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Fundoscopic / Ophthalmoscopic Exam

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Introduction
The retina is the only portion of the central nervous system visible from the exterior.
Likewise the fundus is the only location where vasculature can be visualized. So much of
what we see in internal medicine is vascular related and so viewing the fundus is a
great way to get a sense for the patients overall vasculature. But the fundoscopic exam
can discover pathological process otherwise invisible, examples are plentiful, and
include recognizing endocarditis, disseminated candidemia, CMV in an HIV infected
patient, and being able to stage both diabetes and hypertension.

Types of Opthalmoscopes
Traditional Direct Ophthalmoscope
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_3/panel_0/panel_builder/panel_0/image.img.620.high.jpg'

alt='traditional opthalmoscope'>
PanOptic Direct Ophthalmoscope
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_3/panel_0/panel_builder/panel_1/image.img.620.high.jpg'

alt='panoptic opthalmoscope'>

Opthalmoscope Settings
Aperture/Filter Dial
The aperture/filter dial allows the opthalmoscope to be used for different purposes.
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_1/panel_0/image.img.620.high.png' alt='fundoscope

settings'>
Large/Medium/Small light source: Ophthalmoscopes usually have 2 or 3 sizes of
light to use depending on the level of pupil dilation. The small light is used when the
pupil is very constricted (i.e. well lit room, no pupil dilators used). The large light is best
if using mydriatic eye drops to dilate. Most commonly in a dark, non-dilated pupil, the
medium sized light is used.
Half light: If, for example, the pupil is partially obstructed by a lens with cataracts, the
half circle can be used to pass light through only the clear portion of the pupil to avoid
light reflecting back
Red free: Used to visualize the vessels and hemorrhages in better detail by improving
contrast. This setting will make the retina look black and white.
Slit beam: Used to examine contour abnormalities of the cornea, lens and retina.
Blue light: Some ophthalmoscopes have this feature that can be used to observe
corneal abrasions and ulcers after fluorescein staining.
Grid: Used to make rough approximations of relative distance between retinal lesions.

Focusing Wheel
The focusing wheel is the common source of confusion and leads to decreased use of
the ophthalmoscope. However, this dial is really VERY easy to use! See below to
understand how the focusing wheel works for any direct ophthalmoscope (including the
regular ophthalmoscope and the PanOptic).
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_1/panel_0/image_0.img.620.high.png' alt='focusing the
opthalmoscope'>

Technique --> Finding the Retina


1.

Darken room, ask patient to look at the same point as far as possible in the room
(this will help to dilate the pupil).

2.

Wedge scope against your cheek with hand and then head/hand/scope should
move as one unit.

3.

Use your right hand & your right eye to look at the patients right eye. (Less
important if using the PanOptic.)

4.

Look through the ophthalmoscope, if you are nearsighted and have taken off your
glasses, you may need to adjust the focusing wheel towards the negative/red until
what you see at a distance is in focus.

5.

Direct the ophthalmoscope 15 degrees from center and look for the red reflex (see
video). Simply follow the red reflex in until you see the retina. If you lose the red
reflex, come back until you find it again and repeat.

6.

To look around the retina using a traditional direct ophthalmoscope, you should
"pivot" the ophthalmoscope, angling up, down, left and right. If using the PanOptic,
you can slightly "pivot" or ask the patient to look up to see upper retina, down to
see lower retina, medial to see medial, latereral to see lateral and finally to look at
the light to visualize the macula.

<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder/panel_0/panel_builder/panel_1/image.img.620.high.jpg'

alt='red reflex'>

Dilating the Pupil


Mydriatic drops. Dilate one eye when you start your H&P and by the time you are done
you will have a good look. In general Tropicamide is considered the safest.

Parasympathetic antagonists: paralyze circular muscle of iris (mydriasis) and the


ciliary muscle (loss of accommodation).
o

Tropicamide: 1-2 drops (0.5%) 15-20 minutes before exam; may repeat
every 30 minutes PRN. Individuals with heavily pigmented eyes may require
larger doses.

Cyclopentolate:1 drop of 1% followed by another drop in 5 min; 2%


solution in heavily pigmented iris.

Atropine: (1% solution): Instill 1-2 drops 1 hour before the procedure.

Homatropine:1 drop of 2% solution immediately before the procedure;


repeat at 10 min intervals PRN.

Sympathetic agonists:
o

Phenylephrine: 1 drop of 2.5% or 10% solution, may repeat in 10-60 min


PRNs

Contraindications: head injury requiring monitoring

Want more information on the use of mydriatic agents for the internist? Please look up
this great article that reviews data on the risk of precipitating acute glaucoma: Pandit, RJ
and Taylor R. Mydriasis and glaucoma: exploding the myth. A systematic review. Diabet Med. 2000
Oct;17(10):693-9.

Clinical Images of the Retina

Normal fundus
Vessels emerge from nasal side of disc. Arteries are narrower than veins.
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image.img.620.high.png' alt='normal retina'>

Pathological Optic Cupping


Note cup-to-disc ratio at least 0.8 (physiologic limit of 0.5).
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_0.img.620.high.jpg' alt='cupping of optic

disc in glaucoma'>

Optic Disk Edema


The optic disc is elevated and its surface is covered by cotton wool spots (damaged
axons) and flame hemorrhages (damaged vessels). Four I's: increased intracranial
pressure (papilledema), infarction, inflammation, infiltration (by cancer).
The first picture below was taken simply by holding smartphone in front of the Panoptic
opthalmoscope!
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_1.img.620.high.jpg' alt='papilloedema of

retina'>

<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_2.img.620.high.jpg' alt='papilloedema of

optic disc in retina'>

Arterio-Venous (AV) Nicking


Chronic hypertension stiffens and thickens arteries. At AV crossing points (arrow)
arteries indent and displace veins.
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_3.img.620.high.jpg' alt='Arterial / venous

nicking of retina (AV nicking)'>

Cotton Wool Spots


Caused by microinfarcts. Exploded ganglion cell axons extrude their axoplasm into
retina. Long DDx: hypertension, diabetes, HIV, severe anemia or thrombocytopenia,
hypercoagulable states, connective tissue disorders, viruses, and others.
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_4.img.620.high.jpg' alt='cotton wool

spots of retina'>

Emboli and Infarcts


Small fleck a Hollenhorst plaque caused from platelet/fibrin/cholestorol embolus.
Resulting in an infarct (gray area above and right of the plaque).
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_5.img.620.high.jpg' alt='retinal emboli

and infarcts'>

Roth Spot
Pale-centered hemorrhage. Caused by several conditions, but usually bacterial
endocarditis. This image was from a patient with staph endocarditis.
<img
src='//stanfordmedicine25.stanford.edu/the25/fundoscopic/_jcr_content/main/panel_buil
der_0/panel_0/panel_builder_5/panel_0/image_6.img.620.high.jpg' alt='roth spot on

retina for endocarditis'>

http://stanfordmedicine25.stanford.edu/the25/fundoscopic.html