Aaqid Akram MBChB (2013) Clinical Education Fellow Fundoscopy Aaqid Akram MBChB (2013) Clinical Education Fellow

Objectives Use opthalmoscope correctly Recognise individual structures of the fundus Features of diabetic and hypertensive retinopathy Document findings appropriately

Opthalmoscope/Fundoscope

Refraction Adjustment (Lens) To correct refractive error of Patient + Examiner If normal = 0 Myopia (short sighted) = concave/negative lens/red Hyperopia (long sighted) = convex/positive lens/green Hyperopia aka hypermetropia

Aperture Adjustment Spot Dependent on pupil dilatation Micro/medium/large Fixation – estimating size/location of lesions Slit – levels of lesion/oedema/lacerations Cobalt Blue – (requires fluorescin) corneal abrasions/ulcerations

Filter Switch Polarising Red Free Eliminates corneal glare + reflection Red Free Retina = grey Disc = white Macula = yellow Veins = blue Arteries = black

Structure of Retina

How to Perform Fundoscopy http://clinicalskills.leeds.ac.uk/cs_ebook/index.html Check that the ophthalmoscope is working; check the batteries, bulb and set to zero Ask patient if they wear contact lenses or glasses. Patient should remove glasses but leave contact lenses in situ. If the patient is extremely short sighted it may be easier to view the fundus whilst they are wearing their glasses Explain procedure and gain consent Ensure optimal lighting conditions – dim lights to dilate patient’s pupils Position patient (sitting, looking straight ahead). Ask patient to focus on something behind examiner’s head. Examiner positions self face to face with patient at eye level Place your free hand against patient’s forehead to set distance from which to work and to avoid clashing heads together. You can then use thumb of this hand to lift patient’s eyelid when necessary Whilst examining, examiner should attempt to keep both eyes open as this will reduce eye fatigue. Hold ophthalmoscope to your right eye in right hand to examine patient’s right eye and vice versa for left eye Hold ophthalmoscope nestled against supraorbital ridge of your own eye, or against glasses if worn Hold ophthalmoscope with index finger resting on focusing wheel and thumb on on/off switch Turn ophthalmoscope on, adjust to largest (not brightest) light source and rack lenses to zero Use thumb to adjust brightness of beam. Too bright a beam is uncomfortable Direct beam of light onto patient’s eye from arms length away and from an angle of 15-20° to the perpendicular. Move slowly in towards patient’s eye This directs beam towards optic disc Look for red reflex and use it to guide you closer to pupil. Observe shape and opacity/transparency of red reflex Move in close to patient’s eye. If both you and the patient have an eye prescription, add these together and use the focusing wheel to adjust the lenses accordingly (EG: Patient prescription = +1, your prescription = -1, set dial at 0) Observe disc: Contour (margin and shape) ColourCup (cup to disc ratio) In order to facilitate observation of quadrants of eye for features of vessels and spaces, ask patient to look up/down/side to side Observe vessels and comment: (AV ratio, AV crossing and indentations, Arterial light reflex? Arteries/veins: how many? Straight/tortuous? Normal calibre? Crossings? Ratio between arteries and veins? Copper/silver wiring?) Observe spaces and comment: (Micro aneurysms? Dot, blot or flame haemorrhages? Cotton wool spots, Hard exudates?) Fundus background: (Exudates? Haemorrhages? Colour) Observe macula (which is temporal to the disc). Ask patient to look directly at the light source and adjust it to the smallest setting: (Any vessels around macula? Pigmented? Any degenerative changes? Can you see the foveal reflex?) Consider the significance of any changes observed Complete process on one eye and repeat on other eye (your left eye to examine patient’s left eye. Adjust seating accordingly) Explain findings to patient Document and discuss findings as appropriate

Red Eye Reflex Reflection of light from fundus Round + clear Opacities: Debris Haemorrhaging Clouding of lens Cataracts Complete loss: Rule out retinal detachment In newborns – may help exclude certain eye conditions, including tumours.

Fundus of the Eye Left Eye.

Optic Disc Optic nerve / retinal vessels Blind spot – no rods/cones Creamy yellow ( darker skin = darker) Sharp margin – less on nasal aspect Round/oval shaped Cup <1/3 of disc Pit where the vessels emerge Artery = brighter/narrower/streak Vein = dull/thicker/no streak Use red free filter to distinguish Check four quadrants after analysing the disc

Papilloedema Optic disc swelling Elevation/obscuring vessels Blurred/absent disc margin Medical Emergency There is also optic atrophy which is usually due to optic nerve disease – chronic glaucoma, optic neuritis, compressive lesions

Four Quadrants Check all four quadrants

Macula + Fovea