It is an instrument about the size of a small
flashlight with several lenses that can
magnify up to about 15 times.
This type of ophthalmoscope is most
commonly used during a routine physical
An indirect ophthalmoscope constitutes a light
attached to a headband, in addition to a small
handheld lens. It provides a wider view of the
inside of the eye. Furthermore, it allows a
better view of the fundus of the eye, even if the
lens is clouded by cataracts.
An indirect ophthalmoscope can be either
monocular or binocular
Establish good Doctor- Patient relationship.
Take his permission.
Explain what are you going to do and why.
Examine the eye generally by inspection for
any obvious abnormalities like ptosis,
exophthalmous, conjunctivitis, scleritis,
swellings or ptyrigium which can
mechanically impairs the direct
Shine torsh light to both eyes to look for the
red reflex so to exclude cataract which may
impairs the procedure.
Inspect the size of the pupils.
If it is small you need to darken the room,
if this fails to dilate the pupil sufficiently,
then use mydriatic, for example ,
mydrilate(1% cyclopentolate), can be
installed. This should never be done in the
unconscious patient and must always be
recorded in the patient notes.
Do not use mydriatics in a patient with glaucoma.
Rememberto revese the effect of medriatic at the
end of the examination by installing 2%
Ask the patient to fixate on a distant target.
If the patient wears glasses with a substantial
correction, It some times facilitate the
examination to perform it with the patients
glasses in place.
The optic disc is examined to assess its
shape, colour and clarity.
The temporal margin of the disc is slightly
paler than the nasal margin. The
physiological cup varies in size but seldom
extends to the temporal and never to the
nasal margins of the disc.
The blood vessels are not obscured as they
cross the disc , nor they are elevated.
The vessels are examined next, the arteries
are narrower than the veins and a brighter
They posses a longitudinal pale streak as a
consequence of light reflecting from their
The retinal veins should be closely inspected
where they enter the optic disc.
In approximately 80% of individuals the veins
pulsate. This pulsation ceases when CSF
pressure increase, therefore the presence of
this retinal venous pulsation is very sensitive
index of normal intracranial pressure.
The fundus is examined for the presence of
haemorrhage or exudates, the position of
which are best shown by a diagram in the
It is useful to characterize the changes in
the optic nerve head that occur in
papilledema as being mechanical or
vascular in nature.
1. Blurring of the optic disc margins
2. Filling-in of the optic disc cup
3. Anterior extension of the nerve head (3D
= 1mm of elevation)
4. Edema of the nerve fiber layer
5. Retinal and/or choroidal folds.
1. Venous congestion of arcuate and peripapillary
2. Papillary and retinal peripapillary hemorrhages
3. Nerve fiber layer infarcts (cotton-wool spots)
4. Hyperemia of the optic nerve head
5. Hard exudates of the optic disc
Papilledema is classified as:
B. Fully developed
2- Disc swelling
3-Blurring of the disc margins
4-Blurring of the nerve fiber layer
Fully developed papilledema:
1.Gross elevation of the optic nerve head
2. Engorged and dusky veins appear.
3. Peripapillary splinter hemorrhages and sometimes
choroidal folds arise
4. Retina striae
In chronic papilledema:
1. Fewer hemorrhages occur.
2. The optic disc cup is obliterated completely.
3. Less disc hyperemia is seen.
4. Hard exudates occur within the nerve head.
5. Optociliary shunts can start showing.
In late disc edema:
1-Secondary optic atrophy occurs
2-Disc swelling subsides
3-Retinal arterioles are narrowed or sheathed
4-The optic disc appears dirty gray and blurred,
secondary to gliosis
5-Retinochoroidal vein shunts(or Optociliary) may be
Brief transient obscurations of vision.
Less commonly, blurred vision, constriction of
visual fields, dyschromatopsia, and/or diplopia.
Cause for concern exists if the headache is
particularly severe or associated with nausea and
vomiting or a sense of pressure around the ears.
Age related macular degeneration (AMD) is one of the most common
causes of poor vision after age 60.
The specific cause is unknown, AMD seems to be part of aging.
Age is the most significant risk factor for developing AMD.
Heredity, blue eyes, high blood pressure, cardiovascular disease,
and smoking have also been identified as risk factors.
AMD accounts for 90 percent of new legal blindness in the US.
Nine out of 10 people have dry AMD which
results in thinning of the macula.
Dry AMD takes many years to develop.
Currently no treatment
The wet form of AMD occurs much less
frequently (one out of 10 people) but is more
In the meantime, high-intensity reading
lamps, magnifiers and other low-vision aids
help people with AMD make the most of
is the loss of some or most of the fibers of
the optic nerve.
loss of vision , colour vision.
