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Opthalmoscopy
- 2. Why?
Ophthalmoscopy is performed:
Trauma around or of the eye itself
Routine diabetic check
As part of a neurological examination
Deteriorating vision
Symptoms associated with visual problems
Headaches
Dizziness
9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 2
- 3. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 3
The ophthalmoscope
Viewing
aperture
Lens
wheel
Lens
indicator
Rheostat
Mask dial
interposes
various sized
and shaped
masks, use
large for general
viewing
small for
fovea/macula
coloured filters
may also be
included
- 4. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 4
Holding the ophthalmoscope 1
Have the lens value(s) set to
“0”
Select a wide white light filter
Hold instrument in right hand,
held to right eye to look in
patient’s right eye
Hold the instrument with the
index finger resting on the
focusing wheel and the thumb
on the rheostat
Limit the brightness of the
beam using thumb - too bright
a beam is uncomfortable
- 5. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 5
Preliminaries
Explain the procedure to the
patient
Inspect the external eye for any
abnormalities
Use a mydriatic or dim the lights
to dilate the pupils
Ask the person to fix their gaze
on a distant object
Place your free hand on the
forehead of the patient - this
sets the distance from which to
approach and avoids clashes of
head as you get nearer. Also
the thumb can be used to hold
the upper eyelid open
- 6. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 6
Holding the ophthalmoscope 2
The instrument MUST be
held close to the examiner’s
eye nestled against the
supraorbital ridge or against
glasses if worn
Look through the aperture
with one eye and close the
other, or leave open if you
prefer
- 7. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 7
Direction of approach
Use the viewing eye to
direct the beam of light onto
the patient’s eye from 0.5 - 1
metre (arms length)
Approach from an angle of
15-20° to the line of gaze
Approach on the same level
as the equator of the
patient’s eye
This approach directs the
beam towards the optic disc,
an important landmark
Fixed gaze
Angle of
approach
Optic disc
- 8. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 8
15 to 20 degrees from point of gaze
Your eyes should be at
the same level as the
patients
Ophthalmoscope light beam
- 9. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 9
Ophthalmoscopy
Note the appearance of
the external eye
structures
Note the red reflex -
use this to guide you in
closer to the pupil
When close to the eye,
use the focusing wheel
to fine tune your focus
on the retinal structures
- 10. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 10
Correct approach should bring you
on or near to the optic disc
Patient’s
right eye
Patient’s
left eye
Superior nasal
Inferior nasal
Superior temporal
Inferior temporal
Superior temporal
Inferior temporal
- 11. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 11
The view of retina
The circled area opposite
shows the likely area that is
illuminated on first
visualising the retina
To view the rest of the
structures move the area of
illumination by adjusting
head-eye-instrument
inclination
If you still have difficulty
seeing structures, try and
find a blood vessel and turn
the focus wheel until the
lines of the vessel become
clear
LEFT
MEDIAL LATERAL
- 12. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 12
Examination of the vessels
Once a vessel is found
you should follow the
length of the vessel as far
as possible to look for
abnormalities
Vessels branch into the
four quadrants of the eye:
superior nasal and
temporal and inferior
nasal and temporal.
The quadrants can be
used to describe where
an abnormality lies
Inferior Nasal Inferior Temporal
Superior TemporalSuperior Nasal
Optic Disk
LEFT EYE
- 13. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 13
The retinal vessels
If you miss or lose the optic
disc: any branching of vessels
form a “V”, the point of the “V”
always points towards the
optic disc
The main vessels branch out
in four directions (see arrows)
Veins are uniform and
burgundy in colour
Arteries have a central pale
line and two outer red walls
- 14. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 14
The macula
The macula is lateral
to the optic disc (about
11/2 disc diameters
away)
Few blood vessels are
seen here
To view the macula
move your light beam
in the direction of the
temples
- 15. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 15
Viewing the fovea
The fovea is a depression in
the centre of the macula and is
the point of central vision, with
maximum concentration of
cones.
This is best viewed at the end
of the examination
Reduce the intensity of the
light and ask the person to look
directly into the light
Now examine the other eye,
remember to swap
ophthalmoscope to the other
hand
- 16. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 16
The retina - what to note
Optic disc
Sharpness
Colour
Optic cup
appearance
Arteries and veins
tortuous or straight
width and colour
the light reflex along
the arterioles
appearance of the
AV crossing
Peripheral fundus
follow each of the 4 main
retinal vessels out for 3-4
disc diameters
haemorrhages
exudates
choroidal changes
scarring
new vessel formation
Culturally based variability in the
colour of the iris and in retinal
pigmentation = darker irises are
correlated with darker retinas.
- 17. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 17
Ophthalmoscopy - summary
Introduce yourself
Explain procedure
Wash hands
Check identity of patient
Gain informed consent
Ask subject to fix vision on
distant object
Dim lights, warn patient
you will be close to the face
Hold instrument to eye with
index finger on lens dial
Approach from shallow
angle (15-20 degrees)
Approach on the same
level as the equator of
subject’s eye
Note & comment on red
reflex
Note & comment on
anterior structures of the
eye
Focus on retina and
Identify optic disc
Follow blood vessels into 4
quadrants
observe macula and fovea