Dr Prachir Agarwal
Moderator : Dr Pradeep Kumar Panigrahi
3/6/2013
• Indirect Ophthalmoscopy is essential for a detailed, panoramic
and complete examination of the fundus
CR Keeler, A Brief...
Outline
 Optical principle of Indirect Ophthalmoscopy
 Comparison between different lenses used
 Comparison of Direct a...
Optics of Indirect Ophthalmoscopy
 The technique is called Indirect because the fundus is
seen through a condensing lens....
If the retina could light up….
Emmetropic
eye
Image of retina
on distant surface
GTT 04
Fundamental Principle of the
Indir...
Condensing lens
Aerial image of retina
Fundamental Principle of
Indirect Ophthalmoscope
GTT 04
Viewing the aerial image with a magnifier
GTT 04
Image is Real and Inverted
The power of the condensing lens determines:
• Working distance
• Magnification
• Field of view
Lens Power
(D)
Static Fiel...
Comparison with Direct Ophthalmoscopy
Retinal Detachment: Principles and Practice, Third Edition Daniel A. Brinton and C. ...
Advantages of Indirect system
• Image not affected by the patients refractive power
• In children
• In eyes with nystagmus...
• Better Resolution.
• Use in operating room for cryo/scleral buckling.
• Better view in presence of media opacities.
• In...
• Difficult to master.
• Small movements alter significantly the size and clarity.
• Inverted and reversed image.
• Relati...
Technique of Indirect ophthalmoscopy
 Adjusting the instrument
 Positioning of the patient
 The examination proper & sc...
Adjustment of Eye piece, Head band
IPD
IPD knob
Adequately adjusted IPD – at arms length
Adjusting IPD
Aperture setting
Filter knob
Rheostat
Technique
Ideal position of the ophthalmoscope
 Axis perpendicular to the visual axis of examiner
 The scope not resting...
IDEAL
POSITION
Head flexed
Head Extended
Positioning the patient
• Proprioception
helps patient to look
in cardinal gazes
• Patient should be
urged to keep the
other eye open
Examination ...
Holding the lens
Pivot
Scleral Depression Technique
 Holding the depressor
• A – Patient looks down, depressor on margin of sup tarsal plate
• B – Depressor advanced into the orbit as patient looks...
Critical in obtaining a binocular (stereoscopic) view
Technique of indirect ophthalmoscopy
Scleral Depression technique
Video Presentation
Fundus drawing-Amsler Dubois chart
Junction of
P Plicata &
P Plana
The Ora
The Equator
Fundus drawing
 Tips for drawing
 Disregard Sup/Inf and Temp/Nasal while drawing
 What ever appears closer to the observer in the
cond...
Fundus drawing
• Right Eye – Localized RD with HST at 11 clock and Lattice at 1 clock
FUNDUS DRAWING
Draw as you see the lesion in the
condensing lens
• Retinal arterioles
• Neovascularization
• Vascular anomalies
• Attached retina
• Vascular tumors
FUNDUS DRAWING – RED SO...
• Hemorrhages
( Pre and retinal)
• Open interior of
retinal breaks
(tears, holes)
• Open interior of
outer layer holes in
...
• Open portion of GRT
or large dialyses
• Inner portion of CRA
• Inner portion of thin
areas of retina
• Open portion of
r...
• Detached retina
• Retinal veins
• Outlines of retinal
breaks
• Outlines of ora
serrata
FUNDUS DRAWING – BLUE SOLID
FUNDUS DRAWING – BLUE SOLID
• VR traction tuft
• Outline of lattice
degeneration (inner X)
• Outline of thin area of
Retina
•Inner layer of retinoschisis
•White with or without
pressure (label)
•Detached parsplana
epithelium anterior to
separatio...
• Cystoid degeneration
• Outline of change in
area or folds of
detached retina
because of shifting
fluid
FUNDUS DRAWING
BL...
• Opacities in the media
• Vitreous hemorrhage
• Vitreous membranes
• Hyaloid ring
• IOFB
FUNDUS DRAWING- GREEN SOLID
• Retinal operculum
• Outline of elevated
Neovascularisation
• Vitreous Substitute –
Silicone Oil, Gas
FUNDUS DRAWING – GR...
• Asteroid hyalosis
• Frosting or
snowflakes on
Retinoschisis or
lattice degeneration
FUNDUS DRAWING – GREEN DOTTED
• Uveal tissue
• Pigment beneath
detached retina
FUNDUS DRAWING – BROWN SOLID
• Pigment epithelial
Detachment
• Choroidal
melanomas
• Nevus
• Choroidal
detachment
FUNDUS DRAWING- BROWN SOLID
• Edge of buckle
beneath detached
retina
• Outline of
Posterior
Staphyloma
FUNDUS DRAWING – BROWN OUTLINE
• I/R, S/R hard
exudate
• S/R gliosis
• Deposits in the
RPE
FUNDUS DRAWING – YELLOW SOLID
• Post-PHC /cryo
retinal edema
• Substance of long
& short ciliary N
• Retinoblastoma
Yellow – stippled-
• Drusen
Yellow C...
