11/13/24, 7\:04 PM Guide | Fundoscopy

Fundoscopy

Table of contents
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Gather equipment

Gather the appropriate equipment\:
Ophthalmoscope
Mydriatic eye drops
Fluorescein eye drops

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Example explanation
" I w i l l b e u s i n g a m a g n i f y i n g t o o l c a l l e d a n o p h t h a l m o s c o p e t o l o o k a t t h e f r o n t a n d b a c k o f y o u r e y e s w i t h t h e l i gh t s o
"
" T o d o t h i s , e a c h o t h e r .
"
I' l l n e e d t o g e t q u i t e c l o s e t o y o u r f a c e. I' l l p l a c e a h a n d o n y o u r f o r e h e a d t o p r e v e n t u s f r o m b u m p i n g i n t o
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" I' l l a l s o b e u s i n g s o m e e y e d r o p s t o d i l a t e y o u r p u p i l s a n d t o h i g h l i g h t a n y p r o b l e m s. T h e d i l a t i n g d r o p s w i l l c a u s e y o u r
v i s i o n t o b e t e m p o r a r i l y b l u r r y a n d y o u' l l b e m o r e s e n s i t i v e t o l i g h t , s o y o u' l l n o t b e a b l e t o d r i v e f o r s e v e r a l h o ur s
a f t e r w a r d s .
"
Gain consent to proceed with the examination.
Position the patient sitting on a chair.
Ask if the patient has any pain before proceeding.

Inspect the external eye

To inspect the external eye, ask the patient to focus on a
fundoscope to carefully examine the eyelids, eyelashes, conjunctiva, sclera, cornea, iris and pupil.

General inspection

Inspect the eye for signs of pathology\:
Eyelids\: note any lumps (benign or malignant), oedema, cellulitis and entropion/ectropion.
Eyelashes\: inspect for loss of eyelashes (can be associated with malignant lesions) or trichiasis (inturning of the eyelashes).
Di
associated with bacterial, viral and allergic conjunctivitis.
Circumciliary injection\: dilated in
suggesting intraocular in
Discharge\: watery discharge is typically associated with allergic conjunctivitis, viral conjunctivitis or normal physiological
production (e.g. reaction to a corneal abrasion/foreign body). Purulent discharge is more likely to be associated with
bacterial conjunctivitis.
Hyphema\: an inferior settled layer of blood in the anterior chamber typically occurring as a result of trauma.
Hypopyon\: an inferior settled layer of ‘pus’ (white cells and debris) in the anterior chamber. Typically associated with severe
corneal ulcers or endophthalmitis, but can also occur secondary to anterior uveitis.
Periorbital erythema and swelling\: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis
(posterior to the orbital septum).
Pupillary abnormalities\: can include abnormal size, shape and asymmetry (see below).
Foreign bodies\: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical
features include redness, pain, watering and a ‘foreign body sensation’
.
Corneal abrasion\: redness, pain, watering and photophobia are common clinical features. Epithelial defects can be very
hard to see with the naked eye but stain brightly with
Corneal ulcer\: typical clinical features include pain, watering, photophobia and a staining epithelial defect with associated
haziness (in

Inspect the pupil

The pupil is the hole in the centre of the iris that allows light to enter the eye and reach the retina.
Assess pupil size
dark).
Normal pupil size varies between individuals and depends on lighting conditions (i.e. smaller in bright light, larger in the
Pupils are usually smaller in infancy and larger in adolescence.
Assess pupil shape
uveitis).
Pupils should be round, abnormal shapes can be congenital or due to pathology (e.g. posterior synechiae associated with
Peaked pupils in the context of trauma are suggestive of globe injury.
Assess pupil symmetry
Note any asymmetry in pupil size between the pupils (anisocoria). This may be longstanding and non-pathological or relate
to actual pathology. If the pupil is more pronounced in bright light this would suggest that the larger pupil is the abnormal
pupil, if more pronounced in dark this would suggest the smaller pupil is abnormal.
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Examples of asymmetry include a large pupil in oculomotor nerve palsy and a small and reactive pupil in Horner’s syndrome.

