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:


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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


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Hyperopes
myopes
Observation system


Lens wheel
Apertures

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

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

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

21. 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


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

23. Normal Fundus

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

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

26. 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)

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

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

29. 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

30. BINOCULAR INDIRECT
OPHTHALMOSCOPY

31. condenser
Inverted
Fundus Image

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

33. Practitioner
Practitioner
Aerial
image
Patient
Condenser
PD Reduction System

34. Aerial
Image
Condenser
Patient

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

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

37. Steeper mirror; smaller
reflected images
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
Page 14.1

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

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

40. Using the BIO
From Nova SO
 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
Optimizing viewing
fills the condenser
distance

41. 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

42. BIO Lenses

44. Keeler
Heine
Welch
Allyn

45. Keeler Wireless BIOs

46. Slit-Lamp BIO

47. Slit Lamp BIO

51. BIO Summary
Page 14.1
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)