Fundus examination

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A precise fundamental lesson on examination of fundus

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Fundus examination

  1. 1. RAJVIN SAMUEL PONRAJ
  2. 2. <ul><li>APPERANCE : Uniform red </li></ul><ul><li>Punctate stippling-periphery </li></ul><ul><li>Varies-color of individual </li></ul><ul><li>Normal choroidal vessels </li></ul><ul><li>- Invisible </li></ul><ul><li>PARTS : DISC </li></ul><ul><ul><ul><ul><ul><li>VESSELS </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> MACULA </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> PERIPHERY </li></ul></ul></ul></ul></ul>
  3. 4. <ul><li>ORA SERRATA – Junction between </li></ul><ul><li>peripheral retina and pars </li></ul><ul><li>plana </li></ul><ul><li>CONTENTS - DENTATE PROCESSES </li></ul><ul><li>ORAL BAYS </li></ul><ul><li>NORMAL VARIANTS : Meridoneal fold </li></ul><ul><li>enclosed bay </li></ul><ul><li>microcystic degeneration </li></ul><ul><li>granulation tissue </li></ul>
  4. 7. LAMINA CRIBROSA NEURORETINAL RIM
  5. 8. DISC: LOCATION –nasal to geometric axis DIAMETER – 1.5mm [1 disc diameter] COLOR – Pale pink SHAPE – Circular EDGES – Regular TERMINATION OF ALL LAYERS EXCEPT NFL CUP: C/D ratio – 0.3 to 0.5
  6. 9. <ul><li>RETINAL SYSTEM : </li></ul><ul><li>CENTRAL RETINAL ARTERY </li></ul><ul><li>AND </li></ul><ul><li>CENTRAL RETINAL VEIN </li></ul><ul><li> 4 major branches </li></ul><ul><li> Arterioles </li></ul><ul><li> Venules </li></ul><ul><li> Capillaries </li></ul><ul><li>CILIARY SYSTEM : POST.CILIARY ARTERIES </li></ul><ul><li> Choriocapillaries </li></ul>
  7. 11. <ul><li>Specialised region of retina </li></ul><ul><li>Diameter – 5.5 mm </li></ul><ul><li>Location – 2 DD - temporal margin of disc </li></ul><ul><li>Color – Yellow; deep pigmented </li></ul><ul><li>4 zones : Foveola -0.35 mm </li></ul><ul><ul><li>Fovea -1.50 m </li></ul></ul><ul><ul><li>Parafovea </li></ul></ul><ul><ul><li>Perifovea </li></ul></ul><ul><li>Retinal vessels </li></ul><ul><li>Cilioretinal artery </li></ul><ul><li> </li></ul>
  8. 12. <ul><li>Fovea - Thin bottom </li></ul><ul><li>thick basement margin </li></ul><ul><li>- prone for macular holes </li></ul><ul><li>-Henle’s layer-oblique cones </li></ul><ul><li>Foveola - Thin pit , Densely cones </li></ul><ul><li>Bowing vitreally- fovea externa </li></ul><ul><li>Umbo - Tiny depression - Foveal light reflex </li></ul><ul><li>bouquet of cones - narrowed </li></ul><ul><li>gateau nucleaire </li></ul>
  9. 13. <ul><li>Posterior pole – loss of foveal light reflex </li></ul><ul><li>drusen </li></ul><ul><li>Retinal vessels – narrowing, increased light reflex </li></ul><ul><li>Equator - chorio , reticular pigmentary degeneration </li></ul><ul><li>Vitreous - liquefaction , floaters ,.. </li></ul>
  10. 14. <ul><li>Why it is performed: </li></ul><ul><li>It can detect some signs & physiological effects of various circulatory, metabolic and neurological disorders. </li></ul><ul><li>Routinely used to assess and diagnose vitro-retinal diseases (such as Diabetic retinopathy, retinal tear and detachment, macular hole, retinal haemorrhage, retinal artery and vein occlusion, choroidal tumor, or macular edema), optic nerve defects, and hereditary diseases. </li></ul>
  11. 15. <ul><li>Fundus examination is used to: </li></ul><ul><li>Identify and locate vitro-retinal and optical nerve defects caused by eye diseases or trauma. </li></ul><ul><li>Examine the extent of the defects or abnormalities to plan a proper treatment. </li></ul><ul><li>Evaluate the success of treatment . </li></ul>
  12. 16. <ul><li>Combination of phenylephrine [2.5 %] & </li></ul><ul><li>tropicamide [1 %] </li></ul><ul><li>then eyes closed </li></ul><ul><li>Dilation attained = 45 min </li></ul><ul><li>Normal reactivity = 4 - 8 hrs </li></ul><ul><li>Conditions which to avoid : iris supported lens </li></ul><ul><li>shallow AC </li></ul><ul><li>Head injury </li></ul>
  13. 18. <ul><li>- retinal arterioles - exudate </li></ul><ul><li>retinal haemorrhage edema </li></ul><ul><li>microaneurysm </li></ul><ul><li>attached retina - vitreous opacity </li></ul><ul><li>hole /break vitreous bleed </li></ul><ul><li>- Retinal venules - pigmentation </li></ul><ul><li>detached retina detached choroid </li></ul><ul><li>outine of break </li></ul><ul><li>- ora serrata /drusen </li></ul><ul><li>hyperpigmentation </li></ul>
