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![Illumination System
• Incandescent lamp: A xenon halogen bright white lamp powered by a 2.5V
non-rechargeable or 3.5V [NiMH (Nickel Metal Hydride) or LiION (Lithium
Ion)] rechargable battery
• Condensing Lens: two in number, one on either side of the aperture dial which
focus the light onto the mirror/prism
• Reflecting mirror/prism : A mirror angled at 45° which is partially reflecting
or has a central peephole. It makes the light cone projected upon the patient eye
appear as if it has originated from the mirror itself](https://image.slidesharecdn.com/directandindirectophthalmoscopy-250820044856-a6fefd52/85/Direct-and-Indirect-Ophthalmoscopy-pptx-14-320.jpg)
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Direct and Indirect Ophthalmoscopy..pptx
- 1. Direct and IndirectOphthalmoscopy Presenter : Dr. Laxmi Dhawal 2nd year, MD Ophthalmology Resident LEIRC
- 2. Introduction • Ophthalmoscopy ->Clinical examination of the interior of the eye by means of ophthalmoscope • Ophthalmoscope -> An instrument containing a perforated mirror and lens used to examine the interior of the eye
- 3. 1848 – Originallyinvented by Charles Babbage 1850 – re-invented by Hermann Von Helmhotlz
- 4. • 1852- Indirectmono Ophthalmoscopy (Reute) • 1861- Binocular Ophthalmoscopy ( Girand-Teulon) Source Source
- 5. • 1900- Scleral depression(Gullstrand) •1933- Modern indirect ophthalmoscope (Charles Schepen) Source Source
- 6. Ophthalmoscopy 1. Distant DirectOphthalmoscopy 2. Direct Ophthalmoscopy : • Hand held direct ophthalmoscopy • Panoptic • Fundus Contact lens • Hurby lens 3. Indirect Ophthalmoscopy Binocular Indirect (BIO) Monocular Indirect (MIO)
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- 10. Uses • Opacities inthe ocular media are seen as dark spots in the red fundal glow • In front of the pupil, it moves in the direction of eye movement Eg. Cells, flare, hyphema • In the pupillary plane, does not move Eg. Mitterndorf dot, PSCC, Vacoules • Behind the pupillary plane, moves opposite the direction of eye movement E.g.: Vitreous hmg”, Asteroid Hyalosis
- 11. • To differentiatebetween the mole and hole on the iris • In oblique illumination, both appears dark • In Distant direct ophthalmoscopy, Mole- Appears dark Hole- red glow is seen • To detect a retinal detachment or fundal mass Both of them are visible as a grayish reflex
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- 14. Illumination System • Incandescentlamp: A xenon halogen bright white lamp powered by a 2.5V non-rechargeable or 3.5V [NiMH (Nickel Metal Hydride) or LiION (Lithium Ion)] rechargable battery • Condensing Lens: two in number, one on either side of the aperture dial which focus the light onto the mirror/prism • Reflecting mirror/prism : A mirror angled at 45° which is partially reflecting or has a central peephole. It makes the light cone projected upon the patient eye appear as if it has originated from the mirror itself
- 16. Viewing System • Condensinglens : These are aspheric lens with ranges varying with every ophthalmoscope model. Eg, +1,+10,+15,+20,+40 and -1,-10,-15-20,-25,-35 in the heine beta 200 • Viewing window : recessed, antireflective coated to avoid glare • Polarizing/red free filter: This is mounted on a separate dial and enables green,red free image viewing of the fundus or a polarized view to detect nerve fiber layer
- 18. Principle of DirectOphthalmoscopy
- 19. Optics of directophthalmoscope
- 21. Technique of directophthalmoscopy Performed in semi dark room Patient seated and looking ahead Observer standing or seated slightly over to the side of eye to be examined Patient’s right eye should be examined by observer with his or her right eye , and left with left Observer should reflect beam of light from ophthalmoscope into patient’s pupil
- 22. once red reflexis seen, the observer should move as close to the patient’s eye as possible (theoretically at the anterior focal plane of the patient’s eye i.e 15.4 mm from the cornea) Focus the direct ophthalmoscope by twirling the dial Once the retina is focused, the details should be examined systematically starting from a) Disc, b) Blood vessels, c) The 4 quadrants of the general background and d) The macula by utilizing the various illumination options and apertures provided in the direct ophthalmoscope
- 23. Features Image Virtual/Erect Field ofview 2 Disc Diopter = 10° Magnification 15x Area of Fundus seen 50-70% Image brightness ½= 4 watts Working Distance 1-2cm Stereopsis None
