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Looking deep into retina : indirect ophthalmoscopy and fundus drawing
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Looking deep into retina : indirect ophthalmoscopy and fundus drawing

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advantages of indirect ophthalmoscopy, optical principle, fundus drawing

advantages of indirect ophthalmoscopy, optical principle, fundus drawing

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  • 1. Dr Prachir Agarwal Moderator : Dr Pradeep Kumar Panigrahi 3/6/2013
  • 2. • Indirect Ophthalmoscopy is essential for a detailed, panoramic and complete examination of the fundus CR Keeler, A Brief History of the Ophthalmoscope, Optometry in Practice ,Vol 4 (2003) :137-45. Introduction 1851 Direct Helmholtz 1852 Indirect Mono-ocular Independent light source Ruete 1861 Indirect Binocular Independent light source Giraud - Teulon 1951 Indirect Binocular Headmounted Integrated, clinically useful Charles Schepens
  • 3. Outline  Optical principle of Indirect Ophthalmoscopy  Comparison between different lenses used  Comparison of Direct and Indirect Ophthalmoscope  Advantages & Disadvantages of Indirect Ophthalmoscope  Technique of Indirect Ophthalmoscopy & Scleral Depression  Documentation of findings (THE FUNDUS DRAWING)
  • 4. Optics of Indirect Ophthalmoscopy  The technique is called Indirect because the fundus is seen through a condensing lens.  The image is formed close to the principle focus of the lens, between the lens and the observer
  • 5. If the retina could light up…. Emmetropic eye Image of retina on distant surface GTT 04 Fundamental Principle of the Indirect Ophthalmoscope
  • 6. Condensing lens Aerial image of retina Fundamental Principle of Indirect Ophthalmoscope GTT 04
  • 7. Viewing the aerial image with a magnifier GTT 04
  • 8. Image is Real and Inverted
  • 9. The power of the condensing lens determines: • Working distance • Magnification • Field of view Lens Power (D) Static Field of View* Magnification Working Distance from Cornea +14 22 4.17 72 mm +20 30 3.25 47 mm +30 40 1.97 26mm
  • 10. Comparison with Direct Ophthalmoscopy Retinal Detachment: Principles and Practice, Third Edition Daniel A. Brinton and C. P. Wilkinson
  • 11. Advantages of Indirect system • Image not affected by the patients refractive power • In children • In eyes with nystagmus • Delivery of LASER • Binocular examination of fundus up-to the periphery. • Large field of view allow for the panoramic view.
  • 12. • Better Resolution. • Use in operating room for cryo/scleral buckling. • Better view in presence of media opacities. • Increased illumination . • Reduced distortion. An additional advantage is that the doctor is at a distance from the patient.
  • 13. • Difficult to master. • Small movements alter significantly the size and clarity. • Inverted and reversed image. • Relative lack of magnification. Disadvantages
  • 14. Technique of Indirect ophthalmoscopy  Adjusting the instrument  Positioning of the patient  The examination proper & scleral indentation  The fundus drawing
  • 15. Adjustment of Eye piece, Head band
  • 16. IPD IPD knob
  • 17. Adequately adjusted IPD – at arms length Adjusting IPD
  • 18. Aperture setting
  • 19. Filter knob
  • 20. Rheostat
  • 21. Technique Ideal position of the ophthalmoscope  Axis perpendicular to the visual axis of examiner  The scope not resting on the nose of the examiner  The eyepiece as close to the examiners pupils as possible  Adequately adjusted IPD
  • 22. IDEAL POSITION Head flexed Head Extended Positioning the patient
  • 23. • Proprioception helps patient to look in cardinal gazes • Patient should be urged to keep the other eye open Examination Proper
