Opthalmoscopy

Dr. Syed Mahbub Ali

HMO MU-I. SOMCH

What is Opthalmoscopy?

Ophthalmoscopy (funduscopy or fundoscopy) is a test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope (or funduscope).

It is done as part of an eye examination and may be done as part of a routine physical examination. It is crucial in determining the health of the retina and the vitreous humor.

History of Ophthalmoscopy

• Ophthalmoscope was first invented by Hermann von Helmholtz(1821-1894), a professor of physics from Germany in 1851.

• He called it an Augenspiegel (eye mirror)

• In 1915, Josh Zele and Jon Palumbo invented the world's first hand-held direct illuminating ophthalmoscope

• Precursor to the device now used by clinicians around the world

• The company started as a result of this invention is Welch Allyn.

Commonly used brands in our country

• Keeler•Heine•Welch allyn

Types of Ophthalmoscope

Direct: This type of ophthalmoscope is most

commonly used during a routine physical examination.Indirect:

Indirect ophthalmoscopy provides a wider view of the inside of the eye and allows a better view of the fundus even if the lens is clouded by cataracts. Used by opthalmologist.

Parts of an ophthalmoscope

How to hold an ophthalmoscope?

Aperture settings

Wide angle view: Illuminates the largest area of fundus for the best possible general diagnosis through a large dilated pupil

Intermediate angle view: Permits easier access through an undilated pupil and in peripheral examination. Particularly useful in pediatric examination.

Macula view: Designed specifically for examination of the macula region of the fundus where a larger beam would create excessive pupillary reaction or patient discomfort.

Glaucoma: Projects a graticule onto the retina to assess the optic cup/disc ratio as an aid to glaucoma diagnosis.

Slit: Used primarily to determine retinal elevations and depressions, but may also be used to assess anterior chamber depth

Fixation Star or Cross: Projects a graticule onto the retina to assess the degree and direction of eccentric fixation, eg, as a result of macula degeneration

Beam filter

Red free: The red-free filter is used to examine the blood vessels in fine detail. By filtering out the red rays, blood vessels are silhouetted black against a dark green background.

Cobalt blue: Used in conjunction with fluorescein dye for the detection and examination of corneal scars and abrasions.

Safety: The unique Keeler safety filter cuts out the ultra violet, visible blue and infrared wavelengths said to cause phototoxic retinal damage with prolonged exposure.

Procedure of Opthalmoscopy

Pre-requisite:• It should be done in a dark room.• Explain whole of the procedure to the

patient.• Pupil is dilated or moderately dilated, but

be careful about mydriatic in Glaucoma or Intra ocular implanted lens (IOL). Dilating the pupil with 1% tropicamide or 1% cyclopentolate. This blurs the near vision for 2-3 hrs.

• Proper positioning: Lying or sitting in chair (better). If lying, move to opposite side when need to examine left eye.

• Appropriate direction.• Proper positioning of the examiner.• Both the eye should be seen

Examination sequence

• At first check your ophthalmoscope’s battery.

• Adjust the ophthalmoscope light to a comfortable brightness.

• Set the ophthalmoscope lens wheel to zero diopters (D) or correct your visual error by glass or ophthalmoscope lens.

• Adjust the focus ring & focus filter.

• Stand 1 hand or half meter apart from the patient in same horizontal plane as patient’s eye.

• Ask the patient to look straight ahead at a distant object – patient should continue to look in this direction even if the examiner’s head obscures the target.

• Patient’s right eye/ your right eye / your right hand /patient’s right side & vice versa.

A distance of about 10-30 cm from the patient try to see through the viewing hole of the ophthalmoscope and focus the light around the patient’s eye. Direction of light should be toward the nose, about 15 degrees from the line of fixation. Instruct the patient to see the distal fixation point with the opposite eye.

• The pupil should appear pink from 10 cm distance. This is the Red reflex.

• Any opacity in the media appear black upon the red reflex.

