Slide 1

Fundoscopy Tutorial

Dr Mark James
Lecturer in Ophthalmology,
UCC

Slide 2
Fundoscopy Learning Outcomes
Knowledge
• Identify the various components of the ophthalmoscope
and describe their corresponding functions.
• List the causes of a poor red reflex or leukocoria in both
adults and children.
• Define key definitions related to visual fields assessment.
• Describe in detail the relevant anatomical relationships
and features of the optic disc, retinal vasculature, and
macula.
• Demonstrate the ability to apply that knowledge in terms
of identifying any abnormalities noted on fundal exam.
• Differentiate between the different types of lesions noted
on fundoscopy and list the differential diagnoses
associated with these abnormalities.
• Describe the clinical signs associated with the more
common or important optic disc, retinal, and macular
disorders.

Slide 3
Fundoscopy Learning Outcomes
Know-how and skill
• Show proficiency in performing a structured
examination of the fundus with the
ophthalmoscope, which includes
assessment of the red reflex.
• Recognize any abnormal signs and apply
their knowledge when determining their
possible causes.
Slide 4
Fundoscopy Learning Outcomes

Competence
• Adopt an empathic and holistic
approach to patient assessment.
• Extrapolate from any abnormal signs
the key relevant features to form a
differential diagnosis with appropriate
management strategies.

Slide 5 Please write your answers on a

Fundoscopy
Background Knowledge Probe
1. Explain what the red-free filter on the
ophthalmoscope is useful for.
2. List 3 causes of a poor red reflex.
3. What is the typical sign on fundoscopy
associated with glaucoma?
4. Describe the key features on fundoscopy
which would indicate the presence of a
central retinal vein occlusion?
5. What are drusen at the macula usually
representative of?
card before reviewing the rest of
the slides. The idea is to get a feel
for what students already know on
this topic and which areas need
more time during the face-to-face
tutorials. If you wish, you can hand
your answers in at the start of the
tutorial, but don’t put your name
on them. For the exercise to be
worthwhile, your answers should
be honest and anonymous, and
will not be marked.

Slide 6
Ophthalmoscope Components
Micro spot aperture - for small, undilated pupil.
Small aperture - for undilated pupil.
Large aperture - for dilated pupil and general eye
exam.
Fixation aperture - for observation of eccentric
fixation, graduated cross hairs for estimating
amount of eccentric fixation or size of lesion.
Slit aperture - for determining various levels of
lesions, e.g. tumours or swollen discs.
Cobalt blue filter - for detecting ocular surface
defects, e.g. corneal abrasions.
Red-free filter - green light absorbed by
haemoglobin – useful for viewing alterations in
vessels, retinal haemorrhages, nerve fibre layer.
Slide 7 Explanation to patient.
Dilate pupil (e.g. Tropicamide 1%).
Darkened room.
Examine red reflex at 6 inches (with a
plus lens selected).
Examination with To examine right eye, stay at patient's
Ophthalmoscope: right side.
Can use a +10 lens close to the eye
See notes to look at the anterior segment (e.g.
lids, cornea, iris, etc.).
Youtube video example Select 0 power lens for examining the
http://www.youtube.com/watch?v=NE_epHjNpfo fundus (depending on own refraction,
and this may well need to be changed
during the exam depending on the
viewing distance and patient’s
refraction).
Ophthalmolscope in right hand, in
front of right eye, right index finger on
focusing lens.
Instruct patient to look at distant
object over your right shoulder.
Rest left hand on patient's forehead if
necessary.
Look for optic disc, commenting on
the 3 ‘Cs’ as mentioned above.
Follow vessels to periphery examining
along all the arcades.
Locate macula (can ask patient to
look directly into the light which may
need to be dimmed to avoid too much
glare and discomfort, or, alternatively,
move the ophthalmoscope light
temporally from the optic disc),
Examine extreme periphery, patient
asked to gaze up, down, left, right to
bring the superior, inferior, nasal, and
temporal retina into view,
respectively.
Repeat for left eye (switch
ophthalmoscope to left hand,
examiner uses their left eye, etc.),
now asking for the patient to look over
your left shoulder initially.
There are a number of useful videos
available on Youtube demonstrating
fundoscopy which may help you to
visualize and recall the above process
more easily, for example:
http://www.youtube.com/watch?v=NE
_epHjNpfo
Slide 8
Case Report:
34 yr old female c/o headaches in the morning on waking, and
bilateral visual obscurations. Hx of high BMI and is taking the OCP.

