Clinical principle ofClinical principle ofDirect OphthalmoscopyDirect Ophthalmoscopy

&&methods of recording methods of recording

observation observation

Farhana AdninFarhana Adnin

B.Optom,4B.Optom,4thth BatchBatch

IICO,CU.CO,CU.

What is What is ophthalmoscopyophthalmoscopy…???…???

&&

ophthalmoscopeophthalmoscope…???…???

TTypes…ypes… Direct Direct ophthalmoscopyophthalmoscopy Indirect Indirect ophthalmoscopyophthalmoscopy

MonocularMonocular BinocularBinocular

Fundus BiomicroscopyFundus Biomicroscopy

direct ophthalmoscopy??direct ophthalmoscopy??

head

neck

body

IInstrumentation…nstrumentation…

Direct Ophthalmoscope consists of ~Direct Ophthalmoscope consists of ~ Illumination system & observation Illumination system & observation

systemsystem

Illumination system Illumination system –light source–light source -condensing lenses-condensing lenses -reflecting prism-reflecting prism -a series of aperture-a series of aperture Observation system Observation system –a peephole–a peephole -a bank of spherical -a bank of spherical

lenseslenses

Ophthalmoscope Ophthalmoscope head,neck, bodyhead,neck, body

Lens strength selector wheel

Selects light size,filter & grid

Concave mirror with a hole in centre

Bulb in here

Connects to rheostate and handle containing batteries

peephole

On/off rheostate

Contains battery here

PrinciplePrinciple

Optics of Optics of direct ophthalmoscope…direct ophthalmoscope…

Cont..Cont..

Characteristics of the Characteristics of the imageimage

VirtualVirtual Erect and Erect and Magnified image.Magnified image. Magnification;Magnification;

MME E = distance from viewers eye to patient’s = distance from viewers eye to patient’s fundusfundus

focal lengthfocal length

= 250mm/16.67mm = 250mm/16.67mm =15X=15X

For emmetrope, MFor emmetrope, MAA =15X =15X

For myope ,moreFor myope ,more

For hyperope, less.For hyperope, less.

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Methods of Methods of OphthalmoscopyOphthalmoscopy

Distance direct ophthalmoscopyDistance direct ophthalmoscopy Illuminating eye from 25-40 inchesIlluminating eye from 25-40 inches

Direct ophthalmoscopyDirect ophthalmoscopy Approach closer to patient.Approach closer to patient.

Set the patient in a semi dark room & instruct Set the patient in a semi dark room & instruct to look at a distant target.to look at a distant target.

Hold ophthalmoscope in right hand and look Hold ophthalmoscope in right hand and look through examiners’r right eye at patient’s right through examiners’r right eye at patient’s right eyeeye

Examine for red reflex at arm’s length (20-Examine for red reflex at arm’s length (20-40cm)40cm) Normal - red glow from choroidNormal - red glow from choroid Look for opacities or loss of reflexLook for opacities or loss of reflex

The examiner moves as close as to the patient The examiner moves as close as to the patient to examine anterior segment with high + powerto examine anterior segment with high + power

ProcedureProcedureof direct of direct

ophthalmoscopy…ophthalmoscopy…

Cont…Cont… Then by reducing + power,crystaline Then by reducing + power,crystaline

lens,vitreous & finally the optic nerve head lens,vitreous & finally the optic nerve head can be observed.can be observed.

Optic disc is visualized first & blood vessels Optic disc is visualized first & blood vessels can be followed then.can be followed then.

After quadrant by quadrant scan of After quadrant by quadrant scan of fundus,the macula is examined. fundus,the macula is examined.

……left eye…left eye…

Clinical UsesClinical Uses1)Light to check pupillary reaction1)Light to check pupillary reaction

2)Media opacities can be detected2)Media opacities can be detected

3)3)Estimation of patients refractive errorEstimation of patients refractive error4)Visuoscopy4)Visuoscopy

5)Small aperture and half moon:5)Small aperture and half moon: when pupil is miosed and in case of media opacitieswhen pupil is miosed and in case of media opacities6)Slit beam6)Slit beam

To view the contours in iris and retinaTo view the contours in iris and retina

7)7)Red Free filterRed Free filter8)Blue filter- 8)Blue filter- stainingstaining

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Clinical Clinical IImportancemportanceTo observe the optical clarity of To observe the optical clarity of

Human EyeHuman Eye

Dark or semi-dark spot over red reflex Dark or semi-dark spot over red reflex OpacityOpacity

If no reflex (whole field dark/Gray)If no reflex (whole field dark/Gray) Totally opaque lensTotally opaque lens Hemorrhage within the eyeHemorrhage within the eye Total RDTotal RD

Crescentic ring in pupillary Crescentic ring in pupillary areaareaSubluxated LensSubluxated Lens

Grayish patchesGrayish patchesRD, Choroidal RD, Choroidal detachment or intra-ocular tumordetachment or intra-ocular tumor

Clinical Clinical IImportancemportance

To evaluate A/C angleTo evaluate A/C angle Shadow technique of evaluating angles

Anterior segment:Anterior segment: # Grossly examine the cornea, lids, sclera, lashes and iris. # Grossly examine the cornea, lids, sclera, lashes and iris.

