Ophthalmoscopy

A presentation on Direct and indirect Ophthalmoscopy and fundus drawing.

1. OPHTHALMOSCOPY
Dr Saurabh Kushwaha
Resident Ophthalmology

2. SCOPE
Introduction
History
Methods of ophthalmoscopic examination
Distant direct ophthalmoscopy
Direct ophthalmoscopy
Monocular indirect ophthalmoscopy
Binocular indirect ophthalmoscopy
Fundus diagram

3. INTRODUCTION
Ophthalmoscopyisaclinicalexaminationof
theinterioroftheeyebymeansofan
Ophthalmoscope
Itisprimarilydonetoassessthestateof
fundusanddetecttheopacitiesofocularmedia

4. HISTORY
Babbageinvented1
st
directophthalmoscopein
1848
HermannvonHelmholtz
revolutionizeditinyear
1850
Binocular indirect
ophthalmoscopy was
introducedbyNagelin
1864

5. METHODS OF EXAMINATION
Distant direct ophthalmoscopy
Direct ophthalmoscopy
Monocular indirect ophthalmoscopy
Binocular indirect ophthalmoscopy

6. DISTANT DIRECT
OPHTHALMOSCOPY
Performedwiththehelpofselfilluminating
ophthalmoscopeoraplanemirrorwithahole
incentre
Distance-20to25cm
Itshouldbeperformedroutinelybeforethe
directophthalmoscope,asitgivesalotof
usefulinformation

7. APPLICATIONS
Todiagnoseopacitiesintheocularmediaseen
asdarkspotsintheredglowatthepupillaryarea
Todifferentiatebetweenamoleandaholeof
theiris
Torecognizedetachedretinaoratumour
arisingfromthefundus
Theplaneoftheopacitiescanbeassessedby
askingthepatienttomovetheeyefromsideto
sidewhiletheexaminerisobservingthepupillary
glow(basedonparallaxprinciple)

8. Opacitiesinfrontofthepupilmoveinthe
directionofeyemovement
Opacitiesinthepupillaryplanedonotmove
Opacitiesbehindthepupillaryplanemove
oppositethedirectionofeyemovement

9. DIRECT OPHTHALMOSCOPY
Itisthemostcommonlypracticedmethod
forroutinefundusexamination
Itisusedtoexaminecentral7to10
degreeofretina
“The physicianusinga direct
ophthalmoscopeislikeaone-eyedEskimo
peeringintoanigloofromtheentrywaywitha
flashlight”

10. PARTS OF DIRECT
OPHTHALMOSCOPE

11. OPTICAL PRINCIPLE
Convergentbeamoflightisreflectedonto
patientsretina
Theemergentraysfrompatientsretinareach
theobserverthroughtheviewingholepresentin
theophthalmoscope
Iftheobserverisnotemmetropicthenthe
correctinglensesmustbeinterposedwhichare
presentintheophthalmoscope

12. OPTICAL PRINCIPLE

13. PROCEDURE
Itshouldbeperformedinsemidarkroom
Ideallythepupilsshouldbedilated
Patientshouldbelookingstraight
Subjectshouldbeexaminedinsittingorlying
downposition
Whileexaminingrighteye,standonrightside,
holdtheinstrumentinrighteyeanduserighteye

14. ACCESSORIES
Aslitdiaphragmallowsaslit-lamptype
observationofelevatedretinallesions
Apinholeorsmallcircleallowsquick
entryintosmallorundilatedpupil
Ahalf-circlediaphragmisusedtoreduce
reflectionsbylimitingtheilluminationbeam
Itisalsohelpfulintheobservationofcertain
fineretinaldetailsthatareseenbestinthe
transitionalzonebetweenilluminatedand
non-illuminatedretina

15. Ared-freefiltermakestheredelements
verydarksothatvesselsandpinpoint
hemorrhagesstandoutclearly
Abluefilterisusedasahandheldlight
sourceforfluoresceinstainingofthe
corneaandusedinfluoresceinangioscopy
Afixationstar,adotorastar-shaped
figure,isusedtodeterminethepatient's
fixation,forlocatinglesionsandfor
measuringeccentricfixation

