182

Fig. 4.21  Membrane in the macula area I. Dense membrane of the vitreous to block the macula

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II. Optic disc

4  Vitreous Diseases

Fig. 4.22  Organized streak in the vitreous I. Streak superior to the optic disc

183

II.    Dilated retinal veins III. Suspending retinal vessels

184

Fig. 4.23  Fibrovascular membrane in the vitreous I.    Carpet-like membrane in the vitreous II. Dilated retinal veins

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III. Subretinal membrane IV. Retinal folds V.    Subretinal depigmentation

4  Vitreous Diseases

Fig. 4.24  Vitreous fibrovascular membrane I.    Membrane superior to the optic disc II. Neovascularization of the optic disc

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III. Retinal veins IV. Neovascularization in the vitreous V.    Multiple ghost vessels

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Fig. 4.25  Vitreous proliferation I.    Membrane anterior to the optic disc and made traction to the retinal vessels II. Neovascularization of the optic disc

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III. Retinal detachment and retinal vessels IV. Subretinal membrane V.    Superficial retinal hemorrhage

4  Vitreous Diseases

Fig. 4.26  Streaks in the vitreous I. Membrane superior to the optic disc and tractional retinal detachment

187

II.    Distorted retinal vessels and disappearing ends in the membrane III. Subretinal streak

188

Fig. 4.27  Membrane in the vitreous I. Membrane in the posterior pole and tractional retinal detachment

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II.    Distorted retinal vessels III. The membrane extended to the mid-periphery

4  Vitreous Diseases

Fig. 4.28  Fibrous membrane and tractional retinal detachment I.    Fibrous membrane with branches attaching to the retina II. Distorted retinal vessels

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III. The membrane extended to the mid-periphery IV. Retinal detachment V.    Old vitreous hemorrhage

190

Fig. 4.29  Membrane in the vitreous I. Membrane in the posterior pole and tractional retinal detachment

References 1. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 2. Allen L. Ocular fundus photography: suggestions for achieving consistently good pictures and instructions for stereoscopic photography. Am J Ophthalmol. 1964;57:13–28.

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II.    Epiretinal membrane in the posterior pole III. Retinal detachment in the macula

3. Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic retinopathy from stereoscopic color fundus photographs: an extension of the modified Airlie House classification. ETDRS report 10. Ophthalmology. 1991;98:786–806. 4. Gass JDM.  Stereo atlas of macular diseases: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997.

5

Papillary Diseases Gangwei Cheng, Zhikun Yang, Rongpin Dai, and Hanyi Min

The optic disc is situated 3 mm nasal to the macular, approximately 1.5 mm × 1.75 mm. The optic nerve is formed by convergence of 1–1.2 million ganglion cells axons at the optic disc. The central pit of the disc is called optic cup (Fig. 5.1). The blood vessels run through the optic disc onto the retina. Müller cells and inner limiting membrane are absent around the optic disc, which cause obvious edema of the rim during papilloedema. The optic disc is the intraocular portion of the optic nerve [1–3]. Its blood supply mainly comes from the capillary plexus from central retinal artery which nourishes the superficial nerve fiber, the Zinn–Haller circle which nourishes the lamina cribrosa and anterior lamina cribrosa area, the pia mater and posterior ciliary artery which nourishes the posterior lamina cribrosa area. During fundus fluorescein angiography, the blood supply of the optic disc can be divided into three layers [2, 4, 5]. The first layer is the deep twilight fluorescence, which appears before any fluorescein comes into the central retina artery and may represent the capillary plexus of the lamina cribrosa. It cannot distinguish the capillary pattern. The second layer is the superficial grape cluster-like fluorescence, which can display the capillary and represents the capillary plexus before the lamina cribrosa. The former two layers won’t exceed the optic margin either. The third layer is the surface radial capillary and appears after the arteriole development. Some researchers suggest it would belong to the radial peripapillary capillary (RPC). RPC is the radial superficial capillary plexus coming out of the optic disc. The fluorescein staining shows it strides over the main veins with little anastomoses and a few arteriole-feeding points. The vein that gathers the RPC to the optic disc is called radial epi-papillary