#Use +13 or 13D lenses in your ophthalmoscope. The #Use +13 or 13D lenses in your ophthalmoscope. The ophthalmoscope and your face should be about 2 to 3 inches ophthalmoscope and your face should be about 2 to 3 inches away from the patient to examine the rest.away from the patient to examine the rest.

Vitreous: Vitreous: Vitreous floaters are best seen with a + 6 or 7 Vitreous floaters are best seen with a + 6 or 7 D lens in place.D lens in place.

DiscDisc FundusFundus MaculaMacula

Basics & Fundamentals of Basics & Fundamentals of Recording Ophthalmoscopic Recording Ophthalmoscopic

Findings:Findings:1]Fundal glow1]Fundal glow

2] Disc 2] Disc ~shape ~ margin~color~vessels emerged~shape ~ margin~color~vessels emerged

~cup/disc ratio ~neural rim~cup/disc ratio ~neural rim3]Retina3]Retina~periphery{4quadrants}~periphery{4quadrants}haemorrhage,exudate,pighaemorrhage,exudate,pig

mentarymentary

changes,vascularizationchanges,vascularization

~macula (~macula (foveal reflex,any abnormality like foveal reflex,any abnormality like

hole,scar,oedema,haemorrhage)hole,scar,oedema,haemorrhage)

~vessels ~vessels (vascular reflexes,A/V ratio,crossing,new vessels(vascular reflexes,A/V ratio,crossing,new vessels))

~choroidal vessels~choroidal vessels

optic discoptic disc Move as close to the patient as possible.Move as close to the patient as possible. Find the optic discFind the optic disc

Examine the optic discExamine the optic disc

shapeshape--round to oval; diameter (1.5-1.7)round to oval; diameter (1.5-1.7)

marginmargin--sharp or dull;occasionally a pigment ring or sharp or dull;occasionally a pigment ring or conus.conus.

colour: colour: red-yellow ; temporal part may appear pale.red-yellow ; temporal part may appear pale.

vessels emerged from disc: vessels emerged from disc: Noticed to see Noticed to see neovascularization.neovascularization.

Cont…Cont…

C/D ratio (cup/disc)C/D ratio (cup/disc)

ISNT ruleISNT rule

RetinaRetina

PeripheryPeriphery- lighter than central area- lighter than central area AV ratio AV ratio (normal 2:3)(normal 2:3) Fundus colour :Fundus colour :Darker with pigmented Darker with pigmented

skin or retinitisskin or retinitis pigmentosapigmentosa Pale with arterial occlusionPale with arterial occlusion

MaculaMacula- - appears darker than central areaappears darker than central area

-3mm temporal to disc.-3mm temporal to disc.

- Central foveal reflex- Healthy/ dull- Central foveal reflex- Healthy/ dull

Clinical recording of Clinical recording of Ophthalmoscopic Ophthalmoscopic

findings…findings…In normal case…In normal case… Shape- roundShape- round Marjin-sharpMarjin-sharp Colour-pinkColour-pink C/D ratio- 0.3:1 (supposing)C/D ratio- 0.3:1 (supposing) A/V ratio- 2:3A/V ratio- 2:3 Macula – healthy & bright foveal Macula – healthy & bright foveal

reflex. reflex.

Blurred disc margin

pink disc

Disc swollen / raised

glaucoma

normal

papilloedema

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Pale, featureless disc

optic atrophy

BRVO

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Hard exudates

Haemorrhage

Microaneurysm

non-proliferative diabetic

retinopathy

Proliferative diabetic

retinopathy

Age-related Macular Age-related Macular DegenetationDegenetation

Wet form: abnormal blood Wet form: abnormal blood vessel growth w/ hemorrhage vessel growth w/ hemorrhage and protein leakageand protein leakage

Dry form: Drusen Dry form: Drusen

(cellular debris) build-(cellular debris) build-upup

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Move on to the front of Move on to the front of the eyethe eye

Dendritic ulcer (herpes virus) on the cornea inspected with cobalt blue light

Foreign body

cataract

Corneal ulcer

Oil droplet reflex in Oil droplet reflex in KeratoconusKeratoconus

References1.Theory & practice of Optics & Refraction…A.K.Khurana

2.Clinical Procedure in Optometry

3.Primary Care Optometry… Theodore Grosvenor

4.Essentials of Ophthalmology…S.K.Basak

5.Internet