Direct Ophthalmoscopy/Fundoscopy

Presentation describing the technique used in direct fundoscopic/opthalmoscopic exam, with some illustration of common pathologies as well as the use of fluorescein to reveal corneal injuries.

Note: there is a typo on slide 7. This slide should instead read "Central Serous Retinopathy (CSR)".

Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.

1. Direct ophthalmoscopy/fundoscopy Dr. Robert Ferris

2. Direct Indirect Two distinct methods of ophthalmoscopy

3. The ophthalmoscope is used to examine the vitreous humor and fundus of the eye to assess the health of the retina, optic nerve and vasculature

4. Diabetic retinopathy note characteristic “dot” and “blot” haemorrhages

5. Diabetic retinopathy note “cotton wool spots”

6. Central retinal artery occlusion

7. Central Serious Retinopathy (CSR)

8. Papilloedema

9. Direct Ophthalmoscopy This method is far more commonly seen in general practice/outpatient clinics Handheld device with multiple settings

10. Correct technique When examining patient’s RIGHT eye, hold the scope in your RIGHT hand and use your RIGHT eye to view Steady the patient’s head with left hand Begin with scope ~15cm from patient and find red reflex, then move closer Adjust focus with dioptre lens to view optic nerve Scan up, down, left and right to visualise vessels, and move farther to visualise the macula and fovea Repeat the same technique with the left eye, reversing your hands and viewing eye

11. Pupillary dilation Some practitioners use midriatic eye drops, such as tropicamide 0.5%, an antimuscarinic agent, to dilate the pupil and allow easier examination of the fundus This is not always done, and sometimes avoided due to the possibility of precipitating an acute closed angle glaucoma, although the risk is typically minor

12. Fluorescein Non-irritating dye used to stain the cornea to allow easier identification of damage/injury Ophthalmoscope not required, but blue light extremely useful

13. Corneal abrasion

14. Dendritic ulcer seen in herpes simplex keratitis

15. References Moran Eye Centre (2018), ‘How to use the Direct Ophtalmoscope ’, MoranCore Ophthalmology Resource , accessed at http://morancore.utah.edu/basic-ophthalmology-review/how-to-use-the-direct-ophthalmoscope/ on 14/10/2020 University of Iowa Healthcare (2016), ‘ Fluorescein staining of the cornea’, EyeRounds.org , accessed at https://webeye.ophth.uiowa.edu/eyeforum/atlas-video/fluorescein-staining.htm on 20/10/2020 Tapsell , S. (2011), ‘ Fluorescein ’, Eye Learning , accessed at http://eyes.gp-surgery.com/key-skills/fluorescein/ on 20/10/2020 American Diagnostic Corporation (2020), ‘How to Use an Ophthalmoscope’, accessed at https://www.adctoday.com/learning-center/about-ophthalmoscopes/how-use-opthalmoscope on 13/11/2020 Das, J.M. (2014), ‘Direct Ophthalmoscopy’, SlideShare , accessed at https://www.slideshare.net/joemdas/direct-ophthalmoscopy?qid=248ff6ef-4691-4724-a554-4a008c01f76d&v=&b=&from_search=1 on 13/11/2020 Surendran , A. (2009), ‘Principles of Ophthalmoscopy’, SlideShare , accessed at https://www.slideshare.net/draswinikumars/principles-of-ophthalmoscopy on 13/11/2020 Mayo Clinic (1998), ‘Diabetic retinopathy’, accessed at https://www.mayoclinic.org/diseases-conditions/diabetic-retinopathy/symptoms-causes/syc-20371611 on 13/11/2020

16. References, contd. Varma , D., Cugati S. (2013), ‘A review of central retinal artery occlusion: clinical presentation and management’, Eye 27: 688–697 Higgins, G., ‘Diabetic Neuropathy’, accessed at http://www.higginseyesurgeon.com/diabetic-retinopathy.html on 13/11/2020 NeoVision Eye Centre, ‘Direct Opthalmoscope ’, accessed at https://www.neovisioneyecenters.com/our-technologies/ophthalmoscopy/direct-ophthalmoscope/ on 13/11/2020 Stanford School of Medicine, ‘ Fundoscopic / Ophthalmoscopic Exam’, Stanford Medicine 25 , accessed at https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html on 16/11/2020 Liew , G., Mitchell, P., Yin Wong, T. (2006), ‘Fundoscopy: to dilate or not to dilate?’, British Medical Journal 332: 7532 University of Iowa Healthcare (2016), ‘Central Serous Retinopathy (CSR)’, EyeRounds.org , accessed at http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/central-serous-retinopathy-csr.html on 17/11/2020