capillary (REC) and the veins that gather the RPC to the retinal veins is called RPC Proper. The optic disc stereoscopic photography (ODSP) is regarded as one of the most important ways of optic nerve evaluation [1, 6, 7]. Since it can read the related spatial position, the ODSP can directly show the rises and falls of the optic nerve head and relations between different layers. Compared with traditional optic nerve photography, ODSP can reveal the height of the optic nerve, the extent of the rim depression, the layers of vascular lesions, and the depth of occupying masses more accurately, which is of great importance to the interpretation of glaucoma, optic edema, masses, and dysplasia. Besides the diagnosis, the ODSP can also monitor the progression of diseases sensitively and objectively [4, 5]. It is the main evaluation method in the follow-up of glaucoma. The traditional optic nerve photography is affected by multiple factors, such as the shooting angle and exposure intensity, so the early changes can easily be neglected and misdiagnosis may occasionally happen. More reliable photography methods are needed to improve the sensitivity and specificity of discrepancy detection. ODSP applies the principle of parallax imaging and is less affected by light and shooting angles, which makes it more suitable for the monitoring of disease progression. Although more advanced instruments which has been widely used in glaucoma such as OCT, VF, ODSP is regarded popularly as the gold standard in the diagnosis and follow-up of glaucoma [1, 7]. Edema of papilla due to optic neuritis, intra-cranial tumor, optic vasculatis, etc. can be easily observed by binocular lens [8]. The optic pit, masses, or congenital anomaly are also included in this chapter.

G. Cheng · Z. Yang · R. Dai · H. Min (*) Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China e-mail: [email protected] © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_5

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Fig. 5.1  Normal optic disc

Fig. 5.2  ISN’T rule of normal optic disc I. The inferior rim was the widest II. The superior rim was the second widest

III. The nasal rim was the third widest IV. The temporal rim was the narrowest V. The optic cup

5  Papillary Diseases

Fig. 5.3  Glaucomatous optic disc change I. The temporal rim of the optic disc was lost II. Sharply bending bayoneting vessels

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III. Bifurcating area of retinal artery IV. The residual rim

194

Fig. 5.4  Glaucomatous optic disc change I. The C/D ratio was enlarged to about 0.9 II. The temporal rim is lost III. Multiple sharply bending bayoneting vessels IV. Choroidal atrophy and exposed sclera and choroidal vessels (β zone, blue area)

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V. Surrounding irregular hyper- and hypo-­pigment area (α zone, brown area) VI. The branch of the artery out like a stair-step

5  Papillary Diseases

Fig. 5.5  Glaucomatous optic disc change I. The C/D was enlarged to about 0.8 II. The inferior rim was lost (notch)

195

III. β zone IV. α zone

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Fig. 5.6  Glaucomatous optic disc change I. The C/D was enlarged to about 0.6

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II. Small hemorrhage at the edge of the optic disc

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Fig. 5.7  Disc change in glaucoma I. The C/D ratio was about 0.8

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II. Thinning of the inferior rim III. Sharply bending bayoneting vessels on the edge of the optic disc

198

Fig. 5.8  Glaucomatous optic disc change I. The area of the cup, the C/D ratio was 0.7

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II. Sharply bending bayoneting vessels

5  Papillary Diseases

Fig. 5.9  Glaucomatous optic disc change I. C/D ratio was 0.9 II. The superior rim is lost

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III. Sharply bending bayoneting vessels IV. Exposure of laminal cribrosa

200

Fig. 5.10  Glaucomatous optic disc change I. The C/D ratio enlarged to about 0.8

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II. The rim is lost

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Fig. 5.11  Glaucomatous optic disc change I. Enlarged C/D to about 0.7

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II. The notch of the rim

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Fig. 5.12  Glaucomatous optic disc change I. Enlarged C/D ratio to about 0.9

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II. The rim is lost

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Fig. 5.13  Glaucomatous optic disc change I. The C/D ratio was enlarged to about 0.9 II. The inferior-temporal rim was lost

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III. Sharply bending bayoneting vessels IV. Different color of vessels in and outside the optic disc

204

Fig. 5.14  Glaucomatous optic disc change I. Enlarged C/D to about 0.8

G. Cheng et al.

II. The pale temporal side of the optic disc

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Fig. 5.15  Glaucomatous optic disc change I. Enlarged C/D ratio to about 0.8

205

II. Sharply bending bayoneting vessels III. The inferior temporal rim is lost

206

Fig. 5.16  Glaucomatous optic disc change I. Enlarged C/D ratio to about 0.9 II. The rim is lost

G. Cheng et al.

III. The thin artery with sheath surrounding the artery IV. Multiple thinning of NFL

5  Papillary Diseases

Fig. 5.17  Notching of the optic disc I. Enlarged C/D ratio to about 0.8

207

II. Notching at the inferior edge of the optic disc

208

Fig. 5.18  Glaucomatous optic disc change I. Enlarged C/D ratio to about 0.9 II. Notching at the superior temporal edge of the optic disc

G. Cheng et al.

III. Notching at the inferior temporal edge of the optic disc IV. β zone V. α zone

5  Papillary Diseases

Fig. 5.19  Glaucomatous optic disc change I. End stage of glaucoma, the C/D ratio is 1.0 and the disc is pale

209

II. β zone III. α zone

210

Fig. 5.20  Myopic changes of the optic disc I. The estimated boundary of posterior staphyloma II. Choroidal atrophy

G. Cheng et al.

III. Leopard fundus changes

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Fig. 5.21  Neovascularization of the optic disc I. Neovascularization of the optic disc

