CS - Ophthalmoscopy and Auroscopy

Question 1

What are the steps involved in a Fundoscopy/Opthalmoscope exam?

Answer 1

1). Introduction
2). Observation
3). Asses fundal reflex
4). Examine fundus
5). Repeat of fellow eye
6). Conclusion

Question 2

What would you cover in the “Introduction” section of a Fundoscopy/Opthalmoscope exam?

Answer 2

A. Wash hands with water or alcohol gel

B. Prepare ophthalmoscope

C. Introduce self and confirm patient’s name and date of birth

D. Explain procedure and gain consent to examine the eye

E. Position patient sitting on a chair or the edge of a bed with knees together

F. Give clear instructions: fix target, keep head and eyes steady, do not look at the light or the
examiner

G. Ask the patient if they have ever had the procedure done before.

H. Explain that you are going to look at the back of the eyes with a light. Also explain that you are going to come very close and that you may have to put your hand on the patient’s head to steady yourself and avoid your heads touching.

• The patient should sit on a chair, or the edge of the couch, with the knees together.
• The patient and the examiner can leave their usual distance glasses or contact lenses on. Particularly in patients with very high refractive error it can be better to examine them through their glasses.

I. Explain to the patient that the room will be darkened. The patient should be asked to fix on a distant target at eye level that you have identified for them and also reminded not to look at the examiner or the ophthalmoscope. The fixation target should compel the patient to keep their eyes in the ‘primary’ position (not looking to either side or up or down). They should also be reminded to keep their head still, but carry on blinking and breathing as normal.

Question 3

What would you cover in the “Observation” section of a Fundoscopy/Opthalmoscope exam?

Answer 3

A. Take time to observe for;

B. The position (ptosis/retraction) and health (redness/swelling) of the eye lids

C. The position of the eyes looking for evidence of a squint (inward, outward or vertical
displacement)

D. The pupils in terms of relative size to each other and regularity of shape.

E. The conjunctiva and sclera for any discolouration, redness, discharge or lesions.

Inspect both eyes for any obvious abnormalities.

Comment on any positive findings first then any relevant negative findings.

Question 4

What would you cover in the “Assess fundal reflex” section of a Fundoscopy/Opthalmoscope exam?

Answer 4

Technique to assess BOTH retinal reflections at same time;
A. Hold the ophthalmoscope in your dominant hand
B. Switch on the device and turn the light to the maximum brightness and the lens power to zero
C. Stand at arms length from the patient
D. Hold the sight hole very close to your own eye and look at both of the patient’s eyes at the
same time
D. You should see the normally central round dark pupil space light up brightly with shimmering
red, yellow and orange colours. This is known as the retinal reflection or ‘red reflex’

Question 5

What would you cover in the “Examine Fundus” section of a Fundoscopy/Opthalmoscope exam?

Answer 5

A. Use the right eye to examine the right eye and vice versa
B. Start about 15 ̊ temporal to the right eye on the horizontal meridian
C. Start on a zero power lens
D. Place your feet close to the patient but then lean back away
E. Gradually move toward the patient, maintaining the red reflex and the optic nerve should be in
view
F. Consider selecting lenses if the fundal detail is out of focus (although this is typically not needed)
G. Follow the direction of the arrows created by the branches of vessel toward the optic nerve
H. Observe the optic nerve head commenting on the margin, colour and cup
I. Follow the four major arcade vessels and examine the adjacent retinal quadrants
J. Finish by examining the fovea (the centre of the macula) by asking the patient to look at the
light

Use the correct eye; right-to-right and left-to-left. This allows you to get very close to the patient and therefore obtain a clear view, whilst also maximising the field of view. Place feet close to the patient where you will be comfortable when examining the eye close up. Then, lean back and start at arms-length from the patient and 15 ̊ temporal to the eye. Observe the red reflex in the pupil space and gradually move in closer towards the patient’s eye keeping the red reflex in your view. Retinal and optic nerve detail will appear.

If the fundal detail is blurry then you may have to select lenses to see vessels more sharply. If you change lenses too quickly you will miss the one that gives you the sharpest view.

If the patient has a high refractive error, it may also be easier to examine the patient whilst they are wearing their spectacles or contact lenses. However, you may find this more cumbersome and practice will highlight which technique you prefer.

