Funduscopy

ophthalmoscopy

1. What is funduscopy? And… Why is it important to you?

2. Web sites of interest: Welch Alleyn www.panoptic.welchallyn.com http://www.welchallyn.com/medical/ go to “optometry student” menu drop down Red Atlas http://www.redatlas.com

3. Review of ocular anatomy

4. Retinal Layers

5. Optic Nerve Anatomy

6. Choroidal Vessels

7. Funduscopy Techniques/instruments Direct Ophthalmoscopy Indirect Ophthalmoscopy Fundus Biomicroscopy Fundus Contact Lens

8. Why do we dilate pupils?

9. Direct Ophthalmoscopy Advantages Portable Easy to use Upright image Magnification  15x Can use w/o dilation Disadvantages Small field of view Lack of stereopsis Media opacities can degrade image

10. PanOptic Ophthalmoscope Manufacturer: Welch Allyn Increased field of view & mag Increased working distance Hand held but less portable www.panoptic.welchallyn.com

11. Indirect Ophthalmoscopy Monocular or binocular Advantages: Wide field of view Binocular instruments provide stereopsis Disadvantages: Requires more skill Decreased magnification (3x) Requires dilation Inverted image

12. Indirect Ophthalmoscopy

13. Fundus Biomicroscopy Field of View & Mag: FOV <indirect but >direct varies w/lens & slit lamp mag Inverted image Stereopsis Dilated pupil Requires skill

14. Fundus Biomicroscopy

15. Fundus Contact Lens Requires physical contact w/eye Viewed w/Biomicroscope Advanced dx & surgery Field of view & Mag vary w/lens design

16. Direct Ophthalmoscopy: Basic skills Optics: Illumination system Magnifier Hyperopes myopes Observation system Lens wheel Apertures

17. Direct Ophthalmoscopy: Basic skills Viewing ocular media Observe red reflex Look for media opacities Cataracts Corneal scars Large floaters

18. Direct Ophthalmoscopy: Basic skills Proper position for central fundus viewing Right eye to right eye Left eye to left eye Don’t rub noses…

19. Direct Ophthalmoscopy: Basic skills Proper position for peripheral fundus viewing

20. Direct Ophthalmoscopy: Exam technique Be systematic Start at optic disc & work radially Observe: Optic disc: C/D ratio Vessels: course & caliber, AV ratio, light reflex, crossings/banking Macula Peripheral fundus

21. Direct Ophthalmoscopy: Basic skills Clinical pearls FOV incr. when closer to Pt. Larger pupil increases FOV Contact lenses Check lens wheel– watch accommodation

22. Normal Fundus

23. Viewing the Optic Nerve Head Observe: Size Shape Color Margins Cup to disc ratio (C/D) horiz & Vert

24. Blood Vessel Evaluation Observe: Vessel diameter Shape/tortuosity Color Crossings Light reflex Artery/Vein (A/V) ratio: after 2 nd bifurcation

25. Hypertensive Retinopathy Scheie classification: I: Thinning of retinal arterioles relative to veins II: Obvious arteriolar narrowing w/focal areas of attenuation III: Stage II + cotton wool spots , exudates & hemes IV: Stage III + swollen optic disk (similar to papilledema)

26. Vessel “Crossings” Normal crossing Direction change “banking’” or “nipping”

27. Arteriolosclerosis Increased light reflex (1/2) “Copper wire” arterioles “Silver wiring” arterioles whitish appearance w/continuing sclerosis Increased A/V crossings

28. Macula Lies about 2DD (disc diameters) temporal to the optic disc Should be avascular May appear darker red than surrounding retina Should see bright foveal reflex on younger pts

29. BINOCULAR INDIRECT OPHTHALMOSCOPY

30. condenser Inverted Fundus Image

31. Practitioner Patient PD Reduction System Condenser Aerial image BIO Principle Page 14.3

32. Practitioner Patient PD Reduction System Condenser Aerial image Practitioner

33. Patient Condenser Aerial Image

34. Light reflecting from retina gathered by condenser Aerial (real) image formed between examiner and condenser Aerial image becomes the object for the binocular indirect ophthalmoscope

35. BIO Condenser Less curved surface toward patient’s eye BIO condensing lenses are biconvex, aspheric designs with one surface more curved than the other Page 14.1

36. BIO Condensers With the less curved condenser surface facing the patient , spherical aberration is reduced and the size of the (interfering) reflected image of the source is smaller Steeper mirror; smaller reflected images Page 14.1

37. Note the “Reflexes” from the Condenser http://www.mrcophth.com/retinacases/retinoschisis2.jpg Retinoschisis

38. Using the BIO From Nova SO Headset correctly positioned Optimizing viewing distance

39. Using the BIO From Nova SO Optimizing viewing distance Start out with the condenser close to the patient’s eye Keeping it normal to the patient’s eye, slowly move the condenser away from the patient Initially, bright white reflexes are seen As the condenser is moved further out to the correct distance, the reflexes soften and the aerial image fills the condenser

40. As the condenser is moved further out to the correct distance, the reflexes soften and the aerial image fills the condenser Initially, bright white reflexes are seen

41. BIO Lenses

42.                                               Heine Keeler Welch Allyn                                                                                                       

43. Keeler Wireless BIOs

44. Slit-Lamp BIO

45. Slit Lamp BIO

46. BIO Summary The BIO Condenser: illuminates the patient’s retina forms an aerial (real, inverted) image of the patient’s fundus makes both practitioner’s pupils conjugate to patient’s pupil Choosing a higher power condenser: requires a shorter object and image distance increases the illuminated region of the patient’s retina decreases BIO magnification (mainly due to closer object distance) increases BIO field of view (mainly due to closer object distance) Page 14.1