211

II. The thin retinal artery with sheath surrounding the artery III. The optic disc is atrophic and pale

212

Fig. 5.22  Neovascularization in front of the optic disc I. Neovascularization of the optic disc II. Superficial hemorrhage

G. Cheng et al.

III. Deep hemorrhage IV. Dilated retinal veins

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Fig. 5.22 (continued)

213

214

Fig. 5.23  Neovascularization at the optic disc I. The neovascularization is like a butterfly

G. Cheng et al.

II. Twisty artery III. The dilated end of the veins

5  Papillary Diseases

Fig. 5.24  Vitreous hemorrhage in front of the optic disc I. Retinal neovascularization

215

II. Old vitreous hemorrhage III. Fresh vitreous hemorrhage

216

Fig. 5.25  Optic disc hemorrhage I. Vitreous hemorrhage

G. Cheng et al.

II. Superficial hemorrhage III. Deep hemorrhage

5  Papillary Diseases

Fig. 5.26  Hemorrhage in front of the optic disc I. Vitreous hemorrhage II. Superficial retinal hemorrhage

217

III. Elevated posterior hyaloids with strong reflex IV. Deep retinal hemorrhage

218

Fig. 5.27  Hemorrhage of different layers I. Vitreous hemorrhage II. Vitreous hemorrhage close to the retina

G. Cheng et al.

III. Superficial subretinal hemorrhage IV. Deep subretinal hemorrhage V. Outmost subretinal hemorrhage

5  Papillary Diseases

Fig. 5.28  Localized papilledema I. Localized papilledema

219

II. Dilated vein

220

Fig. 5.29  Localized papilledema I. Edema in the part the optic disc

G. Cheng et al.

II. Superficial hemorrhage of the optic disc III. The thin artery with segmental sheath

5  Papillary Diseases

Fig. 5.30 Neuroretinitis I. Mild papilledema

221

II. Paton line III. Elevation of the macula

222

Fig. 5.31  Localized papilledema I. Edema in superior half of the optic disc II. The elevated superior branch artery with part of it blocked by the edematous retinal fiber layer

G. Cheng et al.

III. Distorted and engorged retinal vein IV. FFA shows the estimated area of papilledema

5  Papillary Diseases

Fig. 5.31 (continued)

223

224

Fig. 5.32  Mild papilledema I. The estimated area of papilledema II. Superficial hemorrhage

G. Cheng et al.

III. Deep hemorrhage IV. Distorted and dilated retinal vessels

5  Papillary Diseases

Fig. 5.33  Moderate papilledema I. Apex of papilledema II. Bottom of papilledema

225

III. Paton line IV. Superficial hemorrhage and edema

226

Fig. 5.34  Severe papilledema I. Highly elevated area

G. Cheng et al.

II. Slightly elevated area III. Hemorrhage at the edge of the optic disc

5  Papillary Diseases

Fig. 5.35 Papilledema I. Diffuse elevation of the optic disc like an umbrella

227

II. Striated hemorrhage III. Exudates

228

Fig. 5.36 Papilledema I. Slightly elevated optic disc

G. Cheng et al.

II. Suspected emboli

5  Papillary Diseases

Fig. 5.37  Moderate papilledema I. Moderate elevation of the optic disc

229

II. Striated superficial hemorrhage of the optic disc III. Crawling of the retinal vessels

230

Fig. 5.38 Papilledema I. Highly elevated optic disc II. Flame-shaped superficial retinal hemorrhage

G. Cheng et al.

III. Superficial retinal exudates IV. Distorted retinal vessels around it V. Radial exudates near the macula

5  Papillary Diseases

Fig. 5.38 (continued)

231

232

Fig. 5.39 Papilledema I. Highly elevated optic disc II. Superficial hemorrhage of the optic disc

G. Cheng et al.

III. Grey-whitish exudates of the optic disc IV. Dilated retinal veins V. Thin retinal arteries

5  Papillary Diseases

Fig. 5.39 (continued)

233

234

Fig. 5.40 Papilledema I. Diffusely elevated papillary edema II. Elevated artery

G. Cheng et al.

III. Flame-shaped hemorrhage around the optic disc IV. Elevated and dilated veins V. Patched exudates

5  Papillary Diseases

Fig. 5.41 Papilledema I. Severe papilledema and highly elevated II. Superficial hemorrhage of the optic disc

235

III. Exudates of the optic disc IV. Dilated branches of the retinal veins V. Ghost vessels of the retinal artery

236

Fig. 5.42 Papilledema I. Severe papilledema

G. Cheng et al.

II. Superficial hemorrhage of the optic disc

5  Papillary Diseases

Fig. 5.42 (continued)

