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

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

3. Opthalmoscope/Fundoscope

4. 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

5. 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

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

7. Structure of Retina

8. How to Perform Fundoscopy
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

9. 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.

10. Fundus of the Eye
Left Eye.

11. 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

12. 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

13. Four Quadrants
Check all four quadrants

15. Macula + Fovea