1. Ophthalmoscopy
David Kinshuck

2. This session 1 Over the next hour Ophthalmoscopy in a younger person
Need to practice for older patients
15 minute introduction
Practice on each other for 40 minutes
3 minute summary
If time we may cover refraction

3. This session 2 Very briefly In more detail, ophthalmoscopy itself
External examination
Test pupils
Test visual fields
In more detail, ophthalmoscopy itself
Red reflex
Examine disc
Rest of retina

4. Visual fields

6. Ophthalmoscope controls 1
Play with ophthalmoscope
Work out what the controls are for

7. Ophthalmoscope controls 2

8. Ophthalmoscope controls 3

9. Pupils
Pupils (needs Flash player installed)

10. Red reflex

11. Ref reflex technique Check red reflex from 10 cm, focusing on iris
+3.00 lens?
Actually focus on the pupil margin
Brightest light in ophthalmoscope
Stay on same side of patient for both eyes
Room lights dim

12. ‘white’ reflex ?retinoblastoma
?retinoblastoma

13. Ophthalmoscopy 2 What is your refraction
What is the patient’s refraction
……what lens do you use in the ophth.?
Light travels from patient retina to your retina

14. Ophthalmoscopy 3
Distance: closer you are, the greater the visual field..1” away is best
Pupil size for ophthalmoscope beam must match patient’s pupil size (otherwise get too much reflection)
Too bright…pupil goes small
Too dim..not see
Need room lights off/dim

15. Ophthalmoscopy 4
the closer you get, the larger area of retina seen at one time;
Look in from 2 cm away

16. Ophthalmoscopy 5 Match beam diameter with pupil size.. not too wide
Just right, no reflection
Too wide a beam leads to increased reflection

17. Ophthalmoscopy 6 Match beam diameter with pupil size..not too narrow
Too narrow a beam…too little retina is seen

18. Ophthalmoscopy 7
If beam is too bright, pupil goes small (then get a reflection).
Too dim, won’t see anything!

19. Ophthalmoscopy 8
Patient looks up, doctor down (more comfortable/quicker)

20. Ophthalmoscopy 9 Index finger on focus dial,
Thumb on brightness control (rheostat)

21. Ophthalmoscopy 10
Consider using middle finger to gently touch cheek …steadies ophthalmoscope and prevents banging into eye

22. Ophthalmoscopy 11
Consider resting ophthalmoscope on thumb (which rests over eyebrow) to steady ophthalmoscope and prevent banging into the eye

23. Ophthalmoscopy 12
Hold ophthalmoscope immediately adjacent to your own (observer’s) eye to get the best view.

24. Ophthalmoscopy 13
Examine optic first (looking medially 15o. Otherwise, as soon as light hits the fovea, pupil will go smaller, making examination more difficult.

25. Ophthalmoscopy 14
Use the grid to locate the fovea (the centre of the macula).

26. What is the most important part of the retina for the none-ophthalmologist?
The optic nerve ….
Papilloedema, raised intracrainial pressure & many other conditions

27. How to find the optic nerve
Look medially 15o …optic nerve, pituitary, optic tract/cortex lie on the same 15o axis

28. How to find the optic disc
Vessels point to the optic nerve, so find a vessel fork and move towards optic disc

33. summary What did you find easy Hard Red reflex +3.0 d
Retina focus..your prescription + patient’s
Dim room light
Match beam diameter with pupil size at 2 cm
Get close…2 cm….larger area of retina visible
Beam not too bright otherwise pupil goes small
Patient looks up 15o
Rest finger on cheek?
Follow vessel branching towards the optic disc
Disc is 15o medial
Use grid in ophthalmoscope to locate fovea

34. Refraction 1

35. Refraction 1
Which lens is needed for which eye?

36. Refraction 2 Use the appropriate lens for the eye
Add to your own spectacle prescription for ophthalmoscopy

37. Refraction 3: how to find the plus lens
Focus on something very close

38. Refraction 4: how to find patient’s spectacle prescription
Hypermetropic
lens magnifies
Myopic lens makes everything appear smaller
Emmetropic

39. Refraction 5: examining high myopes
For myopes there is only one focal plane…any further back and you will be out of focus. This is unlike emmetropes: you will be in focus even if you examine from a distance (although only a tiny amount of retina will be visible).
Also, unless you have an excellent ophthalmoscope, you may be best examining by looking through the patient’s own spectacles.