1. Fundoscopy
Holly Wilson

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

3. 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 

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

5. 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!

6. 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

7. 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

8. 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”

9. 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)

10. 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”

11. 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!

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

13. 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

14. 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

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

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

17. 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)

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

19. 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!

20. Macula
Bone spicule pigmentation
Retinitis pigmentosa

21. 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 

22. 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.

23. Questions?