- 24. Field of View(FOV)
- 25. Magnification • Depends onthe refractive power of the patient and the doctor; axial lengths, compensating lenses. • Magnification = Power/4 = 60/4=15 • Refractive error • Hyperopes +10 Magnification = 50/4 = 12.5x • Myopes – 10D Magnification = 70/4 = 17.5x
- 26. Pupil and Opacities •Red-orange fundus glow • Compare pupil size and shape • +1 to +2D lens in the ophthalmoscope and by viewing the pupil at a distance of 40 to 66 cms from the patient • Floaters, Cataract, Corneal distortions, scars, pigment on the lens • Note what motion the opacity has either with or against, using the pupil plane as reference point
- 27. Vitreous • +6 Dor 7D lens • Floaters posterior vitreous detachments and general degenerative changes of the vitreous body • With the retro illumination clearly in focus we ask the patient to look very quickly to their left and right at the back to the fixation point • The floaters will be seen to swirl across as dark cobwebs or filaments within the retinal glow
- 28. Evaluation of thefundus • Disc • Shape • Color • Margins (blurred or distinct) • Any scleral crescents of pigment crescents • Type of nerve head • Cup to disc Ratio (C/D) ratio • Diameter of the physiological cup • Venous pulsation (+) or (-)
- 29. Blood Vessel Evaluation Observe: • Vessel diameter • Shape / tortuosity • Color • Crossing • Light reflex • Artery/Vein (A/V) ratio: after 2nd bifurcation
- 30. Evaluation of themacula • Look for presence of the drusen, pigmentary migration, depigmentation, edema, ARMD and is there a foveal reflex present • Never ask the patient to look at light • Most move temporally with ophthalmoscope into the macula
- 31. Factors influencing thesize of the illuminated retinal area 1. Distance of the eye from the ophthalmoscope 2. The pupil diameter
- 32. Advantages • Simple techniqueto perform • Erect view of the fundus with 15X magnification • Can be performed in undilated pupil • Can be easily performed with the patient sitting upright • Cheap • Rough estimation of refractive error • Opacities in media
- 33. Disadvantages • Lack ofstereopsis • Inadequate illumination in the presence of media opacities • Necessary to place examiner’s face in close proximity to the patient’s face • Severe degradation of the image when significant lens opacities are present • Impossible to adequately examine in case of high degree of astigmatism or spherical ametropia • Does not allow view of the peripheral retina
- 34. Normal Fundus • Orange– red reflex • Clear, no opacity Source - flickr
- 35. Abnormal Fundus Reflex •Bright Red Hemorrhage • White • Arterial occlusion • Coloboma • Retinoblastoma Source - Jaypee
- 36. • Yellow • Tumor •Retinoblastoma • Blue/Black • Choroidal melanoma • Green • Retinal Detachment AAO - Retinoblastoma
- 37. Brückner Test • Howthe Bruckner Test is Performed: 1.The examiner, using a direct ophthalmoscope, positions themselves about one meter away from the patient. 2.The ophthalmoscope's light is directed at both eyes simultaneously, and the examiner looks for the red reflex in each eye. 3.The examiner compares the brightness and color of the red reflexes in both eyes Normal Reflex: • A symmetrical red reflex, appearing as a reddish-orange glow, indicates a healthy visual axis and retina
- 38. Hypermetropia in bruckner,s test Myopiain bruckner,s test Astigmatism in Bruckner’s test Anisometropia in Bruckner’s test Media opacities in Bruckner’s test
- 39. Indirect Ophthalmoscope • Invented ByNagel in 1864 Souce- Jaypee ophthalmoscopy
- 40. Parts of indirectophthalmoscope
- 41. Principle of Indirectophthalmoscope • To make the eye highly myopic by placing a strong convex lens in front of patient’s eye so that the emergent rays from an area of the fundus are brought to focus as a real inverted image between the lens and the observer’s eye Binocular Indirect Ophthalmoscope(AAO)
- 42. Principles 1. Optics offundus image formation 2. Aerial Image 3. Conjugacy of pupil 4. Fundus illumination 5. Binocular observation
- 43. Optics of fundusimage formation Source- Fundus Image formation (AAO)
- 44. Aerial Image Source -An improvement on binocular indirect ophthalmoscopy for diabetic retinopathy - Researchgate
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- 46. Illumination source andBinocular View Source : Conjugate planes
- 47. Compensation for refractiveerror • With indirect method , minor changes in the observer’s accommodation can compensate for major changes in the pt’s refractive error • Compensation for refractive error in pt’s eye can be made without additional lenses • The presbyopic observer, who cannot change accommodation , can compensate by changing observation distance or by using near vision aid