• If total red reflex is lost, it is due to Medial opacity ( cataract, vitreous haemorrhage) or Retinal problem. opacity

Pupillary red reflex

If patient doesn’t cooperate, fix the head by placing your other hand on the patient’s forehead & gently retract the upper eyelid.

Now come close to the patient’s head ,bring the ophthalmoscope to within 1-2cm of the eye . Not to touch the eye lash of the patient. Now you can see inside the eye. At first try to see any vessel, then follow it medially to find out the optic disc.

• Follow the blood vessels as they extend from the optic disc in four directions: superotemporally, inferotemporally, superonasally& inferonasally

• Ask the patient to look up to see superior retina, look down to see inferior retina, look temporally to examine temporal retina ,look nasally to examine the nasal retina

• Finally locate the centre of the macula by asking the patient to look directly at the light .Macula present two disc temporal from the optic disc

SOME COMMON MISTAKES that we can do, must be corrected by the following way:1.Examine at the same level2. Never obstruct the opposite eye 3.Never examine the right eye by left eye and left hand & vice versa4.Never give too much pressure to the head and shoulder

Common misinterpretations

1.Temporal pallor : Normally paler than nasal, often misinterpreted as abnormal

2.Myopic fundus: Myopic eye is large, so disc appears paler ,may be mistaken for optic atrophy.

3.Hypermetropic fundus: Small eye ,disc appears crowded, mistaken for papilledema

4.Drusen: Colloid bodies that may occcur on disc, mistaken for papilloedema

5.Pigmentation on the disc edge :Normal-may make disc seem pale

6.Tortuous vessels: normal

Purpose of Fundoscopy

• Detection of any haziness (opacity) in media,• Detection of any optical error.• To look inside of the eye.

Haziness in media

• Corneal opacity,• Lens opacity,• Vitreous opacity.

• It can be detected while observing the red reflex by moving the ophthalmoscope; Right/Left or up/down.

• If opacity moves opposite to the light:- Corneal opacity.

• If opacity moves towards the light :- Vitreous opacity.

• If opacity is fixed :- Lens opacity

Various opacities in media

Normal red reflex

Corneal opacity cataract

Optical Error

• If focus is hazy, adjust the lens of the ophthalmoscope to (-) or (+) and denote myopia or hypermetropia of the patient, but make sure that your eye is error free.

• If operator's eye power is normal or if he/she using glasses and Still the focus is hazy, it is due to optical error of the patient.

• At first you will have to turn the focus dial clockwise (plus or black lens), if error is corrected – Patient is Hypermetropic.

• If no improvement, then turn the focus dial anticlockwise (minus or red lens), if error is corrected – Patient is Myopic

What will see in fundus?

Retinal field

Disc

Macula

Blood Vessels

Vein

Artery

Optic Disc

• The optic disc or optic nerve head is the location where ganglion cell axons exit the eye to form the optic nerve

• The optic disc represents the beginning of the optic nerve

• There are no light sensitive rods or cones to respond to a light stimulus at this point. This causes a break in the visual field called "the blind spot" or the "physiological blind spot".

Things to be seen: 3c

• Contour(Margin):– The borders of the optic disc should be

clear and well defined

• Color:– Typically the optic disc looks like an orange-

pink area with a pale centre. The orange-pink appearance represents healthy, well perfused neuro-retinal tissue

Cup: As mentioned above the disc has an orange-pink rim with a pale centre. This pale centre is devoid of neuroretinal tissue and is called the cup

Blood vessels

Arteries:They are superficial, tortuous & brighter. Normally arterial walls are invisible, seen as streak, when light is focused bright streak light reflexion is seen.

• Veins : They are thick, deeper & darker. Normally venous pulsation is visible near the disc. • Total vessels count in disc : 7-10, which

include vein & artery. Count only the main vessels not the branches.

• Normal vein : artery = 3:2.

