Year 1 MBChB

Clinical Skills Session

Ophthalmoscopy Reviewed & ratified by: Dr V Taylor-Jones, Mr M Batterbury – Consultant Ophthalmologist

Learning objectives

o To understand the anatomy and physiology of the external and internal

eye and apply it to the practical skill

o To understand the basic use of an ophthalmoscope and be able to identify

a basic structure in your partner's eye

The Ophthalmoscope

Indications for Ophthalmoscopy

Ophthalmoscopy is performed for:

o Trauma around or of the eye itself

o Routine diabetic check

o As part of a neurological examination

o Deteriorating vision

o Symptoms associated with visual problems

Headaches

This enables you to turn on the light source and

dim or brighten as necessary. When turning the

rheostat some ophthalmoscopes have a lock

switch which has to be depressed at the same

time

This is a wheel which can be operated from

either side by rotating up wards or downwards

you can alter the degree of focus

As the focus wheel is turned the number

reflecting the degree of focus (the selected

lenses) you have selected is displayed here

Holding the Ophthalmascope

o Hold instrument in right hand, held to right

eye to look in patient’s right eye and vice

versa.

o Hold the instrument with the index finger

resting on the focusing wheel and the thumb

on the rheostat.

o At the start of the examination, you will be

inspecting the anterior segment of the eye,

and therefore you will rotate the lens wheel

to magnify your view. The lens value will

change- to give a positive dioptre (magnified

view, like reading glasses) the lens value should be green. Once you have

finished examining the anterior segment, you will rotate the focus wheel

to return to “0”.

o Select a wide mask.

o Limit the brightness of the beam using thumb - too bright a beam is

uncomfortable.

o The instrument MUST be

held close to the

examiner’s eye nestled

against the supraorbital

ridge or against glasses if

worn

o Look through the aperture

with one eye and close the

other, or leave open if you prefer

Indications for Ophthalmoscopy

A patient may have ophthalmoscopy performed if they present;

o For a routine health check

o For an occupational health check

o For a diabetes check

o For a check if they suffer with hypertension

o With changes in vision

o With pain

o Following trauma (head/ eye)

o With a foreign body

Or this may be done as part of a cranial nerve assessment.

This list is not exhaustive.

Patient safety

Considerations

Whilst explaining the procedure to the patient, consider;

o That a mydriatic agent (drug resulting in

pupil dilation) may be required or the lights

should be dimmed to dilate the pupils

o Asking the person to fix their gaze on a

distant object

o Placing your free hand on the forehead of

the patient - this sets the distance from

which to approach and avoids clashes of

head as you get nearer. Also the thumb can

be used to hold the upper eyelid open

Image attributed Nutschig at the English

language Wikipedia

Inspection of external structures

Inspect peri-orbital tissues, eye lashes, and anterior segment for any

abnormalities

As you can see

from this picture

contact lenses

are often hard to

visualise.

Image attributed to Evan Herk

Foreign body- iron filing

Direction of approach

Use the viewing eye to direct the

beam of light onto the patient’s

eye from 0.5 - 1 metre (arm’s

length)

Approach from an angle of 15-

20° to the line of gaze

Approach on the same level as

the equator of the patient’s eye

This approach directs the beam

towards the optic disc, an

important landmark.

Ophthalmoscopy

Note the red reflex and use this to guide you in closer to the pupil. The examiner’s

eyes should be at the same level as the patients.

When close to the eye, use the focusing wheel to fine tune your focus on the

retinal structures

Red eye reflex, on a patient with

blue eyes and dilated pupils.

Optic disc (blind spot) & optic cup

The correct approach should bring you on or near to the optic disc;

The view of the retina

Document all findings clearly and ensure all abnormalities reported to your

supervisor.

Examination of the vessels

Once a vessel is found you should follow the vessel as far as possible to look for

abnormalities

The retinal

vessels branch

into the 4

quadrants of the

eye;

o Superior

nasal and

temporal

o Inferior

nasal and

temporal

Use the

quadrants when

describing the

retina of any

abnormalities.

The Retina

If you miss or lose the optic disc: any

branching of vessels form a “V”, the

point of the “V” always points towards

the optic disc.

The main vessels branch out in four

directions

Veins are uniform and burgundy in

colour whereas arteries have a central

pale line and two outer red walls

Normal retina, right eye with some pigmentation at optic disc.

Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2).

DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain

The retina - what to note

Optic disc:

Look for;

o Sharpness

o Colour

o Optic cup appearance

Arteries and veins:

Consider;

o Are they tortuous or straight

o The width and colour

Patients with darker irises may be more difficult to examine as there retina may

also appear darker.

Glossary

o Mydriatic – A drug that causes pupillary dilatation, aiding eye

examination, eg; atropine/ phenylephrine drops

Peer Feedback

06 Y 1

Ophthalmoscopy peer feedback with logo .docx

Video

https://stream.liv.ac.uk/6rabkzzt