NeurologyTier 2Topic

Fundoscopy

What it shows

Direct visualisation of the optic disc, retina, macula, and retinal vasculature - a core neurological examination for raised intracranial pressure, optic nerve pathology, and vascular disease
Routine in any patient with headache, visual disturbance, suspected raised ICP, diabetes, or hypertension

Findings

Finding	Significance
Papilloedema	Bilateral disc swelling from raised ICP - blurred margins, venous engorgement, loss of venous pulsation
Optic disc pallor	Optic atrophy - prior optic neuritis, compression, ischaemia, toxic/nutritional optic neuropathy
Unilateral, painful disc swelling	Optic neuritis (vs papilloedema - usually bilateral, painless)
Flame haemorrhages, cotton wool spots	Hypertensive or diabetic retinopathy
Cherry red spot	Central retinal artery occlusion

Interpretation

Papilloedema vs optic neuritis - papilloedema is usually bilateral and painless with preserved acuity early; optic neuritis is usually unilateral, painful with eye movement, with early visual loss and a relative afferent pupillary defect (RAPD)
Venous pulsations present -> ICP likely normal; their absence is not specific but their presence is reassuring

Acting on findings

Papilloedema -> urgent neuroimaging +/- lumbar puncture (opening pressure) to identify the cause of raised ICP
Optic neuritis -> MRI brain/orbits (demyelination workup - MS risk), consider high-dose corticosteroids for visual recovery (does not alter long-term MS risk)

Associations

Idiopathic intracranial hypertension, space-occupying lesions, malignant hypertension, multiple sclerosis, giant cell arteritis (AION)

Chronic papilloedema

Chronic untreated papilloedema -> progressive, potentially irreversible optic atrophy and visual loss

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