237

238

Fig. 5.43  Papilledema on FFA I. Diffuse edema and elevation of the optic disc

G. Cheng et al.

II. Blocked fluorescence of the optic disc (hemorrhage) III. Fluctuant vein

5  Papillary Diseases

Fig. 5.44 Neuroretinitis I. Elevation and hemorrhage inferior to the optic disc II. Elevation and hemorrhage superior to the optic disc

239

III. Grey-whitish exudates IV. Intermediate retinal exudates V. Ghost vessel of the deep retinal vessel

240

Fig. 5.45  Optic disc vasculitis I.  Massive flame-shaped hemorrhage around the optic disc and papilledema

G. Cheng et al.

II. Superficial hemorrhage of the optic disc III. Grey-whitish exudates inferior to the hemorrhage IV. Multiple vitreous hemorrhage

5  Papillary Diseases

Fig. 5.46  Optic disc vasculitis I.  Massive flame-shaped hemorrhage around the optic disc and papilledema

241

II. Superficial hemorrhage of the optic disc III. Superficial grey-whitish exudates IV. Macular edema

242

Fig. 5.47  Hypertensive retinopathy I. White sheath of retinal vessel (chronic exudates)

G. Cheng et al.

II. Salus sign, the A/V ratio was 1:3 III. The number of optic disc vessel is reduced

5  Papillary Diseases

Fig. 5.48  Optic atrophy I. Atrophic and pale optic disc

243

II. Oblique retinal vessels

244

Fig. 5.49  Optic atrophy I. Atrophic and pale optic disc II. Enlarged pale area

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III. Thin retinal artery IV. Dilated retinal vein

5  Papillary Diseases

Fig. 5.50  Melanocytoma of the optic disc I. The melanocytoma of the optic disc is elevated

245

II. Fibrillated margin

246

Fig. 5.51  Melanocytoma of the optic disc I.  Melanocytoma in front of the optic disc and covers the disc completely

G. Cheng et al.

II. Dispersed pigment in the vitreous III. Pigment proliferation close to the retina

5  Papillary Diseases

Fig. 5.52  Optic pit I. Small oval depression in the inferior-­temporal optic disc

247

II. Wrinkle of the retina

248 Fig. 5.53  Optic pit I. The optic pit is about 3/4PD II. The area of choroidal coloboma III.  Hypopigmentation of the choroid

G. Cheng et al.

5  Papillary Diseases

Fig. 5.54  Myelinated nerve fiber I. Myelinated nerve fiber around the optic disc

249

II. Some retinal vessels covered by the myelinated nerve fiber

250

Fig. 5.55  Optic disc dysplasia and glaucoma I. Tilted disc II. Enlarged C/D ratio to about 0.8

G. Cheng et al.

III. The deepened cup IV. β zone V. α zone

5  Papillary Diseases

Fig. 5.56  Choroidal coloboma inferior to the optic disc I. Tilted disc II. Area of choroidal coloboma

251

III. Residual membrane IV. The straight retinal vessels

252

Fig. 5.57  Choroidal coloboma inferior to the optic disc I. Tilted disc II. Exposure of choroid

G. Cheng et al.

III. Patched choroidal pigment IV. The boundary of coloboma V. Narrowing retinal artery

5  Papillary Diseases

Fig. 5.58  Morning glory syndrome I. The deep cup of the optic disc II. The optic sheath posterior to the lamina cribrosa III. The sclera circle

253

IV. The choroidal circle V. The retinal vessel out from the optic disc VI. Translucent tissue of the lamina cribrosa

254

References 1. Mckinnon Stuart J. The valve of stereoscopic optic disc photography. Glauocoma Today; 2005. p. 31–3. 2. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 3. Allen L. Ocular fundus photography: suggestions for achieving consistently good pictures and instructions for stereoscopic photography. Am J Ophthalmol. 1964;57:13–28. 4. Jagadeesh B, Davinder SG, Donald LB, et al. A comparison of optic disc grading using clinical examination and stereoscopic photography in the Tema Eye Survey. Invest Ophthal Vis Sci. 2011;52:254.

G. Cheng et al. 5. Mwanza JC, Grover DS, Budenz DL, et al. A comparison of cup-to-­ disc ratio estimates by fundus biomicroscopy and stereoscopic optic disc photography in the Tema Eye Survey. Eye. 2017;31:1184–90. 6. Sharma NK, Hitchings RA. A comparison of monocular and ‘stereoscopic’ photographs of the optic disc in the identification of glaucomatous visual field defects. Br J Ophthalmol. 1983;67:677–80. 7. Richard AS, Ying GS, Pearson DJ, et  al. Utility of digital stereo images for optic disc evaluation. Invest Ophthalmol Vis Sci. 2011;51:5667–74. 8. Sung V, Bhan A, Stephen AV, et  al. Agreement in assessing optic discs with a digital stereoscopic optic disc camera (Discam) and Heidelberg retina tomography. Br J Ophthalmol. 2002;86:196–202.

