Examination: Pupil dilatation with one drop tropicamide 1% in each eye and waited for 15 minutes (Note: even with dilatation, only about a third of the fundus is visible with a direct ophthalmoscope) Instructed to look at a located spot no matter what, so that looked slightly to the left when the right eye was examined and vice versa 1. External eye? With large diameter aperture 2. Fundal (red) reflex? Dialed up a +10DS lens in the lens wheel and observed the eye from 10cm Examined left eye with the left eye and right eye with the right eye and closed the other eye Placed hand on forehead so that fingers are splayed but the thumb is on the upper lid to hold the lid open Normal reflex? Absent reflex (in adults: seen in cataracts, vitreous haemorrhage or retinal detachment, in children in congenital cataracts, retinal detachment, vitreous haemorrhage or retinoblastoma)? White reflex (leukocoria) (in children may be a sign of retinoblastoma, congenital cataract, persistent fetal vasculature, coats disease or retinal detachment))? Mittendorf dot (small congenital lens opacity often present in normal healthy eyes)? 3. Optic disk: Slowly moved closer and at the same time gradually reduced the power of the lens in the wheel and focused on the crystalline lens, the vitreous and finally the fundus Once a blood vessel on the fundus has been located then moved along it and located the point at which it branched and moved field of view in the direction in which the apex of the branch was pointing to locate the optic disk. Contour? - Borders clear and well defined (normal)? - Borders blurred (may suggesting optic disc swelling (papilloedema) secondary to raised intracranial pressure)? Colour? - Orange-pink doughnut with a pale centre (normal)? - Pale (suggesting optic atrophy as a result of optic neuritis, advanced glaucoma or ischaemic vascular events)? Cup? - Cup-to-disc ratio of 0.3 (cup occupies ½ of the height of the optic disc) (normal)? - Increased cup-to-disc ratio (suggesting eg glaucoma)? 4. Retina: Started at the disc and followed the vessels in each quadrant (superior temporal (ST), superior nasal (SN), inferior nasal (IN), inferior temporal (IT)) with using the green ( red-free) filter for enhancing the appearance of blood vessels and haemorrhages by making blood show up black Assessed peripheral fundus by asking patient to look in the eight cardinal directions. Adjusted lens in the wheel slightly as the periphery is closer to than the optic disc requiring more focusing power (plus lens) (Note: veins relatively large and dark red, arteries relatively thin and pale) Hypertensive Retinopathy Grade 1 disease: - Generalised arteriolar narrowing (copper or silver wiring)? Grade 2 disease: - Arteriovenous (AV) nipping/nicking (compression of venules at sites of arteriovenous crossing)? Grade 3 disease: - Cotton wool spots? - Flame haemorrhages? - Hard exudates Diabetic Retinopathy Background diabetic retinopathy: - Microaneurysms (may be clinically indistinguishable from small dot and blot haemorrhages)? - Dot and blot haemorrhages? Pre-proliferative diabetic retinopathy: - Cotton wool spots ('soft exudates')? - Venous changes (venous beading and venous loops) and intraretinal microvascular anomalies (IRMA) (not to be expected to be recognised)? Proliferative diabetic retinopathy: - Neovascularisation? Advanced diabetic retinopathy: - Vitreous haemorrhage? - Retinal detachments? - Rubeosis? Diabetic maculopathy: - Hard exudates? - Macular oedema (not to be expected to be recognised)? Branch retinal vein occlusion? 5. Macula: Asked to look directly into the ophthalmoscope by using a smaller aperture beam Foveal reflex better seen with a green (red-free) filter Hard exudates? Drusen (most commonly caused by age-related macular degeneration)? Cherry red spot (typical for central retinal artery occlusion)? Normal result: Normal fundoscopy with normal red reflex, no media opacities; optic disk shape, colour, margins and cup-to-disk ratio normal, no new vessels or haemorrhages on the disk; vessels normal with no signs of retinopathy with all vessels followed into the peripheral fundus and normal macula Resource(s): American Academy of Optometry: Direct Ophthalmoscopy BMJ: How to use the ophthalmoscope Geeky Medics: Fundoscopic Appearance of Retinal Pathologies Geeky Medics: Fundoscopy (Ophthalmoscopy) – OSCE Guide Loyola University Chicago: Lumen Flash Card. Topic: Fundus Stanford Medicine: Fundoscopic / Ophthalmoscopic Exam