Binocular Indirect Ophthalmoscopy

Original article contributed

Vedant Sathye, Peter A.Karth, MD
by:
All contributors: Peter A.Karth, MD and Vinay A. Shah M.D.
Assigned editor: Vinay A. Shah M.D.
Assigned status Up to Date by Vinay A. Shah M.D. on September
Review:
22, 2017.

Ophthalmoscopy is a routine exam done by ophthalmologists to examine the inside of the back
of the eye, also known as the fundus or posterior segment. Although there are several types of
ophthalmoscopy, we will focus on Binocular Indirect Ophthalmoscopy or BIO, for short, in this
article. BIO is one of the ways used to view the retina, with a wide field of the retina and
stereoscopic view. BIO also allows dynamic observation of the retina by moving the BIO device,
lens, and applying scleral depression. The process is indirect because the fundus is viewed
through a hand held condensing lens.

Contents
1 History
2 Mechanics and Optics
3 Technique to Perform BIO
4 Additional Aspects
5 References

History
The earliest ideas about ophthalmoscopy dates back to 1846 when Dr. William Cumming, a
front runner in the field of ophthalmology, wrote that every eye could be made luminous if the
axis from a source of illumination directed towards a person's eye and the line of vision of the
observer were coincident. Five years later, in 1851, Hermann von Helmholtz designed the first
direct ophthalmoscope for medical use. A year later Christian Ruete made modifications to
Helmholtzs design by implementing a concave focusing mirror, and thereby introduced indirect
ophthalmoscopy to allow for a stereoscopic and wider view of the fundus. Dr. Steven Schepens
improved on the original design in 1945 by adding a second lens for the other eye. This allowed
him to see an inverted and reversed view of the fundus, with a relatively large field of vision.

Mechanics and Optics

Device

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The BIO device consists of a headband, binocular lens with mirrors, and a light source (see
diagram). The examiner wears the device by positioning the headband around his or her head
so that the binocular lenses sit directly in front of their eyes. Mirrors in the device split the light
reflecting back toward the examiner so the image may be presented to each of the examiners
eyes. The light is between the doctor's eyes just above the bridge of their nose.

Hand-held Condensing Lenses

During use, a hand held condensing lens is held by the examiner, a few inches above the
patients eye. The purpose of this lens is to gather the light rays coming out of the patients
eyes which are divergent due to the power of the cornea. This lens presents a real horizontally
and vertically inverted image in front of the hand held condensing lens. The power of the
condensing lens determines three things: viewing distance, magnification, and field of view.
Typical lenses used have a range of:+14D to +30D (D=diopter). As the lens dioptric power
increases magnification decreases and field of vision increases. Low power(i.e. +14D to +18D)
lenses offer strong magnification but a relatively smaller field of view, and below about +20D,
the lens needs to be held further from the patient's eye, which may be difficult for some
examiners. There are many different types of lenses that doctors also use. Aspheric lenses are
general multi purpose lenses that are used when not looking for anything in specific.

Filters

BIO devices may include filters. A yellow filter offers protection to the user because of the
decreased intensity of light entering the patient's eye and may even offer protection to the
patients retina or provide comfort to the patient. Red-Free filters can be used to view blood,
membranes, and highlights whitish portions of the retina, if present.. Cobalt Blue filters can be
used to more clearly view the eye after a fluorescein angiography.

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Technique to Perform BIO
1. Adjustment of the ophthalmoscope
2. Adjust headband crown
3. Adjust the pupillary distance
4. Check illumination intensity. Usually start with lower illumination and slowly increase
illumination as needed and as tolerated by the patient. Check for a proper
elevation/position. Check can be done by extending arm or by looking at a wall.
5. Apply filter if desired
6. Positioning the patient - Patient should be in a supine position
7. Patient should be looking directly up, initially (primary position)
8. Examiner should initially stand to the side of the patient, leaning over the patient
9. Insert handheld lens approximately 2 inches away from patient's eye, moving it closer or
farther away to focus and refine the view
10. Examiner swivels his view around to view different parts of the retina, by tilting the
head and walking around the patient
11. The doctor instructs the patient to look at various extremes of their vision

Additional Aspects
Dilation

The examiner looks through the pupil to view the posterior segment of the eye.. However, the
undilated pupil restricts the view field of view dramatically. Doctors will generally decide to
administer dilating drops. Mydriatics are dropped into the eye. Mydriatics come in two forms:
parasympathetic antagonists such as Tropicamide, or sympathetic agonists such as
Phenylephrine. Parasympathetic antagonists are used to paralyze the iris sphincter muscle
while sympathetic agonists are used to stimulate the iris dilator muscle. Through this enlarged
pupil the examiner is able to view the periphery of the retina.