6

Choroidal Diseases Donghui Li, Hanyi Min, and Weihong Yu

The choroid is a vascularized and pigmented tissue layer lying between the retinal pigment epithelium (RPE)-Bruch membrane complex and the sclera [1]. It extends from the ora serrata anteriorly to the optic nerve posteriorly. The choroid appears in light to dark brown color and sponge-like shape, with thickness of 0.22  mm posteriorly and 0.10– 0.15  mm anteriorly. It consists of four layers microscopically, suprachoroidal space, stroma layer, choriocapillaris, and Bruch’s membrane. Suprachoroidal space is not an actual space. It is a transition zone between the pigmented sclera and the choroid stroma, which is composed of collagen fibers, elastic fibers, fibrocytes, melanocytes, ganglion cells, and nerve plexuses. The choroid attaches to sclera through bundles of connective tissue that are distributed randomly anteriorly and vertically posteriorly. No blood vessels were found in the suprachoroidal space, except for those passing through. The choroid stroma mainly consists of blood vessels, collagen fibers, and nerve fibers [2, 3]. Haller’s layer is the outer layer of large vessels with melanocytes and nerve fibers. The arteries in Haller’s layer are typical small arteries, which are not fenestrated and have internal elastic lamina and smooth muscles. The medium vessel layer (Sattler’s layer) is located inside Haller’s layer, with vessels highly intertwined. The vessels in Sattler’s layer are not fenestrated as well. The choriocapillaris has abundant capillaries. And these capillaries are larger than those elsewhere, with diameter 40–60 μm to allow two or three red cells to pass through at a time. The vessel walls have multiple fenestrations, especially on the side facing the retina. In the shape of lobule, spindle or trapezoid, the choriocapillaris is a mosaic of lobules that function independently. A precapillary arteriole originated from small choroidal arteries supplies the corresponding lobule. And venous blood drains from the peripheral area of lobules, then to the choroidal veins.

Bruch’s membrane is also called glass membrane, with 2  μm thick centrally, 2–4  μm peripapillarily, and 1–2  μm peripherally. Bruch’s membrane can be subdivided into five layers under electron microscope (from the outermost to the innermost): basal lamina of the choriocapillaris (approximately 0.14  μm thick), outer collagenous zone (approximately 0.7  μm thick), elastic fiber area (approximately 0.8 μm thick), inner collagenous zone (approximately 1.5 μm thick), and basal lamina of the retinal pigment epithelium (approximately 0.3 μm thick). Perfusion of the choroid comes both from the long and short posterior ciliary arteries, which are branches of the ophthalmic artery. The 10–20 short posterior ciliary arteries become the principal blood suppliers for choroidal circulation, while the long posterior ciliary arteries supply the ciliary body and anterior portion of choroid. The choroidal circulation is one of the microcirculations with the highest rates of blood flow in the body. More than four times blood flow was found in per tissue gram of the choroid than that of the renal cortex. Seventy percent of all the blood in the globe is held in the choriocapillaris at any one time. The unique structure of the choroid makes it possible to dissipate heat, nourish retinal pigment epithelium, and deliver nutrients up to the outer portion of the inner nuclear layer of retina. The choroidal diseases mainly consist of tumors (choroidal melanoma, metastatic carcinoma, hemangioma, choroidal osteoma, and hematological malignancy), vascular disorders (choroidal effusion, neovascular membranes, etc.), inflammation (uveitis, central serous chorioretinopathy, VKH, etc.), and others (suprachoroidal hemorrhage). Due to the choroidal diseases locate deeply and beneath the RPE, the successful stereoscopic pairs rely on not only the clear media, but also the characteristics, height, contrast of the lesions [4–6].

D. Li · H. Min (*) · W. Yu Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_6

255

256

D. Li et al.

Fig. 6.1  Vascular layers of the choroid Blue arrowhead: the layer of large vessels (Haller’s layer); red arrowhead: the layer of middle vessels (Sattler’s layer); yellow asterisk: the choriocapillaris

Fig. 6.2  Ultrastructure of Bruch’s membrane 1. Basal lamina of the retinal pigment epithelium 2. Inner collagenous layer 3. Elastic fiber layer 4. Outer collagenous layer 5. Basal lamina of the choriocapillaris

Fig. 6.3 VKH I. Exudative retinal detachment at the posterior pole

II.    Punctate leakage on FFA III. Pigment epithelial detachment (PED)

6  Choroidal Diseases

Fig. 6.3 (continued)

257

258

Fig. 6.4 VKH I. Exudative RD simulating multiple lakes

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Fig. 6.5 Choroiditis I.    The area of exudative retinal detachment at the posterior pole II. Punctate exudates at the superficial retina

