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  1. 1. What is funduscopy? And… Why is it important to you?
  2. 2. Web sites of interest: Welch Alleyn   go to “optometry student” menu drop down Red Atlas 
  3. 3. Review of ocular anatomy
  4. 4. Retinal Layers
  5. 5. Optic Nerve Anatomy
  6. 6. Choroidal Vessels
  7. 7. Funduscopy Techniques/instruments Direct Ophthalmoscopy Indirect Ophthalmoscopy Fundus Biomicroscopy Fundus Contact Lens
  8. 8. Why do we dilate pupils?
  9. 9. Direct Ophthalmoscopy Advantages      Portable Easy to use Upright image Magnification 15x Can use w/o dilation Disadvantages    Small field of view Lack of stereopsis Media opacities can degrade image
  10. 10. PanOptic Ophthalmoscope Manufacturer: Welch Allyn Increased field of view & mag Increased working distance Hand held but less portable
  11. 11. Indirect Ophthalmoscopy Monocular or binocular Advantages:   Wide field of view Binocular instruments provide stereopsis Disadvantages:     Requires more skill Decreased magnification (3x) Requires dilation Inverted image
  12. 12. Indirect Ophthalmoscopy
  13. 13. Fundus Biomicroscopy Field of View & Mag:   FOV <indirect but >direct varies w/lens & slit lamp mag Inverted image Stereopsis Dilated pupil Requires skill
  14. 14. Fundus Biomicroscopy
  15. 15. Fundus Contact Lens Requires physical contact w/eye Viewed w/Biomicroscope Advanced dx & surgery Field of view & Mag vary w/lens design
  16. 16. Direct Ophthalmoscopy: Basic skills Optics:   Illumination system Magnifier    Hyperopes myopes Observation system   Lens wheel Apertures
  17. 17. Direct Ophthalmoscopy: Basic skills Viewing ocular media   Observe red reflex Look for media opacities    Cataracts Corneal scars Large floaters
  18. 18. Direct Ophthalmoscopy: Basic skills Proper position for central fundus viewing Right eye to right eye Left eye to left eye Don’t rub noses…
  19. 19. Direct Ophthalmoscopy: Basic skills Proper position for peripheral fundus viewing
  20. 20. Direct Ophthalmoscopy: Exam technique Be systematic Start at optic disc & work radially Observe: Optic disc: C/D ratio  Vessels: course & caliber, AV ratio, light reflex, crossings/banking  Macula  Peripheral fundus 
  21. 21. Direct Ophthalmoscopy: Basic skills Clinical pearls FOV incr. when closer to Pt.  Larger pupil increases FOV  Contact lenses  Check lens wheel– watch accommodation 
  22. 22. Normal Fundus
  23. 23. Viewing the Optic Nerve Head Observe: Size  Shape  Color  Margins  Cup to disc ratio (C/D) horiz & Vert 
  24. 24. Blood Vessel Evaluation Observe: Vessel diameter  Shape/tortuosity  Color  Crossings  Light reflex  Artery/Vein (A/V) ratio: after 2nd bifurcation 
  25. 25. Hypertensive Retinopathy Scheie classification: I: Thinning of retinal arterioles relative to veins II: Obvious arteriolar narrowing w/focal areas of attenuation III: Stage II + cotton wool spots, exudates & hemes IV: Stage III + swollen optic disk (similar to papilledema)
  26. 26. Vessel “Crossings” Normal crossing Direction change “banking’” or “nipping”
  27. 27. Arteriolosclerosis Increased light reflex (1/2) “Copper wire” arterioles “Silver wiring” arterioles  whitish appearance w/continuing sclerosis Increased A/V crossings
  28. 28. Macula Lies about 2DD (disc diameters) temporal to the optic disc Should be avascular May appear darker red than surrounding retina Should see bright foveal reflex on younger pts
  30. 30. condenser Inverted Fundus Image
  31. 31. BIO Principle Page 14.3 Practitioner Aerial image Patient Condenser PD Reduction System
  32. 32. Practitioner Practitioner Aerial image Patient Condenser PD Reduction System
  33. 33. Aerial Image Condenser Patient
  34. 34. Aerial (real) image formed between examiner and condenser Aerial image becomes the object for the binocular indirect ophthalmoscope Light reflecting from retina gathered by condenser
  35. 35. BIO Condenser Page 14.1 BIO condensing lenses are biconvex, aspheric designs with one surface more curved than the other Less curved surface toward patient’s eye
  36. 36. Steeper mirror; smaller reflected images BIO Condensers With the less curved condenser surface facing the patient, spherical aberration is reduced and the size of the (interfering) reflected image of the source is smaller Page 14.1
  37. 37. Note the “Reflexes” from the Condenser Retinoschisis
  38. 38. Using the BIO Headset correctly positioned From Nova SO Optimizing viewing distance
  39. 39. Using the BIO From Nova SO  Start out with the condenser close to the patient’s eye  Keeping it normal to the patient’s eye, slowly move the condenser away from the patient  Initially, bright white reflexes are seen  As the condenser is moved further out to the correct distance, the reflexes soften and the aerial image Optimizing viewing fills the condenser distance
  40. 40. Initially, bright white reflexes are seen  As the condenser is moved further out to the correct distance, the reflexes soften and the aerial image fills the condenser
  41. 41. BIO Lenses
  42. 42. Keeler Heine Welch Allyn
  43. 43. Keeler Wireless BIOs
  44. 44. Slit-Lamp BIO
  45. 45. Slit Lamp BIO
  46. 46. BIO Summary Page 14.1 The BIO Condenser:  illuminates the patient’s retina  forms an aerial (real, inverted) image of the patient’s fundus  makes both practitioner’s pupils conjugate to patient’s pupil Choosing a higher power condenser:  requires a shorter object and image distance  increases the illuminated region of the patient’s retina  decreases BIO magnification (mainly due to closer object distance)  increases BIO field of view (mainly due to closer object distance)