Fundus examination

fundus

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.

18. What will you see in fundus ?

19. RETINAL FIELD

20. DISC

21. Macula

22. VEIN Artery

23. 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.

24. 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

25. 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. 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.

27. 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.

28. Common retinal abnormalities

29. 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

30. 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.

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

32. 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.

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

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

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

36. 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.

37. 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.

38. 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 .

39. 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 

40. 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 .

41. 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.

42. 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

43. GLAUCOMA

44. Hypertensive retinopathy Keith-Wagner- Barker classification

45. 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

46. 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

47. 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

48. Grade 3 Cotton wool exudate Blot Haemorrhage Flame shaped

49. Grade 4

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

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

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

53. 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.

54. P roliferative retinopathy

55. Fundoscopy findings in different conditions

56. 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)

57. Central retinal artery occlussion

58. Roth spots

59. Thank you