preliminary idea on Fundoscopy

2. What is Opthalmoscopy?

3. 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).

4. 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.

5. History of Ophthalmoscopy

6. • 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)

7. • 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.

8. Commonly used brands in
our country
• Keeler
• Heine
•Welch allyn

9. Types of Ophthalmoscope

10. 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.

11. Parts of an ophthalmoscope

13. How to hold an ophthalmoscope?

15. Aperture settings

16. 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

17. 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.

18. Procedure of Opthalmoscopy

19. 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.

20. • 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

21. Examination sequence

22. • At first check your
ophthalmoscope’s
battery.
• Adjust the
ophthalmoscope light
to a comfortable
brightness.

23. • 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.

24. • 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.

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

26. 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.

27. • 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.
Pupillary red reflex
opacity

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

29. 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.

30. • 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

31. • 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

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

33. 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

34. 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

35. Purpose of Fundoscopy

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

37. 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

38. Various opacities in media
Normal red reflex
Corneal opacity cataract

39. 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.

40. • 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

41. What will see in fundus?

42. Retinal field

43. Disc

44. Macula

45. Blood Vessels
Vein
Artery

46. 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

47. • 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".

48. 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

49. 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

50. 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.

51. • 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.

52. Common retinal abnormalities

53. 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

54. 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

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

56. 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

57. Red lesion
Dot 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
Dot haemorrhage
Blot haemorrhage

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

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

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

61. Pathology in Optic Disc
Common abnormality in optic disc:
• Optic disc swelling (Papilloedema/ Papillitis)
• Optic atrophy.
• Glaucomatous cupping.
• Abnormal vessels.

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

63. 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.

64. • 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.

66. 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 .

67. • 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 .

68. 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.

69. 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.

70. Types
1. primary
2. secondary

71. 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.

72. Papilloedema Optic atrophy
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.

73. 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

74. Glaucoma
CDR= .4
CDR= .77

75. Progression of
glucomatous
Optic nerve
Damage

76. 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.

77. Grade 1

78. Grade 1

79. 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,

80. Grade 2
Normal AV nipping

81. 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

82. Grade 3
Cotton wool
exudate
Blot Haemorrhage
Flame shaped

83. Grade 4

84. Hypertensive Retinopathy

85. Diabetec Retinopathy
Classification of Diabetic Retinopathy
–Non-proliferative ‘background’
retinopathy without maculopathy,
–Maculopathy,
– Pre-proliferative retinopathy,
– Proliferative retinopathy

86. Non-proliferative ‘background
retinopathy without maculopathy
Blot hemorrhage
Dot hemorrhage
Hard Exudate

87. Maculopathy
Hard exudate
Dot and blot
Haemorrhage
Macular oedema Macular oedema, exudates, dot & blot
hemorrhage

88. Pre proliferative retinopathy
Features 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.

89. Pre-proliferative retinopathy

90. Proliferative diabetec retinopathy
Abnormal blood
vessels

91. HTN with DM

92. Fundoscopy findings in
different conditions

93. Retinitis pigmentosa
1.Retinal
pigmentation
2.Thin Blood
vessels
3.Pale optic disc

94. Central retinal vein occlusion
1.Dilated and
tortuous retinal
veins
2.Diffuse intraretinal
haemorrhage in all
4 quadrants
3.Cotton wool spots
4.Swollen optic disk
5. Retinal oedema

95. Central retinal artery occlusion
1. Retina appears
pale due to Retinal
edema
2. Optic disc
swelling
3. Macula with
cherry-red spot on
white-yellow
background

96. Acute Leukaemia
Acute leukemia:
Intra-retinal
white-centered
hge. (Roth spot)
Cotton-wool
spots

97. Aplastic anaemia
Disc edema
Retinal hge

98. Vitreous haemorrhage
preretinal- unclotted
blood with
boatshaped
configuration,
moving towards
gravity

99. Sub arachnoid Haemorrhage
Disc swelling
Retinal hge
Subhyaloid hge
Vitreous hge

100. Photocoagulation scar mark

101. Retinal detachment
Mobile
Convex
Corrugated
retina

102. Retinoblastoma
Leukocoria
Direct
visualization of
tumor
(Multi globulat-
-ed white mass with
overlying retinal
detachment)

103. Roth’s spot
Bacterial endocarditis
DM , Leukemia
Pernicious anemia
HTN,AIDS

104. Cytoid body
Systemic lupus erythematosus.

105. IOL (intra ocular lens)
Anterior chamber IOL Posterior chamber IOL

106. Thank You