259

III. Sub-retinal exudates IV. Pigment epithelial detachment (PED)

260

Fig. 6.6  Grey-white lesion at the superficial choroid I.    Sub-retinal yellowish-white exudates II. Sub-retinal grey-white exudates

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III. The annular zone of reactive pigment hyperplasia

6  Choroidal Diseases

Fig. 6.7  Obsolete multifocal choroiditis I. Multiple patches of sub-retinal pigment hyperplasia

261

262

Fig. 6.8  Choroidal granuloma caused by tuberculosis I.    The sub-retinal elevation temporal to the macula (tuberculoma) II. Deep retinal exudates

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III. Macular edema with peripheral retinal folds IV. Retinal detachment

6  Choroidal Diseases

Fig. 6.9  Polypoidal choroidal vasculopathy (PCV) I.    Orange-red nodular elevations of the retinal pigment epithelium II. Deep retinal hemorrhage

263

III. Deep retinal exudates IV. The fovea

264

Fig. 6.10  Polypoidal choroidal vasculopathy (PCV) I.       The highest elevation of the pigment epithelial detachment II.    Deep retinal hemorrhage, in the shape of dark red dot III. Sub-retinal hemorrhage (red and well demarcated)

D. Li et al.

IV.   Sub-retinal pigment epithelial (Sub-RPE) hemorrhage (black and well demarcated) V.    Intra-retinal exudates VI. The fovea

6  Choroidal Diseases

Fig. 6.11  Polypoidal choroidal vasculopathy (PCV) I.       Orange-red lesion II.    Sub-retinal hemorrhage III. Sub-retinal pigment epithelial (Sub-RPE) hemorrhage (black and well demarcated)

265

IV. Old sub-RPE hemorrhage (green grey) V.    Intra-retinal hard exudates

266

Fig. 6.12 PCV I.    Orange-red lesion II.  Massive Sub-retinal pigment epithelial (Sub-­ RPE) hemorrhage (black and well demarcated)

D. Li et al.

III. Sub-retinal hemorrhage IV. PED

6  Choroidal Diseases

Fig. 6.13  Choroidal hemangioma I. Choroidal hemangioma infra-temporal to the macula

267

II.    Exudative retinal detachment III. Hyperfluorescence of the tumor in fluorescein angiogram

268

Fig. 6.14  Choroidal hemangioma I.       The choroidal hemangioma was located at the superior temporal quadrant, with the macula involved II.    Sub-retinal exudative membrane at the surface of the hemangioma III. Macular edema

D. Li et al.

IV. Reactive pigment hyperplasia around the tumor edge

6  Choroidal Diseases

Fig. 6.15  Choroidal hemangioma I.    The reddish orange elevation beneath the retina II. Leakage at the margin of the hemangioma

269

III. Mottled pigment hyperplasia at the tumor edge IV. Dense laser spots (grade IV photocoagulation reaction)

270

Fig. 6.15 (continued)

D. Li et al.

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Fig. 6.16  Choroidal hemangioma before and after treatment I. Choroidal hemangioma inferior to the optic disk (before treatment)

271

II.    Choroidal hemangioma on the day of receiving laser treatment III. The hemangioma shrinked after laser treatment

272

Fig. 6.17  Post-treatment choroidal hemangioma I.    Pigment hyperplasia in the area after laser treatment II. The reddish orange untreated region of the tumor

D. Li et al.

III. Retinal detachment in the macula IV. The fibrous membrane on the optic disc

6  Choroidal Diseases

Fig. 6.18  Choroidal melanoma I.    The highly elevated tumor on inferior-­temporal blood arc II. Superficial pigment hyperplasia

273

III. Retinal detachment around the tumor IV. Punctuate depigmentation

274

Fig. 6.19  Choroidal melanoma I.    The highly elevated tumor at the nasal margin of the optic disk II. Superficial pigment hyperplasia

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III. Retinal detachment around the tumor IV. The optic disc

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Fig. 6.20  Choroidal tumor I. The round-like elevated tumor was located at the temporal side

275

II. Mottled pigment hyperplasia on the surface

276

Fig. 6.21  Choroidal tumor I. Sub-retinal elevation

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II. Peripheral retinal folds

6  Choroidal Diseases

Fig. 6.22  Metastatic choroidal carcinoma I. The grey-yellow elevation superior to the optic disk, with mottled pigment hyperplasia on the surface

277

II. Retinal detachment surrounding the lesion

278

Fig. 6.23  Choroidal osteoma I.    The lesion of choroidal osteoma temporal to papilla

D. Li et al.

II. Star-shaped exudates around the lesion III. Dilated veins

6  Choroidal Diseases

Fig. 6.24  Follow-up of choroidal osteoma I.    The highest elevation of choroidal osteoma; I-1 The choroidal osteoma demonstrated shrinkage and reduced elevation II. Dystrophy of retina and choroid; II-1 Enlargement of the dystrophy area and sclerosis of the choroidal vessels