- 48. Characteristics of theimage • Real • Inverted • Magnified (3x with =20D Eyewiki- Biorender.com
- 49. Procedure • Explain procedure •At least 1 attendant in examining room • Patient should be in comfortable position • Darken room & keep both eyes open • Dilated pupil • Adjust head band • Eye piece are as close to the pupil as possible (+2.0 d in eye piece to compensate the accommodation) and is perpendicular to pupillary axis • Adjust IPD • Force a wall approx. 40 cms away & adjust the illumination mirror such that the illumination field is vertically centralized to the observation ports.
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- 51. Examination proper • Proprioceptionhelps patient to look in cardinal gaze • Patient should be urged to keep the other eye open
- 52. Technique for holdingand focusing the condensing lens
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- 54. Indirect ophthalmoscopy byindentation • Also known as dynamic indirect ophthalmoscopy • The main purpose of this examination is to view peripheral retina Indication: • To differentiate between retinal lesion due to vitreous traction or retinal lesion without vitreous traction • To differentiate between retinal tear and retinal hemorrhage lying in extreme periphery • To look for subtle or hidden lesions in case of retinal detachment
- 55. Schepens scleral depressor(with thimble) Schocket double ended scleral depressor Josephberg Besser scleral depressor Flynn Scleral depressor Scleral indentation
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- 60. Advantages • An excellentfield of view (approx. 40 degree) • The ability to move around the patient and therefore enlarge upon the field of view • A stereoscopic view • Excellent illumination • Scleral indentation
- 61. Disadvantage of indirectophthalmoscope • Direct ophthalmoscopy is comparatively easy to learn than indirect • Inversion of image with indirect method of ophthalmoscopy—need practice to overcome • Instrument diplopia in learners who accommodate on inverted image & necessarily converge as well causing homonymous diplopia • Less magnification • Patient is more uncomfortable with bright light
- 62. Direct vs IndirectOphthalmoscope
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- 65. Reference • Practical Ophthalmology– AAO 8th edition • Kanski’s Clinical Ophthalmology – 9th edition
- 66.
Editor's Notes
- #3 Originally invented by babbage but its importance was not recognized and it was re invented by hermann
- #7 Routinely done before doing a direct ophthalmoscopy Equipment needed- self illuminated ophthalmoscope or plane mirror with a hole in center
- #8 Should be performed in a semi dark room The ophthalmoscope should be kept at a distance of 20-25cm from the patient’s eye Normally a red reflex is seen at the pupillary area
- #10 The plane of the opacities can be assessed by asking the patient to move the eye from side to side while the examiner is observing the pupillary glow (based on parallax principle)
- #13 Light source Battery housing Head pad Viewing aperture Focusing dial for Rekoss disc Window indicator of lens power
- #15 Last one-graticule
- #17 •illuminating=light passes through Lens 1 → Aperture → Lens 2 → Mirror The mirror reflects the focused light into the patient’s eye Creates a cone of light entering the eye through the cornea, pupil, and onto the retina Aperture is placed so that its image is focused on the retina (for emmetropic eyes), forming a clear disk of light Viewing System Reflected light from the illuminated retinal area exits the eye (through pupil, lens, cornea) In emmetropic eyes, rays leave the cornea as parallel rays Some rays hit the mirror and are lost; others pass through the viewing aperture Compensating lenses behind the aperture help focus the retinal image for non-emmetropic eyes (like eyeglasses)
- #18 3 basic principles described by Hermann von Helmholtz pt & observer should be emmetropic retina of the pt should be sufficiently illuminated optical alignment of light source & observer’s pupil If the patient’s eye is emmetropic, light rays emanating from a point on the fundus emerge as a parallel beam. If this beam enters the pupil of an emmetropic observer, the rays are focused on the observer’s retina and form an image of the patient’s retina on the observer’s retina. This is called direct ophthalmoscopy.