Inspect the eyelids

Assess lid position\: ptosis can be a sign of Horner’s syndrome (often very subtle ptosis) and oculomotor nerve palsy (can
vary from partial to complete ptosis).
Assess the lid margins\: crusting and in
Inspect the external eye
Causes of red eye
Below is a non-exhaustive list of causes of red eye, with their associated clinical features.
Painless red eye\:
Conjunctivitis\: di
debris. Bacterial conjunctivitis typically has more purulent discharge than viral or allergic conjunctivitis.
Subconjunctival haemorrhage\: a
conjunctiva surrounding it.
Episcleritis\: sectoral area of subconjunctival injection (unilateral). The subconjunctival injection in episcleritis is
super
Dry eye\: caused by de
(obstruction of meibomian glands). Clinical features include di
in
Painful red eye\:
Scleritis\: deep pinkish localised conjunctival injection (unilateral), visual acuity may be reduced, minimal watery
discharge, photophobia and a tender globe (causing the patient to wake at night). Symptoms tend to progressively
worsen and individuals commonly have other connective tissue diseases.
Uveitis\: circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, reduced visual acuity,
watery discharge, photophobia and pain are common clinical features.
Corneal abrasion\: eye redness, pain, watering and photophobia are common clinical features. Epithelial defects can
be very hard to see with the naked eye but stain brightly with
Corneal ulcer\: typical clinical features include pain, watering, photophobia and a staining epithelial defect with
associated haziness (in
Acute angle-closure glaucoma (AACG)\: typical clinical features include signi
circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a
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mid-dilated unreactive pupil.
Foreign bodies\: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical
features include redness, pain, watering and a ‘foreign body sensation’
. Foreign bodies may be hidden under the top
and bottom of the eyelid.

Ophthalmoscope overview

Parts

Viewing window\: this is where you look through to observe the eye.
Filter switch\: allows you to select a light
Aperture dial\: adjust the size of the light beam.
Diopter dial\: adjusts the lens used to view the eye.
Diopter power display\: shows the current lens being used.
Rheostat\: adjusts the intensity of the light beam.
On/o

Aperture size (beam size)

Micro aperture\: used for viewing the fundus through very small undilated pupils.
Small aperture\: used for viewing the fundus through an undilated pupil.
Large aperture\: used for viewing the fundus through a dilated pupil and for the general examination of the eye.
Slit aperture\: can be helpful in assessing contour abnormalities of the cornea, lens and retina as it makes elevation easier to
see.

Filter

Cobalt blue
Red-free
Practitioner side of the ophthalmoscope
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Prepare to perform fundoscopy

1. It is essential to darken the room for the examination. Make sure the patient is positioned seated prior to turning out the lights
to avoid accidents.
2. Dilate the patient's pupils using short-acting mydriatic eye drops such as tropicamide 1%. You will be unable to monitor pupil
reactions once dilating drops have been applied, furthermore assessing vision, colour vision, double vision and visual
be less accurate once drops are instilled.
3. Ask the patient to look straight ahead for the duration of the examination (asking the patient to
as a light switch can cause confusion if you then obstruct the view of this target).

Assess the fundal re

Correct terminology
The term fundal re
colour.
In patient's with lighter skin, the re
re

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the fundal re
you can see the patient and their eye clearly from a distance\:
If you have normal visual acuity, you can set the diopter dial to 0.
If you have a refractive error but are planning to wear glasses/contact lenses that correct this when using the
ophthalmoscope you can also set it to 0.
If you have a refractive error and are not going to wear your glasses/contact lenses you should adjust the diopter dial to
match your prescription (e.g.
-2).