• Hyperpigmentation as a
result of previous Rx
with cryo/PHC/Diathermy
• Completely Sheathed
vessels
• Pigment within deta...
• Pigment within choroid or
pigment epithelial
hyperplasia within
attached retina (e.g. RP)
• Pigment demarcation line
at ...
• Edge of buckle
beneath attached
retina
• Outline of CRA
FUNDUS DRAWING – BLACK OUTLINE
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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Looking deep into retina : indirect ophthalmoscopy and fundus drawing

  1. 1. Dr Prachir Agarwal Moderator : Dr Pradeep Kumar Panigrahi 3/6/2013
  2. 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. 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. 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. 5. If the retina could light up…. Emmetropic eye Image of retina on distant surface GTT 04 Fundamental Principle of the Indirect Ophthalmoscope
  6. 6. Condensing lens Aerial image of retina Fundamental Principle of Indirect Ophthalmoscope GTT 04
  7. 7. Viewing the aerial image with a magnifier GTT 04
  8. 8. Image is Real and Inverted
  9. 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. 10. Comparison with Direct Ophthalmoscopy Retinal Detachment: Principles and Practice, Third Edition Daniel A. Brinton and C. P. Wilkinson
  11. 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. 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. 13. • Difficult to master. • Small movements alter significantly the size and clarity. • Inverted and reversed image. • Relative lack of magnification. Disadvantages
  14. 14. Technique of Indirect ophthalmoscopy  Adjusting the instrument  Positioning of the patient  The examination proper & scleral indentation  The fundus drawing
  15. 15. Adjustment of Eye piece, Head band
  16. 16. IPD IPD knob
  17. 17. Adequately adjusted IPD – at arms length Adjusting IPD
  18. 18. Aperture setting
  19. 19. Filter knob
  20. 20. Rheostat
  21. 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. 22. IDEAL POSITION Head flexed Head Extended Positioning the patient
  23. 23. • Proprioception helps patient to look in cardinal gazes • Patient should be urged to keep the other eye open Examination Proper
  24. 24. Holding the lens Pivot
  25. 25. Scleral Depression Technique  Holding the depressor
  26. 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. 27. Critical in obtaining a binocular (stereoscopic) view Technique of indirect ophthalmoscopy
  28. 28. Scleral Depression technique
  29. 29. Video Presentation
  30. 30. Fundus drawing-Amsler Dubois chart Junction of P Plicata & P Plana The Ora The Equator
  31. 31. Fundus drawing
  32. 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. 33. Fundus drawing • Right Eye – Localized RD with HST at 11 clock and Lattice at 1 clock
  34. 34. FUNDUS DRAWING Draw as you see the lesion in the condensing lens
  35. 35. • Retinal arterioles • Neovascularization • Vascular anomalies • Attached retina • Vascular tumors FUNDUS DRAWING – RED SOLID
  36. 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. 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. 38. • Detached retina • Retinal veins • Outlines of retinal breaks • Outlines of ora serrata FUNDUS DRAWING – BLUE SOLID
  39. 39. FUNDUS DRAWING – BLUE SOLID • VR traction tuft • Outline of lattice degeneration (inner X) • Outline of thin area of Retina
  40. 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. 41. • Cystoid degeneration • Outline of change in area or folds of detached retina because of shifting fluid FUNDUS DRAWING BLUE CIRCLE/INTERRUPTED LINES
  42. 42. • Opacities in the media • Vitreous hemorrhage • Vitreous membranes • Hyaloid ring • IOFB FUNDUS DRAWING- GREEN SOLID
  43. 43. • Retinal operculum • Outline of elevated Neovascularisation • Vitreous Substitute – Silicone Oil, Gas FUNDUS DRAWING – GREEN SOLID
  44. 44. • Asteroid hyalosis • Frosting or snowflakes on Retinoschisis or lattice degeneration FUNDUS DRAWING – GREEN DOTTED
  45. 45. • Uveal tissue • Pigment beneath detached retina FUNDUS DRAWING – BROWN SOLID
  46. 46. • Pigment epithelial Detachment • Choroidal melanomas • Nevus • Choroidal detachment FUNDUS DRAWING- BROWN SOLID
  47. 47. • Edge of buckle beneath detached retina • Outline of Posterior Staphyloma FUNDUS DRAWING – BROWN OUTLINE
  48. 48. • I/R, S/R hard exudate • S/R gliosis • Deposits in the RPE FUNDUS DRAWING – YELLOW SOLID
  49. 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. 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. 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. 52. • Edge of buckle beneath attached retina • Outline of CRA FUNDUS DRAWING – BLACK OUTLINE

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