1. Medical Instruments I Practical Use of the Ophthalmoscope and Otoscope Amanda Kocoloski, OMS IV Primary Care Associate/DFM Fellow

2. Objectives Understand how to use the following equipment:Understand how to use the following equipment: OphthalmoscopeOphthalmoscope OtoscopeOtoscope Learn the fundoscopic exam and introduce the ear examLearn the fundoscopic exam and introduce the ear exam Begin to appreciate normal eyes and ears by practicing on colleagues and instructorsBegin to appreciate normal eyes and ears by practicing on colleagues and instructors

3. Ophthalmoscope Basics Ophthalmoscope AnatomyOphthalmoscope Anatomy Ophthalmoscope OperationOphthalmoscope Operation Red ReflexRed Reflex Examination of the FundusExamination of the Fundus

4. Ophthalmoscope Anatomy View of the scope from the doctor’s perspective

5. Ophthalmoscope Anatomy (Continued) View of the scope from the patient’s perspective

6. In the Office/SP Lab

7. Ophthalmoscope Operation Turning it on:Turning it on: Depress button and rotateDepress button and rotate Adjust to about mid-brightnessAdjust to about mid-brightness

8. Ophthalmoscope Operation Use the large, round, white beamUse the large, round, white beam Smaller may be helpful if pupil is not dilatedSmaller may be helpful if pupil is not dilated Set the wheel used for changing the lens at zero dioptersSet the wheel used for changing the lens at zero diopters

9. Eye Anatomy

10. Red Reflex Reflection of light off of retinaReflection of light off of retina Pink to red in colorPink to red in color Should be equal in both eyesShould be equal in both eyes Presence indicates there are NO opacities within the following areas:Presence indicates there are NO opacities within the following areas: Tear FilmTear Film CorneaCornea Anterior Chamber – Aqueous FluidAnterior Chamber – Aqueous Fluid LensLens Vitreous FluidVitreous Fluid

11. Conditions With Absence of the Red Reflex CataractsCataracts Opacity of the lensOpacity of the lens Detached retinaDetached retina RetinoblastomaRetinoblastoma Artificial globe/eyeballArtificial globe/eyeball

12. Ophthalmoscopic Exam: Red Reflex Have your patient look up and over your shoulderHave your patient look up and over your shoulder To visualize the red reflex, stand about 15 inches from your patient’s eyeTo visualize the red reflex, stand about 15 inches from your patient’s eye

13. Ophthalmoscopic Exam: Fundus Your right eye to patient’s right, your left to patient’s leftYour right eye to patient’s right, your left to patient’s left Place your free hand on the patient’s shoulder or forehead for stabilizationPlace your free hand on the patient’s shoulder or forehead for stabilization Beginning from the temporal aspect move in toward your patient’s eye to begin examination of the fundusBeginning from the temporal aspect move in toward your patient’s eye to begin examination of the fundus Keyhole phenomenonKeyhole phenomenon Focus by adjusting the diopter if necessaryFocus by adjusting the diopter if necessary Should be unnecessary if neither you nor the patient have uncorrected refractive errorsShould be unnecessary if neither you nor the patient have uncorrected refractive errors

14. Ophthalmoscopic Exam: Fundus Identify VesselsIdentify Vessels Veins: Large darker vesselsVeins: Large darker vessels Artery: Smaller brighter vesselsArtery: Smaller brighter vessels Optic diskOptic disk Located on nasal aspectLocated on nasal aspect Sharp margins; nasal may be blurredSharp margins; nasal may be blurred Yellow/orangeYellow/orange Physiologic optic cupPhysiologic optic cup Macula and FoveaMacula and Fovea Located on temporal aspectLocated on temporal aspect Best visualized: stare directly at the lightBest visualized: stare directly at the light

15. Ophthalmoscopic Exam: Fundus A:V ratio Arteries are 2/3 to 4/5 the diameter of veins AV nicking (”Gunn sign”) Associated with hypertension Pathological arterial circulation impedes venous flow at their intersection Cup to disk ratio Cup is caused by central depression Divide width of physiologic cup by the disk Normal ratio is ≤ 0.5

16. Ophthalmoscopic Exam: AV Nicking

17. Ophthalmoscopic Exam: Fundus Spontaneous venous pulsations Normal as veins emerge from disc May be reduced or absent in with elevated pressure Papilledema Optic nerve swelling Often associated with increased intracranial pressure Almost always bilateral

18. Ophthalmoscopic Exam: Right Fundus Photo and corresponding diagram of a normal fundus. Note that the retinal vessels all stop short of and do not cross the fovea.

19. Ear Exam

20. Examination of the External Ear Inspect the auricle for deformitiesInspect the auricle for deformities Skin tags/pitsSkin tags/pits Lymph nodesLymph nodes Epidermoid cystEpidermoid cyst Squamous/basal cell CASquamous/basal cell CA Pain, discharge, or inflammation?Pain, discharge, or inflammation? Perform the tug testPerform the tug test

21. Otoscopic Basics

22. Otoscopic Examination of the EAC and TM Straighten the ear canalStraighten the ear canal Adults- pull superior and posteriorAdults- pull superior and posterior Children– pull posterior and maybe inferiorChildren– pull posterior and maybe inferior Hold otoscope between your thumb and fingers; rest hand on patient’s faceHold otoscope between your thumb and fingers; rest hand on patient’s face Handle may point downward or toward patient’s eyebrowHandle may point downward or toward patient’s eyebrow Right hand when looking in the right ear, left hand when looking in the left earRight hand when looking in the right ear, left hand when looking in the left ear

23. Otoscopic Examination of the EAC and TM Under direct visualization: Insert the speculum into the ear canal, directing it forward and downwardUnder direct visualization: Insert the speculum into the ear canal, directing it forward and downward Inspect the canal with insertionInspect the canal with insertion Inspect the tympanic membraneInspect the tympanic membrane colorcolor contourcontour anatomical structuresanatomical structures

24. Otoscopic Examination of the EAC and TM Normal right ear Normal left ear Pars flaccidaIncus Cone of light Pars tensa Malleus Pars tensa Umbo

25. References Bates’ Guide to Physical Examination, Chapter 5. Bates’ Guide to Physical Examination, Chapter 5. http://www.medicine.ucsd.edu/clinicalmed /introduction.htmhttp://emedicine.medscape.com/article/120 1779-overview http://www.medicine.ucsd.edu/clinicalmed /introduction.htm Vaughan & Asbury's General Ophthalmology, 17e