The document provides details on performing a fundus examination, including: - The history of the ophthalmoscope and its modern use - Preparation steps like pupil dilation - Proper positioning and examination technique - What to expect to see in a normal fundus exam, including the optic disc, blood vessels, macula - Common abnormalities that may be observed, such as cotton wool spots, exudates, hemorrhages - Conditions like glaucoma, hypertensive retinopathy, and diabetic retinopathy that can be assessed during the exam

1. FUNDUS EXAMINATION
Dr. Akhil Deshmukh

2. Ophthalmoscope
was first invented
by Hermann von
Helmholtz(1821-
1894), a professor
of physics from
Germany in 1851.

3. • In 1915, Josh Zele and Jon Palumbo invented
the world's first hand-held direct illuminating
ophthalmoscope.
• Precursor to the device now used by clinicians
around the world
• The company started as a result of this
invention is Welch Allyn.

4. Pre-requisite
• It should be done in a dark room.
• Explain whole of the procedure to the patient.
• Pupil is dilated or moderately dilated, but be
careful about mydriatic in Glaucoma or Intra
ocular implanted lens (IOL). Dilating the pupil
with 1% tropicamide or 1% cyclopentolate.
This blurs the near vision for 2-3 hrs.

5. Proper positioning
• Lying or sitting in chair (better). If lying, move
to opposite side when need to examine left
eye.
• Appropriate direction.
• Proper positioning of the examiner.
• Both the eye should be seen

6. Examination sequence

7. • Adjust the
ophthalmoscope light
to a comfortable
brightness.
•Set the
ophthalmoscope lens
wheel to zero diopters
(D) or correct your
visual error by glass or
ophthalmoscope lens.
•Adjust the focus ring
& focus filter.

8. • Stand 1 hand or half meter apart from the
patient in same horizontal plane as patient’s
eye.
• Ask the patient to look straight ahead at a
distant object – patient should continue to
look in this direction even if the examiner’s
head obscures the target.

9. Patient’s right eye/ your right eye / your right hand
/patient’s right side & vice versa.

10. • A distance of about 10-30 cm from the patient
try to see through the viewing hole of the
ophthalmoscope and focus the light around
the patient’s eye.
• Direction of light should be toward the nose,
about 15 degrees from the line of fixation.
Instruct the patient to see the distal fixation
point with the opposite eye.

11. The pupil should appear
pink from 10 cm distance.
This is the Red reflex.
•Any opacity in the media
appear black upon the red
reflex.
•If total red reflex is lost, it
is due to Medial opacity
(cataract, vitreous
haemorrhage) or Retinal
problem. Pupillary red
reflex opacity

12. If patient doesn’t
cooperate, fix the
head by placing your
other hand on the
patient’s forehead &
gently retract the
upper eyelid.

13. Now come close to
the patient’s head
,bring the
ophthalmoscope to
within 1-2cm of the
eye . Not to touch the
eye lash of the
patient. Now you can
see inside the eye. At
first try to see any
vessel, then follow it
medially to find out
the optic disc.

14. • Follow the blood vessels as they extend from
the optic disc in four directions:
superotemporally, inferotemporally,
superonasally& inferonasally .
• Ask the patient to look up to see superior
retina, look down to see inferior retina, look
temporally to examine temporal retina ,look
nasally to examine the nasal retina.

15. • Finally locate the centre of the macula by
asking the patient to look directly at the light .
• Macula present two disc temporal from the
optic disc.

16. SOME COMMON MISTAKES
• must be corrected by the following way:
1.Examine at the same level
2. Never obstruct the opposite eye
3.Never examine the right eye by left eye and
left hand & vice versa
4.Never give too much pressure to the head
and shoulder

17. Haziness in media
• Corneal opacity,
• Lens opacity,
• Vitreous opacity.
• It can be detected while observing the red
reflex by moving the ophthalmoscope;
Right/Left or up/down.

19. What will you see in fundus?

20. RETINAL FIELD

21. DISC

22. Macula

23. VEIN
Artery

24. OPTIC DISC
• The optic disc or optic nerve head is the
location where ganglion cell axons exit the eye
to form the optic nerve
• The optic disc represents the beginning of the
optic nerve.

25. • Things to be seen: 3c
-Contour(Margin): – The borders of the optic disc
should be clear and well defined
-Color: – Typically the optic disc looks like an
orange-pink area with a pale centre. The orange-
pink appearance represents healthy, well
perfused neuro-retinal tissue
-Cup: As mentioned above the disc has an
orange-pink rim with a pale centre. This pale
centre is devoid of neuroretinal tissue and is
called the cup

26. Cup: As mentioned
above the disc has an
orange-pink rim with a
pale centre. This pale
centre is devoid of
neuroretinal tissue
and is called the cup

27. Blood vessels
• Arteries:
They are superficial, tortuous & brighter.
Normally arterial walls are invisible, seen as
streak, when light is focused bright streak light
reflexion is seen.

28. • Veins :
-They are thick, deeper & darker. Normally
venous pulsation is visible near the disc. •
Total vessels count in disc : 7-10, which
include vein & artery. Count only the main
vessels not the branches.
-Normal vein : artery = 3:2.