279

III. The choroidal neovascular membrane (CNV); III-1 Scarring of the CNV IV. Pseudopod-like projections of the choroidal osteoma; IV-1 Slightly extension of the pseudopod-like projections

280

Fig. 6.24 (continued)

D. Li et al.

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Fig. 6.25  Hypertensive choroidal infarction I.    Depression of the delineated area and exposure of the large choroidal vessels II. Retinal arteries became thinning and straight

281

III. Retinal veins were dilated with A/V = 1:3–1:4 IV. The macula was located at the margin of the depression area

282

Fig. 6.26  Choroidal detachment I. Lobulated extrusion to vitreous cavity of detached choroid

D. Li et al.

II. Dilated retina veins

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Fig. 6.27  Choroidal coloboma I. Margin of surgical excision of choroid

283

II.    Exposed sclera with dotted pigments III. Located bleeding of the choroidal basin

284

Fig. 6.28  Congenital choroidal coloboma I.       Punctate scar, causing a tractional retinal fold II.    Sclera exposed III. Multiple large choroidal vessels

D. Li et al.

IV. Hyperpigmentation around the coloboma V.    Suspended infratemporal retinal artery

6  Choroidal Diseases

Fig. 6.29  Choroidal coloboma I.       Choroidal dystrophy and staphyloma change II.    Mottled pigment deposition, with large choroidal vessels being visible III. Suspended hyperpigmentation

285

IV. Arteries stretching over the coloboma V.    Occult vessels stretching into the coloboma, untraceable of its end proximate to the optic disk

286

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Fig. 6.30  Congenital choroidal coloboma I.    Large choroidal coloboma inferior to the optic disk, with the exposed sclera II. Suspended retinal vessels

III. Large choroidal vessels at the junction of the coloboma and normal retina IV. Hanging retinal vessels down to the coloboma V.    Mottled pigments at the margin of the coloboma

References

4. Kenneth GN.  Bilateral choroidal osteoma in three siblings. Am J Ophthalmol. 1990;109:656–00. 5. Yeh S-I, Chang W-C, Chien-Hsiu W, et al. Characteristics of peripapillary choroidal cavication detected by optic coherence tomography. Am J Ophthamol. 2013;120:544–22. 6. Augsburger JJ, Coats TD, Lauritzen K.  Localized suprachoroidal hematomas. Ophthalmoscopic features, fluorescein angiography and clinical course. Arch Ophthmol. 1990;108:868–72.

1. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Tyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 2. Gass JD.  Stereoscopic atlas of macular diseases: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997. 3. Gasperini J, Cunninghan ET, et al. How to recognize and treat choroidal folds. Rev Ophthalmol. 2006;4:11.

7

Fundus Changes After Vitreoretinal Surgery Hanyi Min, Erqian Wang, and Huan Chen

Vitreoretinal surgery mainly consists of scleral surgery (external-route) and pars plana vitrectomy. The former aims to relieve vitreoretinal traction or close retinal breaks through external scleral indentation buckling with silicone sponge, while the latter is used for vitreous opacities clearance, vitreoretinal traction relief, and retinal structure restoration by removing part or the whole vitreous through three ports via pars plana vitrectomy. Stereopsis is the foundation of vitreoretinal surgery [1–3]. During the scleral buckling surgery, the exact spot of intraocular lesions (i.e., retinal holes) on the sclera could be accurately located with the help of binocular indirect ophthalmoscope, thus a successful surgery could become possible. Similarly, fine stereopsis is needed to identify lesions such as hemor-

rhages, the position of the epiretinal membrane, the distance from the retina to the lesions, the exact position and its adjacent structures of blood vessels during vitrectomy. When the peripheral scleral compression is applied, it is necessary to identify the height of compression and the relative distance from the lens. Thus, the surgeon can decide whether to cut or to aspirate, or use auxiliary equipment such as forceps and/or scissors to complete the operation [3–5]. Vitreoretinal surgery is complicated, and a lot of practice or a long learning curve should be done before being an independent surgeon. By learning the following preoperative and postoperative stereo-grams, readers may better, more quickly, more deeply understand the diagnosis and surgical treatment of posterior segment surgery.