Scleral Depression

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A technique commonly used with BIO is scleral depression. This complements the dynamic
viewing of the retina and vitreous. The forward and inward curvature of the globe in the
anterior portion of the eye obscures and prevents far peripheral viewing Therefore, scleral
depression (or special contact lenses such at Goldman 3-Mirror contact lens) is needed to
indent the scleral and bring the peripheral retina into view.. To depress the sclera, a scleral
depressor is placed against the sclera (either on the globe or on the eyelid overlying the globe)
and gentle firm pressure is applied. This pushes the sclera and the retina into the examiners
field of view during the BIO exam.

To the examiner, the scleral depressor creates an elevation at the point of depression
(bump). By looking into the depression the doctor can view more of the peripherals of the
fundus. Scleral depression is also a helpful way of examining patients who complain of flashes
and floaters or patients who are at risk of peripheral retinal anomalies such as tears or
detachments. When patients have high risk symptoms, scleral depression is highly
recommended to allow complete viewing of the retina

References
"Fundoscopic / Ophthalmoscopic Exam." Fundoscopic (Ophthalmoscopic) Exam. Stanford
Medicine, n.d. Web. 09 July 2016.
"Red Reflex Examination in Neonates, Infants, and Children." Pediatrics 122.6 (2008): 1401-404.
AAP Publications. American Academy of Pediatrics, 2008. Web. 11 July 2016.
Trobe, Jonathan. "The Eyes Have It: Optic Fundus Signs." The Eyes Have It: Optic Fundus Signs.
University of Michigan, 2009. Web. 11 July 2016.
Lusby, Franklin W. "Ophthalmoscopy: MedlinePlus Medical Encyclopedia."Ophthalmoscopy:
MedlinePlus Medical Encyclopedia. US National Library of Medicine, 23 Feb. 2015. Web. 12 July
2016.
Agarwal, Prachir. "Looking Deep into Retina : Indirect Ophthalmoscopy and Fundus Drawing."
Looking Deep into Retina : Indirect Ophthalmoscopy and Fundus Drawing. Slideshare, 25 Aug.
2013. Web. 21 July 2016.
"Helmholtz, Schepens, and Now: The Evolution of the Modern Binocular Indirect
Ophthalmoscope." Ophthalmology Web. Ophthalmology Web, 16 Feb. 2005. Web. 14 July
2016.
"Commonly Used Dilating Drops (mydriatic Medications)." - PG CFA / Knowledgebase.
KBPublisher, 8 Mar. 2008. Web. 21 July 2016.
Binocular indirect ophthalmoscope. The light source mounted above and between the
examiner's eyes illuminates the condenser, which images the source at the periphery of the
patient's pupil. The illumination does not overlap the observation beam. The condenser lens is
handheld; it forms an inverted aerial image of the retina. Digital image. The Free Dictionary.
N.p., n.d. Web. 16 Sept. 2016.

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Teknik Pemeriksaan BIO

Funduskopi Indirek
1. Pasien diberi tetes mata mydriatil 30 45 menit sebelum pemeriksaan dilakukan
2. Mengatur alat ophtalmoscope yang akan digunakan
3. Mengatur ukuran headband crown sesuai dengan kepala
4. Mengatur jarak pupil pemeriksa pada headband (interpupillary distance)
5. Periksa intensitas iluminasi. Dimulai dari iluinasi rendah dan secara perlahan-lahan ditingkatkan
sampai batas yang dapat ditoleransi oleh pasien. Periksa sudut posisi yang sesuai. Pemeriksaan dapat
dilakukan dengan memperpanjang lengan atau diarahkan ke arah dinding
6. Pasang filter bila diperlukan
7. Posisikan pasien pada posisi supine
8. Pasien melihat lurus ke arah atas (posisi primer)
9. Pemeriksa berdiri di samping tempat tidur dan posisi sekitar kepala dan mengarah ke pasien
10. Tempatkan lensa 20D dengan jarak 6 cm dari mata pasien, dengan mendongakan kepala pasien dan
berjalan mengelilingi pasien
Pasien diminta untuk melihat ke arah ekstrim berlawanan dengan sudut yang ingin diperiksa

American Academy of Ophtalmogy