Chapter
The Basics: Direct
and Indirect
Ophthalmoscopy
Direct ophthalmoscopy
The direct ophthalmoscope is the instrument of choice for fundus
examination by medical students and physicians. It allows for a magnified, monocular image of the retina and optic disc.
Principle
The instrument illuminates the subjects fundus by light reflected
off a mirror on the instrument head. A perforation in the centre of
the mirror helps the observer view the area illuminated. The emanating rays from the subjects eyes are parallel, assuming the subject
is emmetropic (normal sighted). These rays are converged to a focus
(assuming the observer is also normal sighted) by the observers
cornea and crystalline lens onto the observers retina. The emanating rays from a myopic subjects eye would be convergent and therefore will require a concave lens to make it parallel before entering
Fundoscopy Made Easy
Viewing aperture
Filter control
Graticule control
Lens power wheel
On/off switch and brightness control
The ophthalmoscope.
the observers eye and the converse if the subject is hyperopic. These
lenses are mounted on a wheel on the ophthalmoscope head which
can be dialled appropriately.
Methods
If you are using an unfamiliar ophthalmoscope it would help to familiarise yourself with the colour coding of the lens wheel and the various apertures and filters. To undertake successful ophthalmoscopy
it is essential that both you and the patient are comfortable. Adjust
the height of the patient in such a way that you dont have to stoop
too much. Dim the main lights to allow for physiological mydriasis
if the pupil is not pharmacologically dilated. Tropicamide 1% is a
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The Basics: Direct and Indirect Ophthalmoscopy
short-acting dilator which can be used safely unless contraindicated
by allergy or due to a shallow anterior chamber which may precipitate
an acute glaucoma on dilation of the pupil. A shallow chamber can be
reasonably assessed by using a pen light that is shone from the side of
the cornea, parallel to the iris. Normally the opposite half of the iris
beyond the pupil should be illuminated by your light. If it is shadowed, the configuration of the iris is considered convex, thus indicating a shallow anterior chamber.
Instruct the patient to look at a distant target. Let the patient know that
they can blink if required. Stand at the side of the patient. Ideally use
your left eye and left hand to examine the patients left eye. Rest your free
hand on the patients forehead, using your thumb to hold the upper lid
open if necessary. Use only the minimum required intensity of light. The
field of view of the fundus is increased the closer you are to the patients
eye. For low myopes and low hyperopes it is best to remove their spectacles; however, for high myopes, hyperopes and for subjects with high
astigmatism it is advisable to keep the spectacles on in order to overcome problems associated with magnification, minification or distortion,
respectively. The extra reflexes produced by the spectacle lenses may at
first prove distracting but can be overcome with practice.
Fundoscopy Made Easy
Examination by direct ophthalmoscope.
Examination of the red reflex
Start the examination by doing a distant direct ophthalmoscopy
from a distance of 30 cm using a plano lens in the aperture of the
ophthalmoscope. This technique is used to study the red reflex and
each eye should be compared. While examining the red reflex, ask the
patient to look up or down slightly. If, when the patient looks up, the
opacity appears to move in the same direction within the red reflex,
then it must lie anterior to the pupil plane (i.e. the cornea or the anterior chamber). One that remains stationary must be in the plane of
the pupil and one that moves in the opposite direction to that of the
patients gaze must lie posterior to the pupil plane (i.e. the posterior
lens or vitreous). You may find it easier to move yourself slightly up
or down rather than ask the patient to move their eye to achieve the
same effect.
The Basics: Direct and Indirect Ophthalmoscopy
During ophthalmoscopy it is advisable to keep both eyes open and
suppress the image from the other eye. This reduces the effect of accommodation. It may take some practice to accomplish this.
Examination of the optic disc
Slowly move closer to the patient and at the same time gradually
increase the power of the lens in the wheel to focus on the retina.
The power necessary to focus on the fundus will depend on both
the patients and the observers uncompensated refractive error and
their accommodation. When the patient is looking straight ahead, the
optic disc should naturally come into the field of view. If not, try to
locate a blood vessel on the retina and then move along it and locate
the point at which it branches. Move your field of view in the direction in which the apex of the branch is pointing. By moving along a
blood vessel in this manner the optic disc will be located. You will
need to consider its colour, clear definition of its margins, cup (if
there is one) and the ratio of the size of the cup to the size of the optic
disc (cup disc ratio, denoted as, e.g., 0.3:1, meaning it occupies onethird of the area of the optic disc). Note the capillaries on the optic
disc and look for the presence of a spontaneous venous pulsation.
