1. Direct Ophthalmoscopy
“THE EYE IS A WINDOW TO SYSTEMIC DISEASE”
Sandra Tubito, O.D.
July 2007

2. Discussion Outline Why ophthalmoscopy? Types of ophthomoscopy
Direct ophthalmoscope
Examination Procedure
Setting
External Exam
Internal Exam
What you should see
Pathology
Questions

3. Why ophthalmoscopy?
Only way (and place in the body) that veins and arteries can be seen in their natural state, non-invasively.
Part of general optical screening where direct observation of the structures of the fundus may show:
Disease of the eye itself (e.g. glaucoma, retinal detachment)
Abnormalities indicative of disease elsewhere in the body (e.g. diabetes, hypertension)
Evaluation of ocular complaints

4. Types of Ophthalmoscopes
Direct ophthalmoscope
Indirect ophthalmoscope

5. Types of Ophthalmoscopes
Direct
X15 magnification
10° field of view
Real image
Monocular
Undilated pupil
Maximum resolution of 70µm
Indirect
X2-3 magnification
30° field of view
Inverted and upside down image
Binocular
Dilated pupil
Maximum resolution of 200µm

6. Direct Ophthalmoscope
Illuminating system
Light bulb
Lenses
Reflector
Aperture stops and filters
Different sized stops to change illumination of the retina
Green (red free) filter
Viewing system
Sight hole (3mm in diameter)
Focusing lenses

7. Direct Ophthalmoscope

8. Examination Procedure
Setting
Dark room
Seat patient in comfortable chair with head rest
Ask patient to look at a slightly elevated target on opposite wall

9. Examination Procedure
External Exam
Look at R eye with R eye (L with L)
Place hand on shoulder or forehead
Change viewing angle to 15° to avoid light reflex of cornea

10. Examination Procedure
External Exam
Red Reflex - hold ophthalmoscope at ~50cm and look through sight hole at the ocular media. Find the red reflex in the pupil. Opacities (eg cataracts) can be seen.
Place +8.00D lens in sight hole and move to ~10cm to inspect anterior structures:
lids/lashes
conjunctiva
cornea

11. Examination Procedure
Internal Exam
Turn focus wheel to bring anterior chamber and iris into focus
Gradually reduce power in ophthalmoscope to focus on internal structures:
Lens
Vitreous
Retina

12. Examination Procedure
Internal Exam
Continue turning focus wheel to bring retina/vessels in focus
Follow the vessels to the disc
The ‘arrow’ point to the disc
Examine the disc, vessels, retina, & macula.

13. Things you should see The optic nerve head
Appearance – shape/size (1.5mm in diameter)
Color – disc is pale pink, cup is whitish
Elevation – should be flat
Rim – clear and distinct
Cup/Disc ratio
Ratio of the diameter of the cup to the diameter of the disc

14. Cup /Disc ratio

15. Things you should see Retinal vessels Follow vessels from disc
Arteries
Lighter in color, smaller
Veins
Darker in color, larger
May spontaneously pulsate at the disc (80%)
The ratio of the artery :vein diameter is normally ~ 2:3
Follow vessels from disc
Look at arterio-venous crossings for abnormalities (nicking, compression, elevation, deviation)
Check arterial light reflex. This will get whiter and thicker in arteriosclerosis

16. Arteriovenous changes
Tapering concealment of the vein appearing as ‘nicking’
Elevation of the vein over the artery
Deviation of the vein out of its path
Compression of the vein at the arterio-venous crossing, causing stenosis of the distal vein

17. Things you should see Retina Check the background retina
Look for color differences
areas of hyper or hypo pigmentation
Scarring
Raised areas
Hemorrhages, microaneurisms
Cotton wool exudates
Hard exudates
A more peripheral view can be obtained by having the patient look in different directions OD OS

18. Things you should see Fovea and Macula
Change sight hole to the smallest aperature
Have patient look at the light
Temporal and slightly inferior to the disc
Slightly darker than rest of retina
Central depression/reflex - fovea

19. Pathology - The optic nerve
Optic atrophy

20. Pathology - The optic nerve
“Choked disc” or
Papilledema

21. Pathology – The optic nerve
Glaucomatous cupping

22. Pathology - The optic nerve
Papilledema with
papillary hemorrhages
Disc neovascularization

23. Pathology – Retina / Vessels
Arterial
occlusions

24. Pathology – Retina / Vessels
Circinate exudates

25. Pathology – Retina / Vessels Intra-retinal hemorrhages

26. Pathology – Retina / Vessels
Cotton wool spots

27. Pathology – Retina / Vessels
Neovascularization

28. Pathology - Retina / Vessels
Arterial plaques

29. Pathology – Retina / Vessels
Venous occlusions

30. Pathology - Macula
Drusen

31. Age related macula degeneration
Pathology - Macula
Age related macula degeneration
Hemorrhagic phase

32. Exudative age related macular degeration
Pathology - Macula
Exudative age related macular degeration

33. QUESTIONS?