Follow blood vessels for optic nerve head

Question 6

What would you cover in the “Repeat on fellow eye” section of a Fundoscopy/Opthalmoscope exam?

Answer 6

A. Approach from left hand side of patient
B. Use left hand to hold ophthalmoscope to view left eye with your left eye
C Repeat the ‘flight path’ as above

Question 7

What would you cover in the “Conclusion” section of a Fundoscopy/Opthalmoscope exam?

Answer 7

A. Thank patient and wash hands with alcohol gel or water.
B. Summarise and present findings orally (and in patient’s notes.)

Question 8

What are the features on a traditional Opthalmoscope?

Answer 8

• Sight hole
• Lenses
• On/off brightness

Question 9

What are the features on an Arclight?

Answer 9

• Sight hole
• Lenses
• On/off settings switch

For most examinations the lens rack is best pushed to the top with no lens being used

Question 10

What is wrong with this eye ?

Answer 10

Cupped optic nerve suggestive of glaucoma

Question 11

What is wrong with this eye ?

Answer 11

Pale optic nerve (optic atrophy) – a wide range of causes such as MS, ischaemia, compression

Question 12

What is wrong with this eye ?

Answer 12

Swollen Optic Nerve - if due to raised ICP this is called papilloedema

Question 13

What might cause the loss of the red reflex?

Answer 13

cataracts, corneal scars, or vitreous hemorrhage

Question 14

Describe some of the signs and symptoms of diabetic retinopathy?

Answer 14

Signs;
- Haemorrhage
- Abnormal growth of new blood vessels
- Aneurism
- ‘Cotton wool spots’ (secondary to ischemia from retinal arteriole obstruction)
- Hard exudates
- Retina thickening, oedema

Symptoms;
- gradually worsening vision
- sudden vision loss
- shapes floating in your field of vision (floaters)
- blurred or patchy vision
- eye pain or redness

Question 15

Describe some of the ways that patients can lose vision from diabetic retinopathy ?

Answer 15

Diabetic retinopathy can cause abnormal blood vessels to grow out of the retina and block fluid from draining out of the eye. This causes a type of glaucoma (a group of eye diseases that can cause vision loss and blindness)

Question 16

What might a swollen optic nerve head indicate?

Answer 16

Papilledema is swelling of your optic nerve, which connects the eye and brain. This swelling is a reaction to a buildup of pressure in or around your brain that may have many causes. Often, it’s a warning sign of a serious medical condition that needs attention, such as a brain tumor or hemorrhage

Question 17

What are the steps involved in a Otoscopy exam?

Answer 17

1). Introduction
2). Observation and palpation
3). Prepare device
4). Examine meatus, canal and ear drum
5). Repeat on fellow ear
6). Conclusion

Question 18

What would you cover in the “Introduction” section of a Otoscopy exam?

Answer 18

Introduction
A). Wash hands and don PPE if required
B). Introduce yourself and confirm patient’s name and date of birth
C). Explain the examination and gain consent to perform it
D). Confirm if there is an affected ear and start by examining the normal side first

• Ask the patient if they have ever had the procedure before.
• Explain the examination to the patient, reassuring them that although it may be a little uncomfortable, it should not be painful.
• Confirm they are happy and you have consent to examine.

The patient should sit on a chair, with a chair next to them which you can use if needed. The patient should remove any hearing aids. Always examine the normal ear first and compare to the affected side. In an OSCE situation you may be asked to examine a specific side. Change the speculum when switching ears to avoid spread of infection.

Question 19

What would you cover in the “Observation and palpation” section of a Otoscopy exam?

Answer 19

A. Inspect the pinna, area behind the pinna (mastoid) and the pre-auricular area

B. Assess for symmetry and look for signs such as pits or sinuses, scars, swelling,
erythema or discharge

C. Palpate the pinna, tragus and mastoid process for any masses or tenderness

Observe the external ear before examination with the otoscope. Clean away any discharge. It can be difficult to remove any wax which may obscure the examination. Observe both sides looking for any differences. Look for obvious signs of abnormality e.g.
* Look behind pinna for scars of previous surgery or signs of mastoid swelling (loss of the post-auricular grove/swelling) and tenderness
* Size and shape of pinna. Compare to the other side
* Skin tags, pits or sinuses around the ear
* Signs of trauma to pinna
* Skin lesions including neoplasms
* Look at the size of the meatus
* Note any obvious discharge suggesting infection

Question 20

What would you cover in the “Prepare device” section of a Otoscopy exam?