Optic atrophy can be congenital or acquired
anterior ischemic optic neuropathy or
posterior ischemic optic neuropathy.
diabetes mellitus, trauma, glaucoma, or
toxicity (caused by methanol, tobacco, or
It is also seen in vitamin B12 deficiency and
Paget's disease of the bone.
Toxoplasmosis is a common parasitic
infection. When contracted by a pregnant
woman, toxoplasmosis can pose serious risks
to the unborn baby.
Simple precautions can reduce the chance of
Pregnant women should avoid handling litter
boxes and eating raw meat because the
parasite may originate in cat feces or
If acquired during the first trimester of
pregnancy, the infection can be devastating
to an infant.
Central retinal vein occlusion (CRVO) blocks the main vein in
The blockage causes macular oedema, vision becomes
Floaters due to blood in the vitreous.
Retinal vein occlusions commonly occur with glaucoma,
diabetes, age-related vascular disease, high blood pressure,
and blood disorders.
CRAO usually occurs in people between the ages of 50 and 70.
The most common medical problem associated with CRAO is
Carotid artery disease is found in almost half of the people with
The most common cause of CRAO is a thrombosis. Sometimes
CRAO is caused by an embolus.
Central retinal artery occlusion (CRAO) blocks the central artery
in retina, the ligh.
The first sign of CRAO is a sudden and painless loss of vision.
Loss of vision can be permanent without immediate
Irreversible retinal damage occurs after 90
minutes, but even 24 hours after symptoms begin,
vision may still rarely be saved.
The goal of emergency treatment is to restore
retinal blood flow
Microaneurysms: these are usually the earliest visible change in retinopathy
seen on exam with an ophthalmoscope as scattered red spots in the retina where
tiny, weakened blood vessels have ballooned out.
Hemorrhages: bleeding occurs from damaged blood vessels into the retinal
layers. This will not affect vision unless the bleeding occurs in or near the
Hard Exudates: caused by proteins and lipids from the blood leaking into the
retina through damaged blood vessels. They appear on the ophthalmoscope as
hard white or yellow areas, sometimes in a ringlike structure around leaking
capillaries. Again vision is not affected unless the macula is involved.
◦ Arteriolar narrowing that is almost always
Grade I - 3/4 normal caliber
Grade II - 1/2 normal caliber
Grade III - 1/3 normal caliber
Grade IV - thread-like or invisible
◦ Arterio-venous crossing changes (aka "AV
nicking") with venous constriction and banking
◦ Arteriolar color changes
Copper wire arterioles are those arterioles in
which the central light reflex occupies most
of the width of the arteriole.
Silver wire arterioles are those arterioles in
which the central light reflex occupies all of
the width of the arteriole.
◦ Vessel sclerosis.
Ischemic changes (e.g. "cotton wool spots")
Hemorrhages, often flame shaped.
◦ Ring of exudates around the retina called a "macular
Papilledema, or optic disc edema, in patients with
Visual acuity loss, typically due to macular involvement
A 23 year old man had had intermittent
odourless discharge from his right ear for two
years since experiencing sudden earache
while diving on holiday.
He felt he was deaf in that ear and had
recently noticed some high pitched tinnitus
on the right, although his ear was currently
What does otoscopy of his right tympanic
There is a perforation of the posterosuperior
quadrant of the tympanic membrane.
No cholesteatoma is visible, and the intact
long process of the incus and stapes head
can be seen through the perforation
A 5 year old girl had multiple attacks of otitis
media, was falling behind in her schoolwork,
and was mispronouncing words. Her teacher
felt she was not paying attention in class and
her parents noticed that she turned up the
television volume to unacceptably loud levels.
The picture above shows the otoscopic
appearances. What is the likely diagnosis?
The tympanic membrane is intact but is dull
and a golden colour.
This child has otitis media with effusion (glue
ear). If this is persistent she may benefit from
the insertion of ventilation tubes (grommets
A 28 year old woman had put up with an
intermittent foul smelling discharge from her
ear for over 10 years.
Topical antibiotics controlled her symptoms
for only a few weeks. She had suddenly
become very deaf in the affected ear and had
asked for a specialist opinion. What do the
otoscopic findings suggest?
There is a large mass of infected squamous
epithelium and keratin behind the pars
flaccida - a cholesteatoma.
This can cause infective complications such
as meningitis and may erode into the
labyrinth or facial nerve.
The cholesteatoma therefore needs to be
The operation entails exploring the mastoid
to identify the fundus of the sac, removing
the disease, and grafting the surgical defect.