- #19 A convergent beam of light is reflected into patient ppupil(dotted line) The emergent rays from any point on the patient fundus reach the observer’s retina through the viewing hole in opthalmoscope(continuous line) Emergent rays from the patient,s eye are parallel & brought to focus on the retina of emmetropic observer when accommodation is relaxed Viewing system of a direct ophthalmoscope. A, A bundle of light rays emerges from the emmetropic eye with zero vergence. B, A bundle of light rays emerges converging from the myopic eye with positive vergence; the corrective lens is minus. C, A bundle of rays with negative vergence diverges coming out of the hyperopic eye; the corrective lens is plus.
- #20 Myopic=emergent rays will be convergent & thus can be brought to focus on the observers retina by the help of concave lens therefore, if the pt or/& observer is/are emmetropic , a correcting lens (equivalent to the sum of pt,s & observer ).ref. error must be imposed (from the system of plus & minus lenses, in-built in the modern ophthalmology Hypermetropic=emergent ray from the illuminating area of retina will be divergent & thus can be brought to the focus on the observer’s retina if the latter accommodates , or by the help of a convex lens
- #21 Review the instrument Choose low light setting from the light source Set the aperture to large circle and white color No filtration and no refractive correction
- #22 The D.O Should then be focused by twirling the dial for the reskoss disc,which has several plus-minus powered lasers. Optimal focusing lens on the reskoss disc depends on the pt’s R.E ,EXAMINERS R.E(including unintended accommodation ) & the examn distance
- #25 The area of retina which can be seen at any one time is called FOV The maximum field of view is determined by the most oblique pencil of rays (shaded) that can still pass from one pupil to other 10° or 2 DD Limited by: Peripheral light rays Expanded by : Maximizing pupillary dilation and decreasing working distance FOV in myopic is smaller, larger in hypermetropes than in emmetrope
- #26 25 cm is ordinarily taken as the average distance of most distinct vision for an emmetrope. In metre 0.25 m=1/4 Power of cornea 40 and lens 20 Larger area with least magnification is seen in hyperopes and Smaller area with maximum magnification is noted in myopes
- #29 Disc edema is focused and dioptric power noted. Adjacent retina is focused and diopteric power noted Difference gives the elvation of disc surface. +3D = 1mm elevation of disc in phakic +3D = 2mm elevation of disc in aphakic
- #30 Artery bright red,vein darker with wider calibre
- #32 In Fig. 9A, the ophthalmoscope is relatively far (15 cm) from an emmetropic eye with a 2 mm diameter pupil. Notice that the illumination rays in the eye converge to a very small retinal area.5 With the ophthalmoscope so far from the eye, we would only be able to see an extremely small portion of the retina, perhaps a short segment of a retinal vessel (200-300 μm in diameter) as shown to the right. When theophthalmoscope is brought much closer to the eye, as shown in Fig. 9B, however, a much larger retinal area is illuminated, even with the same size pupil. In this case, we would be able to see the entire optic disk which is about 1.5 mm in diameter. Finally, if we are able to dilate the pupil, a much larger retinal area is visible as shown in Fig. 9C. There, the pupil is 5 mm in diameter while the illumination source is exactly as in 9B. The field of view as shown on the right is about 3 mm in diameter, twice as large as that in 9B. Dilating the pupil with a mydriatic will dramatically increase your ability to view the fundus.