  14. 19. <ul><li>Vitreoretinal chart Optic Disc drawing </li></ul>
  15. 20. METHODS OF EXAMINATION <ul><li>DIRECT OPHTHALMOSCOPY </li></ul><ul><li>INDIRECT OPHTHALMOSCOPY </li></ul><ul><li>INDIRECT SLIT LAMP BIOMICROSCOPY </li></ul>
  16. 21. D IRECT OPHTHALMOSCOPY
  17. 22. <ul><li>An erect upright virtual image </li></ul><ul><li>Magnification = 15 x </li></ul><ul><li>Field of view = 5 degrees </li></ul><ul><li>Optimal working distance upto 2-3 cms </li></ul><ul><li>No stereoscopic view </li></ul><ul><li>Several plus and minus dial up lenses </li></ul><ul><li>Structures - optic nerve, blood vessels of posterior pole </li></ul><ul><li>fovea </li></ul><ul><li>Viewing aperture contains illumination openings </li></ul><ul><li>1. spots 4.fixation target </li></ul><ul><li>2.streak projection 5. calibration grid </li></ul><ul><li>3.Red free filter </li></ul>
  18. 23. <ul><li>Evaluating fundus : </li></ul>
  19. 25. Indirect ophthalmoscopy
  20. 26. <ul><li>An inverted reverse real image </li></ul><ul><li>Magnification = 2 to 4 X </li></ul><ul><li>Field of view = 40 to 50 degrees </li></ul><ul><li>Optimal working distance = 40 to 50 cms </li></ul><ul><li>Good illumination & stereopsis </li></ul><ul><li>Ease of use with scleral indentor </li></ul><ul><li>Lenses from 14 to 30 D range </li></ul><ul><li>Positioning of patient </li></ul>
  21. 27. <ul><li>Head set adjustment </li></ul><ul><li>Eye piece adjustment </li></ul><ul><li>Light beam adjustment </li></ul><ul><li>Choosing ,positioning and technique to hold condensing lens. </li></ul>
  22. 29. <ul><li>12 ‘0’ Clock meridian towards patient’ feet and transforming the image rotated 1 80 degrees . </li></ul><ul><li>Follow vessels and bifurcations in each quadrant then with scleral indentation terminal branches. </li></ul><ul><li>Ora serrata then fundal lesions with relations . </li></ul>
  23. 30. <ul><li>Field of view is proportional to power of lens but inverse of magnification </li></ul><ul><li>Hence wider field will have less magnification with higher powered lenses. </li></ul><ul><li>Higher power lenses used in small pupils, peripheral fundus view. </li></ul>
  24. 32. <ul><li>-Thimble scleral </li></ul><ul><li>depressor </li></ul><ul><li>Pencil type depressor </li></ul><ul><li>Cotton tipped applicator </li></ul>To examine periphery between equator and ora serrata by creating a mound to view. Start superonasal superior ,superotemporal, Inferotemporal, inferior, inferonasal
  25. 35. <ul><li>An inverse real reversed image with hand held lenses </li></ul><ul><li>Field of view = 30 to 40 degrees </li></ul><ul><li>Lens power = + 78 or + 90 D , other lenses= + 60 to 132 D </li></ul><ul><li>Magnifying knob to 10 X or 16 X </li></ul><ul><li>Drawing the slit lamp biomicroscopic view: </li></ul><ul><li>Done on an inverted fundus chart and paper is turned as patients gaze direction changes in respective clock hour meridian. </li></ul>
  26. 36. <ul><li>Performing indirect slit lamp biomicroscopy </li></ul><ul><li>Evaluating fundus : </li></ul>
  27. 38. <ul><li>A plano concave non –contact lens </li></ul><ul><li>High minus power [-55 D] </li></ul><ul><li>Virtual erect image </li></ul><ul><li>To visualize - optic cupping , peri papillary changes </li></ul><ul><li>- Nerve fibre layer thickness [red free filter] </li></ul><ul><li>- Macular lesion level [slit beam side way </li></ul><ul><li>movement] </li></ul><ul><li>[watzke Allen test] </li></ul><ul><li>- Vitreous opacities, strands. </li></ul>
  28. 40. <ul><li>Concavo plano contact lens - virtual , erect image </li></ul><ul><li>Combines stereopsis, high illumination, high magnification [ 10 x] , 20 degree field,.. </li></ul><ul><li>Flat central portion – posterior vitreous and pole </li></ul><ul><li>Angled mirror - 73 deg - area around posterior pole </li></ul><ul><li>67 deg - equatorial fundus </li></ul><ul><li>59 deg - peripheral retina </li></ul><ul><li>Eliminates total internal reflection by replacement with cornea – goldmann contact lens interface. </li></ul>
  29. 42. Provides wide field 130 degree and high power lens A real inverted magnified image is formed It is used in both posterior fundus examination and also Laser pan retinal photo Coagulation.
  30. 43. <ul><li>THANK YOU </li></ul>

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