16. OTHER APPLICATIONS
Pupil-pupilcanbeevaluatedby
comparingsize&shape
Anteriorsegment-with+13to+15Dlensin
ophthalmoscopecornea,lids,sclera,lashes&
iriscanalsobeexamined
Vitreous-with+6to+7Dlensin
ophthalmoscopevitreousfloaters&opacities
canbeexamined

17. ADVANTAGES OF DO
Easy procedure
It can be used in non dilating pupils as well
Easy to carry
Refractive power can be adjusted

18. DISADVANTAGES OF DO
Limited view
Monocular view
Stereoscopic view is not possible

19. DIRECT OPHTHALMOSCOPY

20. MONOCULAR INDIRECT
OPHTHALMOSCOPY
Foreheadrest
Magnifyingeyepiece
Focusinglever
Relaysystem
Filterdial
Irisdiaphragmlever
Illuminationrheostat

21. MONOCULAR INDIRECT
OPHTHALMOSCOPY
Indications
•Smallpupils
•Uncooperativechildren
•Intoleranttobrightillumination

22. MONOCULAR INDIRECT
OPHTHALMOSCOPY
Advantages
•Field of view similar to IO
•Erect real image similar to DO
Disadvantages
•Lack of stereopsis
•Limited illumination
•Fixed magnification

23. BINOCULAR INDIRECT
OPHTHALMOSCOPY
Head mounted Spectacle mounted

24. PARTS OF INDIRECT
OPHTHALMOSCOPE

25. OPTICAL PRINCIPLE
IndirectOphthalmoscopy(IDO)involves
makingtheeyehighlymyopicbyplacinga
highpowerconvexlensinfrontoftheeyeso
thatareal,invertedandlaterallyreversed
imageisformedclosetotheprinciplefocusof
thelens,betweenthelensandtheobserver

26. PROCEDURE
Adjust head band
Eye pieces close to the pupil & perpendicular to
pupillary axis
Adjust IPD
Condensing lens between thumb & index finger
Silver ring side of lens towards the patient's eye

27. PROCEDURE
Eye rotated in the direction of the quadrant to be
examined
Stand 180°away from the quadrant to be examined

28. CHARACTERISTICS
An inverted reverse real image
Magnification = 2 to 4 X
Field of view = 40 to 50 degrees
Optimal working distance = 40 to 50 cms
Good illumination & stereopsis
Ease of use with scleral indentor
Lenses from 14 to 30 D range

29. FILTERS
Greenlight-Nervefiberlayer,
Bloodvessels,microaneurysms
Redlight-Subtlepigmentary
abnormalities
Bluelight-Angioscopy
Yellowfilter-Reduces
photophobia

30. SCLERAL INDENTATION
Toexamineperipherybetweenequator
andoraserratabycreatingamoundtoview
Accessories
•Thimblescleraldepressor
•Penciltypedepressor
•Cottontippedapplicator

31. FACTORS AFFECTING FIELD
OF VIEW
Patient's pupil size
Power of the condensing lens
Over all size of the condensing lens
Refractive error (very small amount)
Distance the condensing lens is held from
the patient's eye

32. ADVANTAGES OF IDO
Largerfieldofview
Easiertoexamineifpatientseye
movementsarepresentandwithhigh
sphericalorastigmaticrefractiveerrors
Lesserdistortionofretinalimage
Stereopsis
Usefulinhazymediaduetoitsbrightlight
andopticalproperty
Canbeusedintraoperatively
Vitreouscanbeexaminedeasily

33. DISADVANTAGES OF IDO
Difficulttolearn
Lessmagnification,thereforedetailsofa
smalllesionnotvisualizedproperly
Difficultwithverysmallpupils
Moreuncomfortabletothepatient

35. FUNDUS EXAMINATION
The fundus of the eye is the interior surface
of the eye opposite the lens and includes the
retina, optic disc, macula, fovea, and posterior
pole
Normal Fundus
•Pink optic disc with cup in centre
•Arteries lighter in colour and narrower than veins
•Red background due to choroidal vessels and
retinal pigment epithelium
•Central macula

36. FUNDUS CHARTING
Amsler-duboisChart
3ConcentricCircle
•Inner-Equator
•Middle-OraSerrata
•Outer-Parsplana
Radiallinesto
describethelocationof
fundusfindinginclock
hours

37. FUNDUS DIAGRAM

38. FUNDUS DIAGRAM

39. FUNDUS DIAGRAM

40. THANK YOU