1. Direct ophthalmoscopy
OP1201 – Basic Clinical Techniques
Anterior eye
Dr Kirsten Hamilton-Maxwell

2. Today’s goals
By the end of today’s lecture, you should be able to explain
Why examining the anterior eye is important
Basic construction and optical principles of the direct ophthalmoscope
How to use it to examine the anterior eye and how to record results
Have some awareness of normal and abnormal anterior eye conditions
Limitations of direct ophthalmoscopy for the anterior eye
By the end of the related practical, you should be able to
Assess and record the health of the anterior eye using direct ophthalmoscopy efficiently and accurately

3. Background Why ocular health assessment is important
What is a direct ophthalmoscope?
Basic ocular anatomy

4. Ocular health Good ocular health is vital to good vision
Optometrists are primary care practitioners
Required to identify ocular health problems
Manage or refer appropriately for treatment
Ocular health examination is one of our primary functions
Today we will look at one of the techniques used to examine the eye – ophthalmoscopy!

5. Ophthalmoscopy An instrument used for assessment of ocular health
Posterior eye
Can also be used for the anterior eye

6. The direct ophthalmoscope
Most contain…
Light source
Eyepiece
Lens rack and power dial
Usually between -15D and +15D in 1D steps
Jump change of ±10/15D
Total range of -30D to +30D
Aperture selector
Filter selector
On/off and brightness control
Power handle
(We will talk more about how it all goes together in the next lecture)

7. Basic ocular anatomy
Anterior eye
Posterior eye

8. Anterior eye anatomy Pupillary margin Eyelashes Lateral canthus
Medial canthus
Cornea
Conjunctiva
Episclera
Lid margin
Lens

9. Procedure
When?
How?
A few examples
Recording results

10. When should I do direct ophthalmoscopy?
This is probably the most important test that you will do
Every patient
Legal requirement!
Just to clarify… the eye health of every patient MUST be assessed, however, direct ophthalmoscopy is not the only method that we can use.
There are no contraindications
i.e. No reason that you should not attempt it on every patient

11. How to do ophthalmoscopy
Set up
Remove spectacles (yours and the patient’s)
Explain what you are doing
Raise the examination chair so you are bending slightly
Dim the room lighting
Hold the ophthalmoscope in your right hand in front of your RE for patient’s RE, swap all to the left side for LE
Hold as close to your eye as possible
Tilt ophthalmoscope to about 20deg to avoid bumping into the patient’s nose

12. How to do ophthalmoscopy
Ask the patient to look at a spot about 15deg temporal, and up slightly
Keep BOTH eyes open (you and the patient) and look through the eyepiece
Using both eyes will help control your accommodation and it will be more comfortable
This will take practice

13. How to do ophthalmoscopy
Systematic examination of
Eyelids and eyelashes
Conjunctiva
Cornea
Iris
Pupil
Lens

14. Eyelids Set the ophthalmoscope lens to +10D
The patient’s eye will be in focus at 10cm away if you are emmetropic
At 10cm away, the magnification is 2.5x
Adjust for your refractive error
Use a lower power if you are a myope (short-sighted)
Use a higher power if you are a hypermetrope (long-sighted)
Wear your spectacles if you have high astigmatism
The patient’s refractive error is not important for the anterior eye exam
Use widest and brightest beam
Look for changes in colour (especially red or brown), lumps, rough areas, ulcerations, loss or irregularity of eyelashes

15. Stye (external hordeolum)

16. Basal cell carcinoma

17. Conjunctiva
As for eyelids, but ask patient to look in 9 cardinal directions of gaze
Up, up-left, left, down-left, down, down-right, right, up-right
Lift eyelid to see upper conjunctiva when eye looks down
Look for changes in colour (especially redness), raised/rough areas, irregularity of blood vessels

18. Allergic conjunctivitis

19. Subconjunctival haemorrhage

20. Pinguecula

21. Cornea, iris and pupil
As for the conjunctiva and lids, but ask the patient to look straight ahead
The cornea
Look for a loss of transparency, ulceration, presence of blood vessels
Iris
Look for irregularities in colour, texture, raised areas, blood vessels, transillumination
Pupil
Look for shape, size and at the pupil margin

22. Corneal arcus

23. Corneal ulcer

24. Iris nevus

25. The lens Is located immediately behind the iris Direct illumination
When looking at the pupil, you are actually looking at the lens
Direct illumination
Shine the light onto the lens
Look for changes in colour (especially white or yellow)
Indirect illumination
Relies on the annoying red glow seen in photographs!
Look for black/grey shadows

26. How to view the lens
Retro-illumination

27. Cataract

28. Lens - retroillumination
This technique is also good for observing corneal lesions and iris transillumination

29. Iris transillumination

30. Recording your findings
Draw abnormalities
Never EVER write NAD or WNL
Legally = Not Actually Done or We Never Looked!
Written description here
Written description here
Be descriptive, even when normal
Be descriptive, even when normal
Colour, size, shape
Colour, size, shape
Record cards always show the RE on the left side of the page
– the way you see the patient!

31. Example of lens recording
Mittendorf dot
Ant
Post
Side view
Front view
This diagram shows the position and the depth

32. Example

33. What to write

34. Limitations

35. Limitations of direct ophthalmoscopy
Direct ophthalmoscopy of the anterior eye is a screening technique
Instrument of choice is the slit lamp
We will cover this later in the year
Low magnification (2.5x for the anterior eye)
No stereopsis (3D vision)
Minimal lighting variability

36. Further reading Elliott, Sections 6.4 to 6.5, 6.20
Become familiar with the procedural steps
Memorise anatomical structures