Fundoscopy Holly Wilson

Plan “The eye exam” – quick recap of CN II, III, IV, VI How to do fundoscopy Spot diagnosis Practice!

Eye examination vs fundoscopy Eye exam = cranial nerves 2, 3, 4, 6 + fundoscopy You will probably just be asked to do fundoscopy But “eye examination” could be a cranial nerve station. Always offer to do fundoscopy in a cranial nerve exam and know how to do it in case they ask! Good understanding of the eyes + how to examine = super prepared 

Eye exam summary IM AFRO Inspection Eye movements Visual acuity Visual fields Pupillary reflexes Opthalmoscopy

Intro WHISPERS Wash hands Hello Introduce Permission “I’ve come to examine your eyes, this will involve…..” Equipment (Snellen chart, red hat pin, opthalmoscope – get everything ready) Reposition patient State of patient (well/unwell, offer analgesia if in pain!) + Signs around the bed (Eye drops, glasses, insulin pen, anti-hypertensives) – look for clues!

Pancoast’s tumour, carotid artery aneurysm Inspection Ptosis Horner’s Loss of sympathetic chain Ptosis (muller’s muscle), miosis, anhydrosis, enopthalmos Myasthenia gravis CNIII - levator palpebrae superioris Position III palsy Ptosis, down & out eye +/- fixed dilated pupil Pupil size Causes of Horner’s Brain Stroke Cord Syringomyelia (cyst) Neck Pancoast’s tumour, carotid artery aneurysm Causes of III palsy Pupil normal Diabetes Pupil dilated Aneurysm, tumour

Movements “Please could you face me. Follow my finger with your eyes.” “Any double vision?” Look for nystagmus – the slow beat is the abnormal one! Central – towards side of lesion (e.g. stroke, MS) Vestibular – away from side of lesion (e.g. benign positional vertigo) SO4 LR6

Acuity “I would examine visual acuity with a Snellen chart…” 6m away, +/- glasses ONE EYE AT A TIME!! Acuity 6/12 = patient can read ZADNH at 6m, whilst a person with good eyesight could ZADNH at 12m Pinhole improves score if problem is refraction (not the retina) If blind as a bat: count fingers, perceive hand movements, light vs dark “Can you read this for me?” One eye at a time, show them a newspaper or similar for near vision “I would also test colour vision with an Ishihara chart”

Fields “Can you see my face clearly?” Central scotoma = macular degeneration “Look at my nose. Cover one eye with your hand. Tell me when you can see my fingers wiggling in the corner of your vision.” Move hand SLOWLY towards centre Bitemporal hemianopia = optic chiasm (pituitary tumour) Homonomous hemianopia = optic tract (MCA stroke) Quadrantinopia = temporal radiations (temporal or parietal stroke) “ I would also examine the blind spot” Move red hat pin horizontally inwards, blind spot at 15º Enlarged blind spot = optic atrophy (MS)

Reflexes Direct and consensual response to light Accommodation Swinging light test Relevant afferent pupillary defect (optic atrophy or retinal blindness) Both pupils dilate when light shone into bad eye, but constrict again when shone into good eye Bad eye has lost direct response but retains consensual response Accommodation “Look into the distance…now look at my finger”

Opthalmoscopy “I am going to have a look at the back of your eye. This will involve me coming close to your face and shining a light in your eyes. Just relax and breathe normally. If it’s too uncomfortable just tell me to stop.” “I would perform this in a dark room ideally with tropicamide eye drops to dilate the pupil.” Look through ophthalmoscopy at your hand to check 1) the light is on and 2) it’s focussed! Use red numbers if you are short sighted Use green if you are long sighted Be prepared to adjust focus as you move in if patient has refractive error!

Begin your approach…. Red reflex Arm’s length Right hand + right eye for patient’s right eye Approach from 45º

Move in closer… the 3 Cs Put your free hand on your patient’s forehead so your head hits your thumb before kissing the patient….. If you can’t find the disc, follow the vessels

Optic disc: the 3 Cs Optic disc Colour (pale = optic atrophy) Contour (blurred = papilloedema) Cup:disc ratio (>0.3 optic atrophy e.g. glaucoma) Cup is dipping of vessels into disc, atrophy causes vessels to exit through periphery

Arteries Narrow (copper wiring) AV nipping Neovascularisation artery forces vein deeper into retina Neovascularisation Diabetic proliferative 

Veins Venous dilations Venous loops Central retinal vein occlusion (snow storm appearance due to flame haemorrhages) HTN Papilloedema Venous loops

Macula “Could you look directly at the light please?” Quickly as uncomfortable for patient Colour (pale + cherry red spot = CRAO) Microaneurysms Hard exudates (fat deposits) Cotton wool spots (infarction of nerve fibres)

Macula Haemorrhages Blot Flame (CRVO) Vitreous – (retinal detachment, proliferative retinopathy )

Macula Drusen Laser photocoagulation scars! Exudates behind retina, round and fuzzy (vs hard exudates are in front of retina) ARMD Dry = atrophic (drusen +++), no Rx Wet = exudative (drusen + neovascularisation/bleeding) , T2DM, photocoagulation and anti-VEGF injections Laser photocoagulation scars!

Macula Bone spicule pigmentation Retinitis pigmentosa

Diabetic retinopathy Background retinopathy Microaneurysms, blot haemorrages (3 or less), hard exudates Pre-proliferative retinopathy Cotton wool spots, blots (>3), venous looping Needs lasering T1DM Proliferative retinopathy Neovascularisation (can lead to vitreous haemorrhage) 50% blind in 5 years 

Hypertensive retinopathy Grade 1 (mild) - Arteriolar narrowing/copper wiring, AV nipping Grade 2 (moderate) – Microaneurysm +/- haemorrhage, cotton wool spot +/-hard exudate. Grade 3 (malignant) - plus optic disc swelling.

Questions?