How to assess for the fundal re

1. Look through the ophthalmoscope, shining the light towards the patient's eye at a distance of approximately one arm's
length.
2. Observe for a reddish/orange/white/yellow/blue re
vascularised retina.
Causes of an absent fundal re
Absence of the fundal re
include vitreous haemorrhage and retinal detachment.
Absence of the fundal re
and retinoblastoma.
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Assess for the fundal re

Assess the anterior segment of the eye

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the anterior surface of the eye adjust the diopter dial to a high green number (e.g.
10 or 15) which changes the ophthalmoscope into a magnifying glass.

How to assess the anterior segment of the eye

1. Stand to the side of the patient and place your hand on the patient's forehead to prevent an accidental collision.
2. Approach the eye and assess the anterior segment using the ophthalmoscope\:
Fluorescein dye can be applied as an eye drop which will stain and
ophthalmoscope if there is damage to the corneal or conjunctival epithelium (e.g. an abrasion).
Look for white opacities on the cornea which may be suggestive of a corneal ulcer.
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Assess the anterior segment of the eye

Assess the fundus

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the fundus, adjust the diopter dial so that it is the net result of yours and the
patient's refractive error\:
If you and the patient have normal visual acuity, set the dial to 0 (e.g. 0 + 0 = 0).
If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive
error of 0 and add the patient's refractive error to this (e.g. 0 + -2 = -2).
If the patient has a refractive error and you have normal visual acuity set the dial to the net refractive error. An example of this
would be (your refractive error of 0) + (patient's refractive error of -2) = a setting of -2.
If the patient has a refractive error and you have a refractive error set the dial to the net refractive error. An example of this
would be (your refractive error of +3) + (patient's refractive error of -2) = a setting of +1.
If things appear out of focus during the assessment, simply adjust the diopter dial until things look sharper.

Assess the optic disc

1. If you are assessing the patient's right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the
hand not holding the ophthalmoscope onto the patient's forehead to prevent accidental collision between yours and the
patient's face.
2. Approaching from a 10-15 degree angle slightly temporal to the patient, move closer whilst maintaining the fundal re
3. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches
point like arrows towards the optic disc).
4. Once you identify the optic disc assess its characteristics including the contour, colour and the cup ("3Cs")\:
Contour\: the borders of the optic disc should be clear and well de
presence of optic disc swelling (papilloedema) secondary to raised intracranial pressure.
Colour\: a healthy optic disc should look like an orange-pink doughnut with a pale centre. The orange-pink colour represents
well-perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of
optic neuritis, advanced glaucoma and ischaemic vascular events.
Cup\: the cup is the pale centre of the orange-pink doughnut mentioned previously. The pale colour of the cup is due to the
absence of neuroretinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as
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the "cup-to-disc ratio"
. A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally
considered normal. An increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can
occur in glaucoma.
Ensure the lights are dimmed for fundoscopy

Assess the retina

5. Methodically assess each quadrant of the retina and the associated vascular arcades in a clockwise or anticlockwise fashion
looking for evidence of pathology\:
Superior temporal (ST)
Superior nasal (SN)
Inferior nasal (IN)
Inferior temporal (IT)
Assess each quadrant of the retina
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Types of retinal pathology
Arteriolar narrowing\: subtle, with generalised arteriolar narrowing with typical copper or silver wire appearance. Most
commonly associated with the early stages of hypertensive retinopathy.
Arteriovenous nipping/nicking\: areas of focal narrowing, and compression of venules at sites of arteriovenous
crossing. The typical appearance involves bulging of retinal veins on either side of the area where the retinal artery is
crossing. Most commonly associated with grade 2 hypertensive retinopathy.
Dot and blot haemorrhages\: arise from bleeding capillaries in the middle layers of the retina and may look like
microaneurysms if small enough. They are most commonly associated with diabetic retinopathy.
Flame haemorrhages\: larger haemorrhages with a
or small veins in the retinal nerve
thrombocytopaenia, retinal vein occlusion and trauma.
Cotton wool spots\: appear as small,
They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
Hard exudates\: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding
leaking microaneurysms. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive
retinopathy.
Neovascularisation\: formation of new blood vessels that appear as a net of small curly vessels, with or without
associated haemorrhages. They may be located on the optic disc or elsewhere on the retina. They are most commonly
associated with advanced proliferative diabetic retinopathy.
Pan-retinal photocoagulation\: the primary treatment for proliferative diabetic retinopathy. Clinically it is seen as
clusters of pale burn marks on the retina which have been created by the laser used in the treatment process.
Branch retinal vein occlusion\: blockage of one of the four retinal veins, each of which drains about a quarter of the
retina. Typical signs include
oedema, and dilated tortuous veins.