Common retinal abnormalities

White/yellow lesions:Cotton wool spots (soft exudates): White fluffy spots with indistinct margin caused by retinal ischemia due to accumulation of axonal proteins in the nerve fiber layer. Causes: Severe HTN, DM, retinal vein occlusion ,SLE,AIDS.

Cotton wool

Hard exudates: Bright yellowish sharp-edged lesions consist of lipid deposition that result from leakage of plasma from abnormal retinal capillaries. Causes: DM, HTN.

Chorioretinal atrophy: Well defined punched out lesion. Cause: Previous retinal inflammation, injury

Hard exudate

Hard exudate

Black lesion:Retinal pigment hypertrophy: Black lesion like bony spicules in periphery. Causes: Retinitis pigmentosa due to any cause, previous injury/laser.

Retinitis pigmentosa

Laser burns: black edged round lesion. Usually in regular pattern. Moles: flat, usually round. Normal findings. Melanoma: raised irregular malignant tumour.

Laser burns

Malignant melanoma

Red lesionDot haemorrhage: Thin vertical haemorrhage that may be difficult to differentiate from microaneurysms seen adjacent to blood vessels. Cause: DM.Blot haemorrhage: Larger full thickness haemorrhages in the deeper layer of retina .Rounded, localized. Causes: DM

Blot haemorrhage

Dot haemorrhage

Flame haemorrhage: Superficial bleed, shaped by nerve fibres into a fan with point towards the disc. Cause: HTN, retinal vein oclusion.

Deep large haemorrhage: Retinal/pre-retinal. Causes: Bleeding diathesis.

Subhyaloid haemorrhage: Irregular superficial with flat top. Causes: Subarachnoid haemorrhage.

Pathology in Optic Disc

Common abnormality in optic disc:• Optic disc swelling (Papilloedema/

Papillitis)• Optic atrophy.• Glaucomatous cupping.• Abnormal vessels.

Optic disc swelling

Optic nerve head swelling can be inflammatory or non-inflammatory . If non-inflammatory: Papilloedema If Inflammatory: Papillitis.

Papilledema

• Caused by raised intracranial pressure.

• Loss of venous pulsation (normally absent in 15% people.)

• Disc is abnormally red.• Margins are blurred, upper nasal

quadrant first, then lower nasal, then temporal margin.

• Physiological cup becomes obliterated.

• Retinal veins are slightly distended.• If papilloedema develops rapidly,

there will be marked engorgement of the retinal veins with haemorrhages & exudates on & arround the disc.

• If develops slowly, may be little or no vascular change.

PAPILLITIS

Ophthalmoscopy • Ophthalmoscopy may show no

abnormalities on retrobulbar optic neuritis.

• Dilatation of retinal arteries and veins on optic nerve disc .

• Possible petty splinter hemorrhages on the optic nerve disc .

• Retinal edema around the optic disc.

• Optic nerve disc has blurred margins

• Reddish (hyperemic) optic nerve disc due to dilatation of blood vessels .

• Possible white exudates on the optic nerve disc .

PAPILLITIS PAPILLOEDEMA

Usually unilateral Usually bilateral

Marked dimness of vision. May be slight dimness of vision. Not loss.

Loss of afferent pupillary reflex Not loss.

Visual field defect is usually central, particularly for red & green.

Peripheral constriction or enlargement of blind spot.

Eye ball is painful & tender. Not painful/tender.

Optic Atrophy

Features of optic atrophy• Disc is small.• Pale.• Loss of function.Added may be • Reduced number of

vessels (< 7).• Margin may be sharp /

blurred.

Types1. primary2. secondary

Primary optic atrophy

• Due to disease of the optic nerve.

• Disc is flat, pale/white.• Clear-cut, sharp margins.• Decreased / loss of vision

Secondary optic atrophy• Due to long standing

papilloedema.• Disc is greyish-white.• Indistinct margins.• Decreased / loss of

vision.

Optic atrophy

Papilloedema

In both picture disc margins are blurred/indistinct & vessels count decreased, but in secondary optic atrophy disc colour is pale & in papilloedema disc colour is abnormally red.