Slide 9 Please write your answers on a

Case Report Questions card before reviewing the rest of
the slides. You should hand your
1. What are the possible causes for answers in at the start of the
symptoms of headache associated with
blurred vision?
tutorial, but don’t put your name
2. Describe the abnormal signs shown in the on them. For the exercise to be
previous slide? worthwhile, your answers should
3. What are the possible causes of these be honest and anonymous, and
signs?
4. What is the most likely diagnosis in this
will not be marked.
case?
5. What features of the headaches are typical
for this?

Slide 10
‘No fundoscopy, no defence’.

www.medicalprotection.org /
Casebook / Volume 22 – Issue 2 /
2014
https://www.medicalprotection.org/
docs/default-
source/pdfs/casebook-
pdfs/ireland-casebook-pdfs/may-
2014.pdf?sfvrsn=ef1070ac_2
Slide 11 While this tutorial mainly
concentrates on fundoscopy,
remember the ophthalmoscope
can also be used for the anterior
segment. As you approach the
surface of the eye, the use of a
‘plus’ lens, e.g. +10 (usually green
number for plus lenses, red for
minus), can allow for a magnified,
focused, illuminated view of the
lids, conjunctiva, cornea, or iris.

Cobalt blue filter

For detecting ocular surface
defects, e.g. corneal abrasions or
dendritic corneal ulcers as in this
slide. What is the most likely
cause of a dendritic ulcer?

Slide 12 Examine for:

Red reflex
Can look for lens opacities using
+6 lens at 6 inches (15cm).
Media opacities obscure the red
reflex, e.g. corneal scars, cataract,
vitreous haemorrhage, and
asteroid hyalosis in adults, but NB
causes of leukocoria in infants -
retinoblastoma (could also be
cataract, corneal scarring,
retinopathy of prematurity, Coat’s
disease, and toxocariasis).

This diagram also shows you one

of the fundoscopy teaching aids
that you may be required to use as
part of your clinical skills exams;
you will usually be asked to look
for one of the seven words that are
present in each eye, three superior
ones and three inferior ones
peripherally at the end of blood
vessels, as well as one macula-
centred one.
Slide 13 Normal red reflex.

Slide 14 No red reflex due to severe

corneal scarring.

Slide 15 What is the name given to the

abnormal sign shown in this
picture? What is the most likely
cause? What potentially life-
threatening cause could be
present?
Slide 16 No red reflex due to dense
cataract.

Slide 17 Vitreous haemorrhage is another

possible cause of a poor red
reflex.

Slide 18 Sometimes the red reflex may

depend on the angle you are
checking from. For example, in
this slide there are numerous
chorioretinal scars, most likely
related to toxoplasmosis. The red
reflex will be present if the
ophthalmoscope light falls upon
normal retina, but may appear
pale if on an area of chorioretinal
scarring.
Slide 19 Approach from an angle of about
R eye 15 degrees temporal to subject’s
visual axis to find optic disc (i.e.
the subject’s blind spot – mapping
out your own blind spot may give
you an idea of what kind of angle
you should be approaching from).

15

Slide 20 If subject is looking straight into

L eye the ophthalmoscope light, that
means the ophthalmoscope light is
15
shining on their macula. Move the
light temporally to find the optic
disc.

Slide 21 Don’t forget, all the retinal vessels

L eye lead back to the disc, so if you find
one instead of the disc, just follow
it.

15

Slide 22 High magnification paradoxically
may make identifying structures
difficult as you’re almost too close
• Be aware of ophthalmoscope to get a clear perspective of what
limitations you’re looking at (e.g. the optic
– high magnification x15 disc can take up your whole field
– small field of view 15
of view).
– monocular view Small field of view does not allow
for quick scanning of the entire
retina.
Monocular view makes assessing
depth difficult as have no
stereopsis (e.g. detecting macular
oedema). The use of the slit
aperture on the ophthalmoscope
can help judge contours (e.g.
swollen disc or choroidal tumour).

Slide 23 Optic disc is 2 disc diameters from

the fovea, and the centre of the
disc is slightly superior to it.
1.5 deg

2 DD
Slide 24 Magnified view of optic disc with
ophthalmoscope occupying most
of examiner’s field of view.
Comment on the 3 ‘Cs’: cup,
colour, contour.
The cup is the central, white
depression where the retinal
vessels pass through, and is
surrounded by the pink
neuroretinal rim. Think of the disc
as a 3-dimensional structure, like a
doughnut, where the centre of the
doughnut corresponds with the
cup of the disc. The cup-to-disc
ratio refers to the vertical height of
the physiological cup compared to
the total height of the disc. In this
case, it would be approx. 0.3, but
this can be difficult to accurately
measure without the 3D view
possible with slit-lamp
biomicroscopy. Pathological
cupping is often indicative of
glaucoma. However, the size of
the disc anatomically is important.
Bigger discs, like those that occur
in large myopic eyes, have bigger
cups as their greater size is still
able to contain the millions of
nerve fibres which make up the
optic nerve. This is known as
physiological cupping. On the
other hand, smaller discs with
smaller cups could be
glaucomatous.