Assess the macula

6. Finally, inspect the macula by asking the patient to brie
found lateral (temporal) to the optic nerve head and is yellow in colour. The central part of the macula, the “fovea” is about the
same diameter as the optic disc and appears darker than the rest of the macula due to the presence of an additional pigment.
Assess the macula
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Types of macula pathology
Hard exudates\: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding
leaking microaneurysms. They are most commonly associated with diabetic retinopathy, grade 3 hypertensive
retinopathy and retinal vein occlusions.
Drusen\: yellow-white
epithelium. Most commonly caused by age-related macular degeneration.
Cherry-red spot\: associated with central retinal artery occlusion which typically presents with sudden profound visual
loss.

Assess the other eye

Repeat assessment of the anterior segment, fundal re
patient from the opposite side and hold the ophthalmoscope in your other hand.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
If mydriatic drops were instilled, remind the patient they cannot drive for the next 3-4 hours until their vision has returned to
normal.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessment and investigations

All of the following further assessments and investigations are dependent on the patient's presenting complaint and in most
cases, none of them would need to be performed\:
Amsler chart\: to assess for central visual loss and distortion which is commonly associated with macular degeneration.
Cranial nerve examination\: to further assess for evidence of cranial nerve pathology (e.g oculomotor nerve).
Blood pressure\: if there are concerns about hypertensive retinopathy.
Capillary blood glucose\: if there are concerns about diabetic retinopathy.
Retinal photography\: to better visualise any abnormalities noted on fundoscopy.

References

1. James Heilman, MD. Adapted by Geeky Medics. Allergic conjunctivitis. Licence\: CC BY-SA. Available from\: [LINK].
2. Adapted by Geeky Medics. Bacterial conjunctivitis. Licence\: Public domain. Available from\: [LINK].
3. FiP. Adapted by Geeky Medics. Subconjunctival haemorrhage. Licence\: CC BY-SA. Available from\: [LINK].
4. Imrankabirhossain. Adapted by Geeky Medics. Episcleritis. Licence\: CC BY-SA. Available from\: [LINK].
5. Kribz. Adapted by Geeky Medics. Scleritis. Licence\: CC BY-SA. Available from\: [LINK].
6. Adapted by Geeky Medics. Blepharitis. Licence\: Public domain. Available from\: [LINK].
7. Jonathan Trobe, M.D. Adapted by Geeky Medics. Anterior uveitis. Licence\: CC BY. Available from\: [LINK].
8. Jonathan Trobe, M.D. Adapted by Geeky Medics. Acute closed-angle glaucoma. Licence\: CC BY. Available from\: [LINK].
9. EyeMD (Rakesh Ahuja, M.D.). Adapted by Geeky Medics. Hypopyon. Licence\: CC BY-SA. Available from\: [LINK].
10. Tripp on Flickr. Adapted by Geeky Medics. Pre-septal cellulitis. Licence\: CC BY 2.0. Available from\: [LINK].
11. Waster. Adapted by Geeky Medics. Miosis. Licence\: CC BY. Available from\: [LINK].
12. Evan Herk. Adapted by Geeky Medics. Foreign body. Licence\: CC BY-SA. Available from\: [LINK].
13 James Heilman MD Adapted by Geeky Medics Corneal abrasion Licence\: CC BY SA Available from\: [LINK]
Source\: geekymedics.com
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