Step 1.
Open the photo. Change the colour of the photo (press Ctrl+U and use the following settings: Colorize->ON, Hue->128, Saturation->32, Lightness->-14).
Step 2.
Now you have to create "scan lines": create a new 4X2 pixels document and set the Zoom Slider on 1600%. Paint the upper pixels by black and the lower pixels by white colours. Press Ctrl+A and apply Edit > Define Pattern.
Step 3.
Now go to your photo and create a new layer. Press Ctrl+A and fill the photo by your pattern. Set the Opacity->20% and press Ctrl+E.
Step 4.
Choose the Elliptical Marquee Tool and make the round selection. Drag this selection in a new document with the black background. In my case I added some effects. And that's it.
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