1. Clinical principle ofClinical principle of
Direct OphthalmoscopyDirect Ophthalmoscopy
&&
methods of recordingmethods of recording
observationobservation
Farhana AdninFarhana Adnin
B.Optom,4B.Optom,4thth
BatchBatch
IICO,CU.CO,CU.

2. What isWhat is ophthalmoscopyophthalmoscopy…???…???
&&
ophthalmoscopeophthalmoscope…???…???

3. TTypes…ypes…
 DirectDirect ophthalmoscopyophthalmoscopy
 IndirectIndirect ophthalmoscopyophthalmoscopy
 MonocularMonocular
 BinocularBinocular
 Fundus BiomicroscopyFundus Biomicroscopy
direct ophthalmoscopy??direct ophthalmoscopy??
head
neck
body

4. IInstrumentation…nstrumentation…
 Direct Ophthalmoscope consists of ~Direct Ophthalmoscope consists of ~
 Illumination system& observation systemIllumination system& observation system
 Illumination systemIllumination system –light source–light source
-condensing lenses-condensing lenses
-reflecting prism-reflecting prism
-a series of aperture-a series of aperture
 Observation systemObservation system –a peephole–a peephole
-a bank of spherical-a bank of spherical
lenseslenses

5. Ophthalmoscope head,neck, bodyOphthalmoscope head,neck, body
Lens
strength
selector
wheel
Selects light
size,filter & grid
Concave mirror
with a hole in centre
Bulb
in
here
Connects to rheostate and
handle containing batteries
peephole
On/off rheostate
Contains battery here

6. PrinciplePrinciple

7. Optics ofOptics of
direct ophthalmoscope…direct ophthalmoscope…

8. Cont..Cont..

9. Characteristics of the imageCharacteristics of the image
 VirtualVirtual
 Erect andErect and
 Magnified image.Magnified image.
 Magnification;Magnification;
MMEE = distance from viewers eye to patient’s fundus= distance from viewers eye to patient’s fundus
focal lengthfocal length
= 250mm/16.67mm= 250mm/16.67mm =15X=15X
For emmetrope, MFor emmetrope, MAA =15X=15X
For myope ,moreFor myope ,more
For hyperope, less.For hyperope, less.

10. 05/21/1505/21/15
Methods of OphthalmoscopyMethods of Ophthalmoscopy
 Distance direct ophthalmoscopyDistance direct ophthalmoscopy
 Illuminating eye from 25-40 inchesIlluminating eye from 25-40 inches
 Direct ophthalmoscopyDirect ophthalmoscopy
 Approach closer to patient.Approach closer to patient.

11.  Set the patient in a semi dark room & instruct toSet the patient in a semi dark room & instruct to
look at a distant target.look at a distant target.
 Hold ophthalmoscope in right hand and lookHold ophthalmoscope in right hand and look
through examiners’r right eye at patient’s rightthrough examiners’r right eye at patient’s right
eyeeye
 Examine for red reflex at arm’s length (20-40cm)Examine for red reflex at arm’s length (20-40cm)
 Normal - red glow from choroidNormal - red glow from choroid
 Look for opacities or loss of reflexLook for opacities or loss of reflex
 The examiner moves as close as to the patientThe examiner moves as close as to the patient
to examine anterior segment with high + powerto examine anterior segment with high + power
ProcedureProcedure
of direct ophthalmoscopy…of direct ophthalmoscopy…

12. Cont…Cont…
 Then by reducing + power,crystaline lens,vitreousThen by reducing + power,crystaline lens,vitreous
& finally the optic nerve head can be observed.& finally the optic nerve head can be observed.
 Optic disc is visualized first & blood vessels canOptic disc is visualized first & blood vessels can
be followed then.be followed then.
 After quadrant by quadrant scan of fundus,theAfter quadrant by quadrant scan of fundus,the
macula is examined.macula is examined.
 ……left eye…left eye…

14. Clinical UsesClinical Uses
1)Light to checkpupillary reaction1)Light to checkpupillary reaction
2)Media opacities can be detected2)Media opacities can be detected
3)3)Estimation of patients refractive errorEstimation of patients refractive error
4)Visuoscopy4)Visuoscopy
5)Small aperture and half moon:5)Small aperture and half moon:
when pupil is miosed and in case of media opacitieswhen pupil is miosed and in case of media opacities
6)Slit beam6)Slit beam
 To view the contours in iris and retinaTo view the contours in iris and retina
7)7)Red Free filterRed Free filter
8)Blue filter-8)Blue filter- stainingstaining

16. 05/21/1505/21/15
ClinicalClinical IImportancemportance
To observe the optical clarity of Human EyeTo observe the optical clarity of Human Eye
 Dark or semi-dark spot over red reflexDark or semi-dark spot over red reflex OpacityOpacity
 If no reflex (whole field dark/Gray)If no reflex (whole field dark/Gray)
 Totally opaque lensTotally opaque lens
 Hemorrhage within the eyeHemorrhage within the eye
 Total RDTotal RD
 Crescentic ring in pupillary areaCrescentic ring in pupillary areaSubluxatedSubluxated
LensLens
 Grayish patchesGrayish patchesRD, Choroidal detachment orRD, Choroidal detachment or
intra-ocular tumorintra-ocular tumor