Answer 20

Prepare device and put on new specula cover

Choose the correct speculum size by selecting the largest one that will still be comfortable for the patient. It may be tempting to use a small speculum for ease of insertion, but this will restricts the view available.

Question 21

What would you cover in the “Examine meatus, canal and ear drum” section of a Otoscopy exam?

Answer 21

A. Straighten the canal by pulling the pinna slowly and gently
B. In adults pull upwards and backwards but in children pull downwards and backwards
C. Warn patient and gently advance the auroscope under direct vision, not looking down the
otoscope yet
D. Look down the otoscope and examine the meatus and ear canal for wax, foreign bodies,
erythema and discharge
E. Next examine the tympanic membrane for changes in colour, bulging of the membrane,
perforation, light reflex, scarring or lesions
F. Gently withdraw the otoscope and dispose or clean the speculum

The tympanic membrane is roughly circular and about 1cm in diameter. It should appear translucent and pearly grey/white with any redness suggesting disease. The cone of light or light reflex is a an important normal sign which should help you identify the drum and other structures. It should extend anteriorly as the light from the scope is reflected forwards off the concave surface of the membrane. In pathological conditions this light reflex may be lost such as when there is pus within the middle ear causing the drum to bulge outwards, losing the concavity.

Question 22

What would you cover in the “Repeat on fellow ear” section of a Otoscopy exam?

Answer 22

A. Place a clean speculum on the otoscope
B. Repeat procedure on fellow ear using your other hand

Question 23

What would you cover in the “Conclusion” section of a Otoscopy exam?

Answer 23

A. Thank patient and wash your hands
B. Summarise and present findings to the patient and examiner

Question 24

What is the general anatomy of the outside of the ear ?

Answer 24

Image

Question 25

What might tragus tenderness and behind the ear tenderness be a sign off?

Answer 25

Press over the tragus for tenderness which might suggest infection of the external auditory meatus or a temporomandibular joint problem.

Palpate behind the ear for tenderness, which might suggest mastoiditis.

Question 26

How would you change your grip on the pinna for children and why ?

Answer 26

With children, pull the pinna back and down

Ear infections are more common in children because their eustachian tubes are shorter, narrower, and more horizontal than in adults, making the movement of air and fluid difficult.

Question 27

How would you hold an Otoscope?

Answer 27

Hold the traditional otoscope near to the end you look through, rather than in the middle or at the far end. This helps to reduce discomfort due to wobble of the instrument, which can be exaggerated while in the ear canal. For the Arclight otoscope you can hold in the middle.

Hold the otoscope like a pencil, between your thumb and index finger. Rest the ulnar side of your hand and little finger gently on the patient’s face so that if they move quickly, your hand will move with them and you will not injure the patient. This is especially useful when examining children.

Question 28

How would you change an otoscope examination for a child?

Answer 28

When examining young children, ask the guardian to seat the child sideways across their lap. One of the adult’s hands should be placed across the child’s head so that it is firmly pressed against the parent’s chest. The adult’s other arm can be placed over the child’s shoulder and chest in order to comfort and secure the child’s hands. This will prevent any sudden movements of the child’s head of hands whilst examining.

Question 29

What can you see in this Otoscopy ?

Answer 29

Wax

Question 30

What can you see in this Otoscopy ?

Answer 30

Chronic inflammation

Question 31

What can you see in this Otoscopy ?

Answer 31

Fungal spores

Question 32

What can you see in this Otoscopy ?

Answer 32

Foreign body

Question 33

What structures can you see deeper in the ear?

Answer 33

• Pars Flacida
• Handle of Malleus
• Pars Tensa
• Cone of light

Question 34

What can you see in this Otoscopy ?

Answer 34

Perforation

Question 35

What can you see in this Otoscopy ?

Answer 35

Pus behind ear drum

Question 36

What can you see in this Otoscopy ?

Answer 36

Perforation and pus

Question 37

What can you see in this Otoscopy ?

Answer 37

Chronic glue ear

Question 38

What would you consider to complete your Otoscopy examination ?

Answer 38

• Cranial nerve examination especially the facial and vestibulocochlear nerves
• Audiometry and tympanometry
• Examination of the oral cavity and local lymph nodes