An important instrument in every day job of critical ill patients . This work shop has been performed to help clinicians to understand how to deal with direct ophthalmoscope and organize diagnostic and life saving fundoscopy findings .

1. THE APPROACH TO THE
DIRECT
OPHTHALMOSCOPE
AND
FUNDUSCOPY
Prepared by : Azah Mukhtar Affat
MMC,MICU
05/4/2018

2. • The RETINA is the only portion of the
central nervous system visible from the
exterior.
• Likewise the fundus is the only location
where vasculature can be visualized. So
much of what we see in internal medicine
is vascular related and so viewing the
FUNDUS is a great way to get a sense
for the patient's overall vasculature.

3. • The direct ophthalmoscope is an
extremely important examination tool
not only for ophthalmologists but for
physicians as well.
• Life and Sight threatened conditions
can be diagnosed with opthalmoscope

4. OBJECTIVES :
• INSTRUMENT DETAILS
• TECHNIQUE OF DIRECT OPHTHALMOSCOPE
• NORMAL AND IMPORTANT ABNORMAL
FUNDUSCOPY

5. • Direct Fundoscopy :
• Produce an upright, or
unreversed , imege of
approximately 15 times
magnification
• Indirect fundoscopy
• Produce an inverted , or
reversed, direct imege
of 2 to 5 times
magnification .

6. • Currently, the ophthalmoscope comes in
various sizes and modifications though all
follow the same optical principle.

9. • Light intensity adjustment dial: This helps
provide an illumination of variable intensity
for eliminating the corneal reflex and patient
comfort

12. • Small spot
• It is used for a small pupil. It also helps decrease
corneal reflexes and increases patient comfort.
• Large spot
• For dialated pupil
• Macular spot/pinhole
• This provides a small spot to observe only the
fovea/macula without any undue light
and enabling viewing through a 1-2mm pupil.

13. • Hemi-spot
• Reduces corneal reflex and provides retinal
depth perception.
• Slit
• Accurate assessment of retinal elevations and
depressions. Assessment of anterior chamber
depth.
• Cobalt blue spot
• Examination of corneal abrasions and scarring

14. • Fixation star (with polar coordinates)
• Accurate eccentric fixation testing, disc
assessment and retinal mapping.
• Red free filter
• This may be combined with all filters.
• For better visualization of blood vessels,
hemorrhages and nerve fibre layer

15. • They help focus the image onto the observers
retina. Need to be selected based on the
subjects refractive status and distance at
which ophthalmoscopy is done.

17. • A trick to decide the appropriate selection of the
condensing lens
• . Observe the light reflex on the retinal vessels. If a
white line is seen then either the patient is
emmtropic or hyperopic. In that case, add plus lens
and the highest plus when the line reflex disappears
is the appropriate power
• . If there is no line of light reflex on the vessels, then
the patient is myopic. Add minus power and the
smallest minus lens when the reflex appears is the
refractive error of the patient.

19. • Glasses should be removed unless the
patient is highly astigmatic or the
observer is highly myopic.

20. • EXAMINATION ENVIRONMENT :
• Patient should be seated comfortably
• Room light should be dimmed
• Pupil should be dialated with medriatic drop
e,g ( Tropicamide 1.0% )

21. • Right eye should be used to view the patient’s
right eye and vice versa.
• They should keep their opposite hand on the
patient’s forehead to support and steady it .
• The examiner should keep both their eyes open
during examination and imagine as if the retina
is at 6 meters to prevent accommodation .

22. • Use focus wheel , look at an object 10
feet away and make sure it is in focus .
• Have the patient focus on a point at a
distance .

23. STEPS :
• The FIRST STEP in the use of an
ophthalmoscope is to do examination at 1m
distance.
• Check the RED reflex

25. • This should be followed by a distant direct
examination at 22-25cm( a comfortable near
vision distance).
• If the examination is done at 10cm, we should
select a +10D condensing lens to view the best
glow. At 25 cm, a +4D lens may be used .

26. • The patient may then be asked to look in the
four cardinal gazes and the movement of the
opacity noted.
• Movement against the ocular movement
means the opacity is behind the nodal point of
the eye (i.e. in the lens or vitreous) while a
movement with would indicate corneal or
anterior segment opacity.

27. • The third step involves moving closer to the
patient and correspondingly increasing the
power in the condensing lens to examine in
detail the magnified anterior segment
structures.
• The fourth step entails reducing the
condensing lens power such that any part of
the retina comes into focus.

28. • While reducing the power, the vitreous cavity will come into
focus and any pathology in it may be seen .
• Once the retina is focused, we may localize any blood vessel
and follow it backwards against the branching pattern to
reach the optic disc. Then move temporally from the disc to
reach the macula. We can ask the patient to look into the
light and the fovea will come into focus. The blood vessels
can be traced into the periphery from the disc to reach
second and third order vessels. This completes the posterior
pole examination to examine the periphery, we ask the
patient to look in the four cardinal gazes while continuing to
focus the retina.

29. NORMAL FUNDUSCOPY

30. Normal fundus :

31. PAPILLOEDEMA :
• Swelling of th optic nerve head , secondary to
raised intracranial pressure; nearly always
bilateral although may be asymmetrical .

38. OPTIC DISC CUPPING :
• Rfers to increase in CDR , Often due to
glaucoma .

41. RETINAL HAEMORRAGE :

46. COTTON WOOL SPOTS :
• Fluffy white patches
• Retinal nerve fiber layers microinfarcts
• Classically seen in Diabetes and Hypertension

49. CENTRAL RETINAL ARTERY
OCCLUSION (CROA)
• Pale fundus with “ cherry red spot” in macula .
• Appears hours after the blockage of central
retinal artery.
• Sudden , profound loss of vision

51. CENTRAL RETINAL VEIN
OCCLUSION
(CRVO)
• Severe tortuosity and dialatation of all
branches of central retinal vein .
• Extensive dot-blot and flame shaped
haemorrhage, and variable cotton wool spots.

53. HYPERTENSIVE RETINOPATHY :
• 1. VASOCONSTRICTION : focal or generalized
• 2. ISCHEMIA : cotton-wool spots.
• 3. LEAKAGE:
– Flame shaped hg and oedema
– Hard exudates with a macular star
configuration and disc swelling in malignant
HTN .

56. Non- Proliferative diabetic Retinopathy
(NPDR)
• First stage of Diabetic retinopathy .
• Microaneurysm and narrowing of blood
vessels , hard exudates, and macular oedema
are the typical findings .
• Vision is usually not affected.

59. Proliferative Diabetic Retinopathy
(PDR)
• Advanced stage of Diabetic Retinopathy.
• Neovascularization is the hall mark .
• Cotton wool spots and haemorrhage also
appear .

62. OPTIC ATROPHY :
• Optic atrophy refers to the death of the retinal
ganglion cell axons
• Signs :
– PRIMARY : pale , flat disc with clearly delineated
margins .
– SECONDARY : white or dirty grey , slighty raised
disc with poorly delineated margin .

63. Optic atrophy :

65. • Using the direct ophthalmoscope
can be challenged at first BUT with
practice it would become an essential
diagnostic tool for physicians