Slide 25 Cup: Profound optic disc cupping.

What is the vertical cup-to-disc
ratio? What is the most likely
cause for this disc appearance?
What does the term ‘bayonetting’
refer to with respect to the
appearance of this disc.
Slide 26 Look out for disc haemorrhages –
Disc hge
a sign of glaucomatous
progression.

Slide 27
Colour: The colour of the disc
may indicate pallor or congestion.
Pale and clearly demarcated discs
may represent optic atrophy as in
this slide. What are the causes of
optic atrophy?

Slide 28
Comparison of pale vs healthy
optic disc.
Slide 29 Contour: Reflects the transition
between the disc and the
surrounding retina. Note blurred
disc margin in this slide and the
obscuration of some of the
overlying retinal blood vessels as
they are hidden beneath the
swollen tissue, and the absence of
a distinct cup.
A yellow-grey disc with blurred
margins ± haemorrhages may
indicate papilloedema – often
bilateral but may be asymmetrical.
If only one disc is definitely
swollen, that may indicate more
local pathology rather that raised
intracranial pressure, and
therefore the term ‘optic disc
swelling’ rather than
‘papilloedema’ might be more
appropriate.

Slide 30 Comparison of swollen vs healthy

optic disc.
Slide 31 What are the causes of unilateral
optic disc swelling?

Slide 32 This swollen disc is also pale.

What is the most likely cause?
Slide 33 Disc swelling from meningioma.

Slide 34 The differential diagnosis for

bilateral optic disc oedema
includes malignant hypertension
and papilloedema (i.e. optic disc
oedema secondary to elevated
intracranial pressure).

Causes of papilloedema:
• tumour
• haemorrhage
• venous sinus thrombosis
• inflammation
• abscess
• meningitis
• carcinomatous meningitis
• idiopathic intracranial
hypertension
• choroid plexus papilloma

Less common causes of bilateral

optic disc oedema:
• infiltration (secondary to
leukaemia, lymphoma, bilateral
optic nerve head glioma, or
metastasis)
• inflammation (sarcoidosis)
• diabetic papillopathy
• toxic exposure (medications)
Slide 35 Retinal vessels
Start at the disc and follow the vessels out
to look for hypertensive and
arteriosclerotic changes. It is helpful to do
this in a structures fashion so that nothing
is missed – for example tracking along
the superotemporal arcade, then the
superonasal one, the inferonasal, and
finally inferotemporal. Look as far as the
mid-periphery for scars (inflammatory,
laser), haemorrhages, exudates, pigment
(bone spicule pigmentation – retinitis
pigmentosa), and pigmented lesions
(choroidal naevi / malignant melanoma).
Examine arteries, veins (slightly thicker),
and perivascular fundus.
The circles represent how travelling along
the inferotemporal arcade using the
magnified view of the ophthalmoscope
may look in the corresponding slides
which follow.

Slide 36

Slide 37
Slide 38

Slide 39

Slide 40
Slide 41 Can you identify the signs of
hypertensive retinopathy in this
slide? What grade (1 to 4) is
present in this case? Grade (1):
generalised arteriolar constriction,
(2) A-V nipping, (3) cotton wool
spots and flame-shaped
haemorrhages, (4) optic disc
swelling.

Slide 42 Diffuse narrowing of arteriolar

vessels in hypertensive
retinopathy compared to those of
normal caliber in a healthy fundus.

Slide 43 Can you spot the signs of

background diabetic retinopathy in
this slide (microaneurysms, dot
and blot haemorrhages)?
Slide 44

dot & blot hges

Slide 45 Can you detect some of the signs

of preproliferative diabetic
retinopathy in this slide (multiple
deep round blot haemorrhages,
vessel changes such as venous
beading, venous loops, intraretinal
microvascular abnormalities
(IRMAs), +/- cotton wool spots -
fluffy white patches indicating
ischaemia)?

Slide 46 Magnified view of cotton wool

spot.
Slide 47 This patient has proliferative
diabetic retinopathy (retinal new
vessels on disc / elsewhere (NVD /
NVE)). Can you identify the signs?

Slide 48 Close-up view (e.g. with an

ophthalmoscope) of previous slide
demonstrating new vessels at the
optic disc (NVD) in proliferative
NVDs diabetic retinopathy.