H. Min (*) · E. Wang · H. Chen Department of Ophthalmology, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, P.R. China © Springer Nature Singapore Pte Ltd. and People’s Medical Publishing House, PR of China 2020 H. Min (ed.), Stereo Atlas of Vitreoretinal Diseases, https://doi.org/10.1007/978-981-13-8399-1_7

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Fig. 7.1  RRD and scleral buckle I.    Retinal tear before operation II. Retinal tear after scleral buckle

H. Min et al.

III. The ridge of the buckle IV. Laser spots around the tear

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.2  Hole just on the scleral buckle I.    Retinal tear on the posterior edge of scleral buckle II. Scleral buckle

289

III. Laser spot around the tear IV. Vitreous band attached to the valve of retinal tear just on the scleral crest

290

Fig. 7.3  Postoperative changes of scleral buckling surgery I.    The ridge of scleral buckle II. The retinal tear

H. Min et al.

III. Retinal folds on the buckle IV. Incomplete reattachment of retina off the buckle

7  Fundus Changes After Vitreoretinal Surgery

291

Fig. 7.4  Retinal fold after scleral buckle I.    Retinal fold cross the ridge after scleral buckle II. Retinal hole made by vitrectomy tip

III. The ridge of buckle IV. Retinal degeneration zone

Fig. 7.5  Retinal slippage after scleral buckle I. Posterior retinal slippage with a retinal ridge

II. The direction of the retinal vessels change by the ridge

292

Fig. 7.6  Local retinal atrophy after cryotherapy combined with scleral buckling for rhegmatogenous retinal detachment I. The posterior boundary of scleral buckles

H. Min et al.

II.    Pigmentation on the buckles III. The sclera exposure due to the depigmentation after cryotherapy

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.7  Retinal detachment after scleral buckling surgery I.       The horse-shoe shaped retinal tear, with its inferior margin reattached to the buckle II.    The flap of the horse-shaped retinal hole III. The area of scleral buckle was encircled by red line

293

IV. A round retinal hole is discovered to be responsible for the incomplete retinal reattachment V.    Local retinal detachment after surgery (white line)

294

Fig. 7.8  Bulbar perforation due to post-bulbar anesthesia I.    The foci of choroidal perforation due to post-­bulbar anesthesia II. The retinal artery above the perforation

H. Min et al.

III. Corresponding retinal hemorrhage

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.9 Old subretinal hemorrhage after perforation of sclera and choroid I. The foci of choroidal perforation, with normal retina above

295

II. Yellow-white subretinal hemorrhage

296

Fig. 7.10  Fundus changes after removal of silicone sponge of scleral buckles I. Corresponding locations of scleral buckles before removal

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II.    Exposure of choroidal vessels III. The sclera

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.11  Choroidal detachment after intraocular surgery I. Choroidal detachment with folds of retina

297

II.    Kiss sign of choroidal detachment III. Local exudative retinal detachment

298

Fig. 7.12  Optic disk membrane after vitrectomy I.    Epiretinal membrane superior temporal to the optic disk II. Membrane on the optic disk

H. Min et al.

III. Distorted retinal vessels IV. Membrane covering the inferior temporal retinal vessels

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.13  Retinal folds after vitrectomy vitreoretinopathy I. The retinal folds, surrounding retinal vessels

299

for

Fig. 7.14  Tractional membrane after laser treatment

proliferative

II.    Subretinal membrane III. Subretinal hyperpigmentation

300

Fig. 7.15 Silicone oil-filled eye after vitrectomy for acute retinal necrosis syndrome I.    The pale optic disk II. Thinning of the macula

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III. Epiretinal membrane IV. Retinal necrosis foci V.    The margin of retinal necrosis at the inferior temporal quadrant

7  Fundus Changes After Vitreoretinal Surgery

Fig. 7.16  Silicone oil-filled eye after pars plana vitrectomy for choroidal melanoma I.       The sclera exposed after resection of the choroid II.    The margin of the remaining retina after choroid resection III. Epiretinal membrane stretching from lesion to the optic disk

301

IV. The subretinal membrane V.    The vessels on the optic disk were distorted by traction

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Fig. 7.17  Silicone oil-filled eye after vitrectomy I.    The reflection of silicone oil, located in front of the retina II. Large area of subretinal membrane and pigmentation

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III. Retinal depression at the non-proliferative area IV. Subretinal hemorrhage

7  Fundus Changes After Vitreoretinal Surgery

303

Fig. 7.18  Trans-retinal fibrosis due to massive operative hemorrhage I.    Epiretinal membrane with tortured vessels II. Massive subretinal fibrosis

III. Three retinal holes on the border of subretinal membrane IV.  Silicone oil reflex

References

3. Schachat AP, editor in-chief. Ryan’s retina. 6th ed. Edinburgh: Elsevier; 2018. 4. Gass JDM.  Stereo atlas of macular diseases: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997. 5. Williamson Thomas H.  Vitreoretinal surgery. 2nd ed. Berlin: Springer; 2013.

1. Tyleer ME. Stereo fundus photography: principles and techniques. In: Saine PJ, Fyler ME, editors. Ophthalmic photography: retinal photography, angiography, and electronic imaging. 2nd ed. Boston: Butterworth-Heinemann; 2002. p. 118–35. 2. Allen L.  Ocular fundus photography: suggestions for achieving consistently good pictures and instructions for stereoscopic photography. Am J Ophthalmol. 1964;57:13–28.