Also note the presence of any pigment, choroidal or scleral crescents
around the disc.
Examination of the retinal blood vessels
Retinal blood vessels should be examined by following the temporal
and nasal arcades from the optic disc. Veins are larger and dark red,
whereas arteries are relatively thinner and lighter (normal artery:vein
ratio is 2:3).
Examination of the macula
The macula is visualised by asking the patient to look at the light source
as this brings the fovea (fixation point) into view. The macula is the area
between the superior and inferior temporal arcades and its centre is
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Fundoscopy Made Easy
the fovea. Since using an excessively bright light can make the macula
difficult to visualise, it may be useful to use a smaller aperture beam
and minimal required intensity.
Examination of the peripheral fundus
Finally, ask the patient to look in the eight cardinal directions to allow
you to view the peripheral fundus Look up, to see the superior
periphery and so on. You will need to adjust the lens in the wheel
slightly as the periphery is closer to you than the optic disc, requiring
more focusing power.
Indirect ophthalmoscopy
Binocular indirect ophthalmoscopy
This technique allows for viewing the fundus at a wider angle which
allows examination of the peripheral retina and also a better view
through lens opacities as well. Binocularity is achieved by the use of
mirrors in the instrument to reduce the pupillary distance of the observer
to about 15 mm. The instrument also carries a light source which is
attached to a headband or spectacle frame worn by the examiner.
The patients pupil may be dilated and background lights dimmed
as for direct ophthalmoscopy. The patient is examined either seated in
a reclining chair or lying on a couch. A condensing lens (varying from
+15 D to +30 D) is held in one hand of the examiner in front of the
patients eye. The image formed is magnified three-fold with a 20 D
lens and is inverted and laterally reversed (superior seen inferiorly and
temporal seen nasally).
Ensure that the patients and the observers eye are aligned before
placing the lens in front of the eye. Check for the red reflex first and
then bring the condensing lens in front of the patients eye. Now
The Basics: Direct and Indirect Ophthalmoscopy
Aerial image of fundus
Condensing lens
Binocular indirect
ophthalmoscope
The binocular indirect ophthalmoscope.
Examination by indirect ophthalmoscope.
Fundoscopy Made Easy
radually pull the lens towards you until the whole lens is filled with
g
the retinal image. Systematically view the patients fundus in primary
and all secondary positions of gaze. Also remember to compare the
two eyes. The ora serrata can be viewed by scleral indentation with
the free hand of the observer under local anaesthetic (proxymetacaine). It is important to remember that you are viewing the superior retina when the patient is looking up despite the image being
inverted and laterally reversed, and this relationship is maintained
for the other quadrants.
Slit lamp biomicroscopy
The fundus also can be viewed by using a non-contact Volk condensing
lens (+60 to +90 D) or a Goldmann contact lens (64 D) and the slit lamp.
This is the most common method of examination of the fundus dilated
or undilated at the ophthalmology clinic. The patients pupil may be
dilated and background lights dimmed as for direct ophthalmoscopy.
Once the patient is positioned comfortably at the slit lamp, the
patient is advised to look straight ahead and not into the light (ask
the patient to look at the examiners right ear with the left eye while
examining the patients right eye and vice versa). The slit lamp viewing piece and the light column are kept at an angle of 90 degrees.
Theintensity of the beam is kept to the minimum possible and the
magnification preferably set at 10 initially. The slit beam is set
around 1.52.5 mm wide and 510 mm long. The beam is focused
onto the patients pupil and the condensing lens aligned at around
1 cm from the patients eye. The slit lamp is then pulled backwards
gradually towards the examiner until it comes into focus with the
aerial image of the fundus between the condensing lens and the slit
lamp. Alternatively, the slit lamp could be drawn back completely
towards the examiner and then gradually moved forwards until the
image comes into focus.
As with indirect ophthalmoscopy, the image from a non-contact Volk
lens slit lamp biomicroscopic examination is inverted and laterally
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The Basics: Direct and Indirect Ophthalmoscopy
reversed. The fundus is viewed systematically in primary and all
secondary positions of gaze. The ora serrata can be brought to view
using the Goldmann three-mirror lens.
Examination by slit lamp biomicroscopy.
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