- #39 Dimmer reflex is normal=when eyes are aligned raysfocus on the fovea which has tightly packed photoreceptors cells which absorb light thus reflex is dimmer Brighter reflex abnormal=when eye deviated the rays focus an extra foveal area (peripheral retina)where photoreceptors cells are less and light reflected more ,thus bright pupillary is seen in strabismic eye
- #40 AHYPEROPE=.Lighter cerscennt is visible at the top of red reflex With increasing degrees of hyperopia,the overall red reflex will become dimmer B.MYOPIA=LIGHTER CRESCENT IS AT THE BOTTOM OF RED REFLEX WITH INCREASING DEGREES OF MYOPIA, THE OVERALL RED REFLEX WILL BECOME DIMMER C.astigmatism=red reflex flattens into a straight line across the pupil rather than a crescent,this occurs due to an increase converging in 1 meridian as compared to other d.Anisometropia =higher the R.E dimmer the reflex so the colour is diffn,size,position &colour of crescents are also clearly diffn in each eye E.Media opacities seen black against fundus reflex,corneal abbrasions and corneal scars will appear as black mark on the red reflex
- #43 Principle-to make the eye highly myopic by placing a strong convex lens in front of pt’s eye Both of the observer’s pupils must be imaged into the patient’s pupil. For this, the observers interpupillary distance must be reduced using mirrors
- #45 A retinal image is formed at optical infinity. B, A condensing lens focuses a bundle of parallel rays to a place closer to the viewer than his or her hand.
- #46 A rays can be traced from the patient’s fundus to the observer’s retina An intermediate,inverted but real image of pt’s fundus is formed in the focal plane of the ophthalmoscopy lens betn the lens and the observer The observer must accommodate this image Usually located within arm’s length of the observer.
- #47 Normal ipd is about 60mm Reduced to 15 mm by use of prism in IDO A) In indirect ophthalmoscopy, the observer’s pupil (O) and patient’s pupil (P) are conjugate to avoid “wasting” light. B) If the condensing lens is too close to the patient’s eye, the peripheral retina will not be illuminated. C) If the condensing lens is too far from the patient’s eye, light from the patient’s peripheral retina will not reach the observer’s eye.
- #48 GULLSTRAND PRINCIPLE:the illuminating and viewing beams must be totally separated through the cornea,pupillary aperture &lens(to avoid reflection)but must coincide bon the retina to permit viewing Illumination System A mirrored beam directs light into the patient’s eye, right in front of the observer’s pupil. This beam passes through the ophthalmoscopy lens. For maximum brightness, the filament image (light source) should be located in the patient’s pupil. Because the patient's pupil and the observer’s pupil are conjugate planes, the filament or an intermediate image must be positioned near the observer’s pupillary plane. 2. Binocular Viewing & Stereopsis Indirect ophthalmoscopy allows binocular vision, meaning the observer uses both eyes. This enables stereopsis (depth perception). To fit both eyes' views through the limited pupil size of the patient, the observer’s interpupillary distance (PD) must be: Smaller than or equal to the image of the patient’s pupil. Reduced using prisms or mirrors (as shown in Fig. 16B). 3. Conjugate Planes The following are optically conjugate (linked in focus) in indirect ophthalmoscopy: Patient’s retina Aerial image (floating image formed by the ophthalmoscopy lens) Examiner’s retina Faceplate of the ophthalmoscope Patient’s cornea This optical alignment ensures a clear and magnified view of the retina.
- #49 Fig;Compensation for refractive error. With the indirect method, minor changes in the observer's accommodation can compensate for major changes in the patient's refractive error. If the patient is emmetropic (E), the aerial image (E') will be 5 cm from the lens; if the observer is 45 cm from the ophthalmoscopy lens, he or she must accommodate for 40 cm (2.5 D). If the fundus detail observed lies in a plane (M) representing 5 D of myopia, the aerial image (M') will be at approximately 20 + 5 = 25 D = 4 cm. The accommodation required will be for 41 cm (2.45 D). A fundus detail representing 5 diopters of hyperopia (H) will form an aerial image (H') at 20 - 5 = 15 D = 6.6 cm, requiring an accommodative increase to 38.3 cm (2.6 D). Thus, minor changes in the examiner's accommodation can easily account for major refractive errors that the patient may have.