17. ClinicalClinical IImportancemportance
 To evaluate A/C angleTo evaluate A/C angle Shadow technique of evaluating
angles
 Anterior segment:Anterior segment:
# Grossly examine the cornea, lids, sclera, lashes and iris.# Grossly examine the cornea, lids, sclera, lashes and iris.
#Use +13 or 13D lenses in your ophthalmoscope. The ophthalmoscope and#Use +13 or 13D lenses in your ophthalmoscope. The ophthalmoscope and
your face should be about 2 to 3 inches away from the patient to examineyour face should be about 2 to 3 inches away from the patient to examine
the rest.the rest.
 Vitreous:Vitreous: Vitreous floaters are best seen with a + 6 or 7 D lens inVitreous floaters are best seen with a + 6 or 7 D lens in
place.place.
 DiscDisc
 FundusFundus
 MaculaMacula

18. Basics & Fundamentals of RecordingBasics & Fundamentals of Recording
Ophthalmoscopic Findings:Ophthalmoscopic Findings:
1]Fundal glow1]Fundal glow
2] Disc2] Disc ~shape ~ margin~color~vessels~shape ~ margin~color~vessels
emergedemerged
~cup/disc ratio ~neural rim~cup/disc ratio ~neural rim
3]Retina3]Retina~periphery{4quadrants}~periphery{4quadrants}haemorrhage,exudate,haemorrhage,exudate,
pigmentarypigmentary
changes,vascularizationchanges,vascularization
~macula (~macula (foveal reflex,any abnormality likefoveal reflex,any abnormality like
hole,scar,oedema,haemorrhage)hole,scar,oedema,haemorrhage)
~vessels~vessels (vascular reflexes,A/V ratio,crossing,new(vascular reflexes,A/V ratio,crossing,new

20. optic discoptic disc
 Move as close to the patient as possible.Move as close to the patient as possible.
 Find the optic discFind the optic disc
 Examine the optic discExamine the optic disc
shapeshape--round to oval; diameter (1.5-1.7)round to oval; diameter (1.5-1.7)
marginmargin--sharp or dull;occasionally a pigment ring or conus.sharp or dull;occasionally a pigment ring or conus.
colour:colour: red-yellow ; temporal part may appear pale.red-yellow ; temporal part may appear pale.
vessels emerged fromdisc:vessels emerged fromdisc: Noticed to seeNoticed to see
neovascularization.neovascularization.

21. Cont…Cont…
 C/Dratio (cup/disc)C/Dratio (cup/disc)

22. ISNT ruleISNT rule

23. RetinaRetina
 PeripheryPeriphery- lighter than central area- lighter than central area
 AV ratioAV ratio (normal 2:3)(normal 2:3)
 Fundus colour:Fundus colour:Darker with pigmented skin orDarker with pigmented skin or
retinitisretinitis
pigmentosapigmentosa
Pale with arterial occlusionPale with arterial occlusion
 MaculaMacula-- appears darker than central areaappears darker than central area
-3mm temporal to disc.-3mm temporal to disc.
- Central foveal reflex- Healthy/ dull- Central foveal reflex- Healthy/ dull

24. Clinical recording ofClinical recording of
Ophthalmoscopic findings…Ophthalmoscopic findings…
In normal case…In normal case…
 Shape- roundShape- round
 Marjin-sharpMarjin-sharp
 Colour-pinkColour-pink
 C/D ratio- 0.3:1 (supposing)C/D ratio- 0.3:1 (supposing)
 A/V ratio- 2:3A/V ratio- 2:3
 Macula – healthy & bright foveal reflex.Macula – healthy & bright foveal reflex.

25. Blurred disc margin
pink disc
Disc swollen / raised
glaucoma
normal
papilloedema

26. 05/21/1505/21/15
Pale, featureless
disc
optic atrophy
BRVO

27. 05/21/1505/21/15
Hard exudates
Haemorrhage
Microaneurysm
non-proliferative diabetic
retinopathy
Proliferative diabetic
retinopathy

28. Age-related MacularAge-related Macular
DegenetationDegenetation
 Wet form: abnormal bloodWet form: abnormal blood
vessel growth w/ hemorrhagevessel growth w/ hemorrhage
and protein leakageand protein leakage
Dry form: DrusenDry form: Drusen
(cellular debris) build-(cellular debris) build-
upup

29. 05/21/1505/21/15
Move on to the front of theMove on to the front of the
eyeeye
Dendritic ulcer (herpes virus)
on the cornea inspected with
cobalt blue light
Foreign body
cataract
Corneal ulcer

30. Oil droplet reflex inOil droplet reflex in
KeratoconusKeratoconus

31. References
1.Theory & practice of Optics & Refraction…
A.K.Khurana
2.Clinical Procedure in Optometry
3.Primary Care Optometry… Theodore Grosvenor
4.Essentials of Ophthalmology…S.K.Basak
5.Internet