29. Common retinal abnormalities

30. Cotton wool spots
White fluffy spots with
indistinct margin
caused by retinal
ischemia due to
accumulation of
axonal proteins in the
nerve fiber layer.
Causes: Severe HTN,
DM, retinal vein
occlusion ,SLE,AIDS.
Cotton wool

31. HARD EXUDATE
Bright yellowish sharp-
edged lesions consist
of lipid deposition that
result from leakage of
plasma from abnormal
retinal capillaries.
Causes: DM, HTN.
Chorioretinal atrophy:
Well defined punched
out lesion. Cause:
Previous retinal
inflammation, injury.

32. Retinal pigment
hypertrophy: Black
lesion like bony
spicules in periphery.

33. Red lesion Dot
haemorrhage:
Thin vertical
haemorrhage that may
be difficult to
differentiate from
microaneurysms seen
adjacent to blood
vessels.
Cause: DM. Blot
haemorrhage: Larger full
thickness haemorrhages
in the deeper layer of
retina .Rounded,
localized.

34. Flame haemorrhage
Superficial bleed,
shaped by nerve fibres
into a fan with point
towards the disc.
Cause: HTN, retinal
vein oclusion.

35. Pathology in Optic Disc
• Common abnormality in optic disc:
• Optic disc swelling (Papilloedema/ Papillitis)
• Optic atrophy.
• Glaucomatous cupping.
• Abnormal vessels

36. Optic disc swelling
• Optic nerve head swelling can be
inflammatory or non-inflammatory .
If non-inflammatory: Papilloedema
If Inflammatory: Papillitis.

37. Papilledema
• Caused by raised intracranial pressure.
• Loss of venous pulsation (normally absent in
15% people.)
• Disc is abnormally red.
• Margins are blurred, upper nasal quadrant
first, then lower nasal, then temporal margin.

38. • Physiological cup becomes obliterated.
• Retinal veins are slightly distended.
• If papilloedema develops rapidly, there will be
marked engorgement of the retinal veins with
haemorrhages & exudates on & arround the
disc.
• If develops slowly, may be little or no vascular
change.

40. PAPILLITIS
• Ophthalmoscopy may show no abnormalities
on retrobulbar optic neuritis.
• Dilatation of retinal arteries and veins on optic
nerve disc .
• Possible petty splinter hemorrhages on the
optic nerve disc .

41. • Retinal edema around the optic disc. • Optic
nerve disc has blurred margins • Reddish
(hyperemic) optic nerve disc due to dilatation
of blood vessels . • Possible white exudates on
the optic nerve disc

44. Optic Atrophy
Features of optic
atrophy
• Disc is small.
• Pale.
•Loss of function.
Added may be
•Reduced number of
vessels (< 7).
•Margin may be sharp
/ blurred.

45. Primary optic atrophy • Due to
disease of the optic nerve. •
Disc is flat, pale/white. • Clear-
cut, sharp margins. • Decreased
/ loss of vision
Secondary optic atrophy • Due
to long standing papilloedema.
• Disc is greyish-white. •
Indistinct margins. • Decreased
/ loss of vision.

46. Optic cup and Cup Disc
ratio(CDR)
• The optic cup is the
white, cup-like area in the
center of the optic disc.
• The ratio of the size of
the optic cup to the optic
disc (or cup-to-disc ratio) is
the cup disc ratio.
• Normally the cup should
take up less than 50% of
the disc,i.e. CDR is <.5
• The CDR is measured to
diagnose Glaucoma

47. GLAUCOMA

48. Hypertensive retinopathy
• Keith-Wagner- Barker classification

49. GRADE 1 Silver wiring
It’s the appearance of
blood vessels in which the
arterial wall becomes so
completely opaque that
the blood column is not
seen and the central light
reflex occupies all of the
width of the arteriole. –
The light is completely
reflected, yielding a white
‘line,’ likened to a silver
wiring

50. Grade 2 • AV nicking:
A vascular abnormality in
the retina of the eye,
visible on ophthalmologic
examination, in which a
vein is compressed by an
arteriovenous crossing •
The vein appears "nicked"
as a result of constriction
or spasm

51. • Salus’s sign: Deflection of retinal vein as it
crosses the arteriole.
• Gunn’s sign: Tapering of the retinal vein on
either side of the AV crossing.
• Bonnet’s sign: Banking of the retinal vein
distal to the AV crossing

52. Grade 3
Cotton wool exudate Blot
Haemorrhage Flame shaped

53. Grade 4

54. • Diabetec Retinopathy Classification of Diabetic
Retinopathy
– Non-proliferative ‘background’ retinopathy
without maculopathy,
– Maculopathy,
– Pre-proliferative retinopathy,
– Proliferative retinopathy

55. Non-proliferative
‘background
retinopathy without
maculopathy Blot
hemorrhage Dot
hemorrhage Hard
Exudate

56. Maculopathy
Hard exudate Dot and
blot Haemorrhage
Macular oedema
Macular oedema,
exudates, dot & blot
hemorrhage

57. Pre proliferative retinopathy
• Venous loops & beading, dot-blot
haemorrhage, large retinal hemorrhage,
cotton wool exudates, macular oedema with
reduced visual acuity, perimacular exudates,
retinal hemorrhages of any size.
• But no proliferative changes.

59. Proliferative retinopathy

60. Fundoscopy findings in different
conditions

61. Central retinal vein
occlusion
1.Dilated and tortuous
retinal veins
2.Diffuse intraretinal
haemorrhage in all 4
quadrants
3.Cotton wool spots
4.Swollen optic disk
5. Retinal oedema
(TOMATO SPLASH
APPEARANCE)

62. Central retinal artery occlussion

63. Roth spots

64. • Thank you