  • 24. Holding the lens Pivot
  • 25. Scleral Depression Technique  Holding the depressor
  • 26. • A – Patient looks down, depressor on margin of sup tarsal plate • B – Depressor advanced into the orbit as patient looks up but no depression applied as yet • C – Scleral depression applied gently to area of interest Scleral Depression technique
  • 27. Critical in obtaining a binocular (stereoscopic) view Technique of indirect ophthalmoscopy
  • 28. Scleral Depression technique
  • 29. Video Presentation
  • 30. Fundus drawing-Amsler Dubois chart Junction of P Plicata & P Plana The Ora The Equator
  • 31. Fundus drawing
  • 32.  Tips for drawing  Disregard Sup/Inf and Temp/Nasal while drawing  What ever appears closer to the observer in the condensing lens is peripheral (anterior)  Observe the disc and follow a vessel to the periphery  Observe the macula at the end for best patient co- operation Fundus drawing
  • 33. Fundus drawing • Right Eye – Localized RD with HST at 11 clock and Lattice at 1 clock
  • 34. FUNDUS DRAWING Draw as you see the lesion in the condensing lens
  • 35. • Retinal arterioles • Neovascularization • Vascular anomalies • Attached retina • Vascular tumors FUNDUS DRAWING – RED SOLID
  • 36. • Hemorrhages ( Pre and retinal) • Open interior of retinal breaks (tears, holes) • Open interior of outer layer holes in retinoschisis • FUNDUS DRAWING – RED SOLID
  • 37. • Open portion of GRT or large dialyses • Inner portion of CRA • Inner portion of thin areas of retina • Open portion of retinal holes in inner layer of retinoschisis FUNDUS DRAWING- RED CROSSED
  • 38. • Detached retina • Retinal veins • Outlines of retinal breaks • Outlines of ora serrata FUNDUS DRAWING – BLUE SOLID
  • 39. FUNDUS DRAWING – BLUE SOLID • VR traction tuft • Outline of lattice degeneration (inner X) • Outline of thin area of Retina
  • 40. •Inner layer of retinoschisis •White with or without pressure (label) •Detached parsplana epithelium anterior to separation of ora serrata •Rolled edges of retinal tears / inverted flap in GRT (curved lines) FUNDUS DRAWING – BLUE CROSSLINES
  • 41. • Cystoid degeneration • Outline of change in area or folds of detached retina because of shifting fluid FUNDUS DRAWING BLUE CIRCLE/INTERRUPTED LINES
  • 42. • Opacities in the media • Vitreous hemorrhage • Vitreous membranes • Hyaloid ring • IOFB FUNDUS DRAWING- GREEN SOLID
  • 43. • Retinal operculum • Outline of elevated Neovascularisation • Vitreous Substitute – Silicone Oil, Gas FUNDUS DRAWING – GREEN SOLID
  • 44. • Asteroid hyalosis • Frosting or snowflakes on Retinoschisis or lattice degeneration FUNDUS DRAWING – GREEN DOTTED
  • 45. • Uveal tissue • Pigment beneath detached retina FUNDUS DRAWING – BROWN SOLID
  • 46. • Pigment epithelial Detachment • Choroidal melanomas • Nevus • Choroidal detachment FUNDUS DRAWING- BROWN SOLID
  • 47. • Edge of buckle beneath detached retina • Outline of Posterior Staphyloma FUNDUS DRAWING – BROWN OUTLINE
  • 48. • I/R, S/R hard exudate • S/R gliosis • Deposits in the RPE FUNDUS DRAWING – YELLOW SOLID
  • 49. • Post-PHC /cryo retinal edema • Substance of long & short ciliary N • Retinoblastoma Yellow – stippled- • Drusen Yellow Crossed • Chorioretinal coloboma FUNDUS DRAWING- YELLOW SOLID
  • 50. • Hyperpigmentation as a result of previous Rx with cryo/PHC/Diathermy • Completely Sheathed vessels • Pigment within detached retina (Lattice, HST) FUNDUS DRAWING- BLACK SOLID
  • 51. • Pigment within choroid or pigment epithelial hyperplasia within attached retina (e.g. RP) • Pigment demarcation line at margin of attached and detached retina FUNDUS DRAWING- BLACK SOLID
  • 52. • Edge of buckle beneath attached retina • Outline of CRA FUNDUS DRAWING – BLACK OUTLINE