- #50 Image magnification:power of eye (60D)/POWER OF THE CONDENSING LENS Eg.20D lens produces 3X lateral magnification 30D lens produces 2X lateral magnification
- #52 Start with minimum intensity
- #53 Pt to lie down in horizontal position
- #54 Ask the reclining fully dilated patient to gaze steadily at a distant target on the ceiling..have pt to look just above and beyond your shoulder..rt shoulder when examining the right eye..help to align your view on posterior pole.. Pt with poor vision extend arm and staer at their outstretched thumb.. While standing above pt direct headset light by tilting head so that it illuminates fundus when focused through condensing lens,,
- #55 Lens used convex +14D,+20D,+28D,+30D Condensing lens grasped between bulb of thumb and and tip of flexed index finger Middle finger holds one lid and thumb of other hand, the other lid Flex the wrist Most lenses are coded either with a white or silver ring, this side is placed towards the patient’s eye
- #56 Holding the condensed lens with non-dominant hand Dominant hand for multiple functions which requires dexetenity like=keeping lid apart when necessary,using scleral depressor,adjusting klnobs of ophthalmoscope,sketch fundus draw Condensing lens grasped betn bulb of thumb & tip of flexed index finger Middle finger holds 1 lid & thumb of other hands,the other lid Flex wrist Most lenses are coded either with a white or silver ring,this side is placed towards the pat SEQUENCE OF examn Media Disc Peripapillary Vesssels Macula VR interface periphery
- #58 In this image, the patient is correctly positioned in supine for BIO. The examiner is gently stabilizing the lens against the patient’s head approximately 2 inches from the eye and performing scleral depression Cotton tipped applicator B-C - Double ended S-type indenter (flat and side view ) Oconnor scleral depressor (usually used intraoperatively) Schocket double ended scleral depressor-josephberg besser scleral depressor,Flynn scleral depressor To examine periphery betn equator & ora by creating a mound to view Start superonasal—sup,suptemporal,IT,inferior,IN Indentation beyond tarsal plate Don’t make mistake of indenting too anteriorly If mound of fundus not seen—u r in wrong position Don’t need too much pressure Use finger than wrist Contraindication of scleral indentation Recent or suspected penetrating injuries,orbital injuries,intraocular SURGERY WITHIN 8 WEEKS,CORRECT INDENETATIONis not believed to enlarge retinal hole or cause RD To depress the sclera, a scleral depressor is placed against the sclera (either on the globe or on the eyelid overlying the globe) and gentle firm pressure is applied. For example, to examine the superior retina with scleral depression, have the patient look inferiorly, place the depressor in the superior lid crease and gently press inward while the patient looks up. When recording your findings, remember that everything in your view is upside down and backward, but in the same clock hour you are examining.
- #59 12 o clock meridian towards pt’s feet & transforming the image towards 180 degree Follow vessels & bifurcation in each quadrant then with scleral indentation terminal branches Ora serrata then fundal lesions with relations Record landmarks that make holes easier th find at surgery Folds,pigment,hemorrhage,vortex veins & vessels can serve as landmarks Ora should be drawn only if it has been examiined
- #62 Instrument=magnifying eyepiece Relay system re-inverts image to a real one Image is focused using eye piece Indication=small pupils,un cooperative children,pt intolerant to bright illumination,one handed technique,person who is monocular
- #67 You still need a 20- or 28-diopter lens in the other hand, but your smartphone serves as the ophthalmoscope, the coaxial light source, and the recording device.” A Positioning of examiner with 20D lens in one hand and smartphone with a flashlight on in another hand. B View of the focused retina on the display screen of a smartphoneThe main concept is to use the smartphone screen to perform the exam rather than a binocular indirect ophthalmoscope FUNDUS IMAGES. (1) Giant retinal tear and (2) retinal macroaneurysm images taken via smartphone funduscopy. Some apps are also available Problems faced : glare caused by the reflection of a smartphone flashlight from a 20D lens,resolution of an image in video mode is not as high as taken in still photography mode