Optic cup and Cup Disc ratio(CDR)

• The optic cup is the white, cup-like area in the center of the optic disc.

• The ratio of the size of the optic cup to the optic disc (or cup-to-disc ratio) is the cup disc ratio.

• Normally the cup should take up less than 50% of the disc,i.e. CDR is <.5

• The CDR is measured to diagnose Glaucoma

Glaucoma

CDR= .4

CDR= .77

Progression of glucomatousOptic nerve Damage

Hypertensive retinopathy

Grade 1 : Arteriolar thickening, tortuosity, increased reflectiveness (‘Silver wiring’).

Grade 2: Grade 1 plus constriction of veins at arterial crossings (‘Arteriovenous nipping/nicking’).

Grade 3: Grade 2 plus evidence of retinal ischaemia (‘Flame shaped or blot hemorrhage and cotton wool exudate’).

Grade 4: Grade 3 plus papilloedema.

Grade 1

Grade 1

Grade 1

Silver wiring: – It’s the appearance of blood vessels in

which the arterial wall becomes so completely opaque that the blood column is not seen and the central light reflex occupies all of the width of the arteriole. –The light is completely reflected,

yielding a white ‘line,’ likened to a silver wire,

Grade 2

Normal AV nipping

Grade 2

• AV nicking: A vascular abnormality in the retina of the eye, visible on ophthalmologic examination, in which a vein is compressed by an arteriovenous crossing

• The vein appears "nicked" as a result of constriction or spasm

Grade 3

Cotton woolexudate Blot Haemorrhage

Flame shaped

Grade 4

Hypertensive Retinopathy

Diabetec Retinopathy

Classification of Diabetic Retinopathy–Non-proliferative ‘background’

retinopathy without maculopathy,–Maculopathy,–Pre-proliferative retinopathy,–Proliferative retinopathy

Non-proliferative ‘background retinopathy without maculopathy

Blot hemorrhage

Dot hemorrhage

Hard Exudate

Maculopathy

Hard exudate

Dot and blotHaemorrhage

Macular oedema Macular oedema, exudates, dot & blot hemorrhage

Pre proliferative retinopathyFeatures of pre-proliferative retinopathy: –Venous loops & beading, dot-blot

haemorrhage, large retinal hemorrhage, cotton wool exudates, macular oedema with reduced visual acuity, perimacular exudates, retinal hemorrhages of any size. But no proliferative changes.

Pre-proliferative retinopathy

Proliferative diabetec retinopathy

Abnormal blood vessels

HTN with DM

Fundoscopy findings in different conditions

Retinitis pigmentosa

1.Retinal pigmentation2.Thin Blood vessels3.Pale optic disc

Central retinal vein occlusion

1.Dilated and tortuous retinal veins2.Diffuse intraretinal haemorrhage in all 4 quadrants3.Cotton wool spots4.Swollen optic disk5. Retinal oedema

Central retinal artery occlusion

1. Retina appears pale due to Retinal edema2. Optic disc swelling3. Macula with cherry-red spot on white-yellow background

Acute Leukaemia

Acute leukemia:

Intra-retinal white-centered hge. (Roth spot)

Cotton-wool spots

Aplastic anaemia

Disc edema

Retinal hge

Vitreous haemorrhage

preretinal- unclotted blood with boatshaped configuration, moving towards gravity

Sub arachnoid Haemorrhage

Disc swelling

Retinal hge

Subhyaloid hge

Vitreous hge

Photocoagulation scar mark

Retinal detachment

Mobile Convex Corrugated

retina

Retinoblastoma

Leukocoria

Direct visualization of tumor

(Multi globulat--ed white mass withoverlying retinal detachment)

Roth’s spot

Bacterial endocarditisDM , LeukemiaPernicious anemiaHTN,AIDS

Cytoid body

Systemic lupus erythematosus.

IOL (intra ocular lens)

Anterior chamber IOL Posterior chamber IOL

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