Slide 49 Close-up view (e.g. with an

ophthalmoscope) of panretinal
photocoagulation (PRP) scars.
Slide 50 Extensive panretinal
photocoagulation (PRP) scars in
treated proliferative diabetic
retinopathy.

Slide 51 ‘Bone-spicule’ pigmentation

through-out the peripheral retina in
a case of retinitis pigmentosa.

Slide 52 Pale retina with attenuated arteries

and cherry red spot at fovea in a
case of central retinal artery
occlusion (CRAO).
Slide 53 Disc swelling, venous tortuosity,
and retinal haemorrhages in all 4
quadrants in a case of central
retinal vein occlusion (CRVO).

Slide 54 Greyish elevation of retina with a

pigmented demarcation line
showing the limits of the retinal
detachment.

Slide 55 Benign flat choroidal naevus.

Slide 56 Choroidal malignant melanoma
demonstrating growth over time.

Slide 57 Macula
The macula is an oval-shaped
yellow spot at the centre of the
retina. This yellow colour protects
the retina from ultraviolet light, and
arises from the presence of lutein
and zeaxanthin – carotenoids
derived solely from the diet.
You will find the macula temporal
to the disc. You should leave this
Macula lutea until last when performing
‘Yellow Spot’ fundoscopy, as it can be
uncomfortable for the patient with
an intense light shining directly
towards their more sensitive
central vision. The foveal reflex is
seen better with a green (red-free)
filter and is at two disc diameters
away from the disc and 1.5
degrees below the horizontal (your
whole field of view is 8 degrees).
Slide 58 Normal macula close up view (e.g.
when viewed through direct
ophthalmoscope).

Slide 59 A circinate ring of hard exudates

(diabetic maculopathy),
Rings of hard exudates haemorrhage (dot, blot, or flame),
pigment deposition / atrophy, or
drusen (age-related macular
degeneration) are among the more
common signs to look out for.

Slide 60 Macula close up view (e.g. when

M1 viewed through direct
ophthalmoscope) of M1: diabetic
maculopathy with hard exudates.
Slide 61 Drusen at macula – a sign of AMD.

Slide 62 Macula close up view (e.g. when

viewed through direct
ophthalmoscope) of drusen in dry
age-related macular degeneration.

Slide 63 Haemorrhage and exudates at

macula in wet AMD.
Slide 64
Case Report Answers
To be discussed in face-to-face tutorial

Slide 65
Case Report:
34 yr old female c/o headaches in the morning on waking, and
bilateral visual obscurations

Slide 66 Please write your answers on a

Case Report Questions card before reviewing the rest of
the slides. You should hand your
1. What are the possible causes for answers in at the start of the
symptoms of headache associated with
blurred vision?
tutorial, but don’t put your name
2. Describe the abnormal signs shown in the on them. For the exercise to be
previous slide? worthwhile, your answers should
3. What are the possible causes of these be honest and anonymous, and
signs?
4. What is the most likely diagnosis in this
will not be marked.
case?
5. What features of the headaches are typical
for this?
Slide 67 Please write your answers on the
Minute Paper same card that you used in
answering the background
• What do you think is the most knowledge probe.
important clinical finding not to miss
when it comes to fundoscopy that you
now understand well, that you didn’t
know before?
• What aspect of fundus examination or
theory do you still find confusing or
least clear?

Slide 68 Fundoscopy teaching aids during

the clinical exam will be either
available for you in the tutorial
room or with Catherine, the staff
nurse in the Diabetic Retinopathy
Screening Office in Room 8. One
of the teaching aids was shown
earlier on in this presentation. With
regards to the model shown in the
picture across, please see the
instructions that come with it which
describes how to view the various
pathologies that you might get
questioned on during the clinical
exam.

Slide 69
Method of Fundoscopy Assessment for Clinical Exam
Instruction / introduction as if examining a real patient
Adjust the setting / room lighting as necessary
Comment on the use of dilating drops, e.g. Tropicamide Technique:
Excellent
Ask subject to fixate on a distant target, usually over the
Good
shoulder of the examiner (e.g. right shoulder if examining Adequate
right eye) Poor
Hold ophthalmoscope in correct hand with finger
on focusing dial to adjust for refractive errors as Speed:
necessary (examiner’s and subject’s) Excellent
Good
Comment on red reflex and the lens power being used Adequate
Poor
Use correct eye, i.e. right eye to examine right fundus
Approach from an angle of about 15 degrees temporal to
subject’s visual axis to find optic disc, commenting on the
disc when found (3 ‘Cs’)
Read correct word – right eye (or identifies pathology on
the Digital Eye Retinopathy Trainer)
Repeat instructions for left eye
Read correct word – left eye (or identifies pathology on the
Digital Eye Retinopathy Trainer)