Fundoscopy

Question 1

Explanation

Answer 1

Wash hands, PPE
Introduce yourself
Patient ID, DOB
Explanation, exposure
Repositioning
Questions - any pain. any questions

Hello, I’m An Nakamura, a 3rd year medical student. I’d like to examine your eyes.
I’ll use a magnifying tool called an opthalmoscope to look at the back of your eyes with the lights off. I will need to get quite close to your face but I will place my hand on your forehead to prevent us from bumping heads.
I will also use eye drops to dilate your pupils. Your vision will be temporarily blurry and you will be more sensitive to light so you will be unable to see or drive for a few hours afterwards

Question 2

Preparation before fundoscopy

• patient
• opthalmoscope

Answer 2

Patient comfortable?
Tropicamide eyedrops => VD
Dim lights
Ask patient to look straight ahead at a distant object

Diopter dial
Normal visual acuity/wearing glasses/contacts => 0
Refractive error => adjust to match prescription

Question 3

Step 1 - fundal reflex

• how would you assess this
• what are you looking for?

Answer 3

Hold opthalmoscope right against forehead+cheek, shining light towards patient’s eye from 1 arms length

Normal => reddish-blue reflection from vascularised retina

No reflex - cataracts/vitreous hemorrhage/retinal detachment/retinaoblastoma in children

Question 4

Step 2 - fundal assessment

• preparation
• optic disc

Answer 4

I am going to place my hand on your forehead

• focus diopter
• assessing R eye => opthalmoscope in R hand, steady yourself with L hand on forehead

Optic disc
-find blood vessels => follow to optic disc
3Cs
Countour - well defined
-blurry - ICP => papillodema
Colour - orange pink doughnut with pale center
-pale => optic atrophy from neuritis, advanced glaucoma, ischemia
Cup - pale (1/3d normal) => no neuroretinal tissue
-large cup => reduced healthy retinal tissue

Question 5

Step 3 - fundal assessment

-retinal vessels

Answer 5

4 branches coming off the optic disc

• superior temporal
• superior nasal
• inferior nasal
• inferior temporal

HTN retinopathy
Arteriolar narrowing - silver wire
Arteriovenous nicking - arteriole compressing venule => bulging venules either side

Diabetic retinopathy
Neovascularisation
Panretinal photocoagulation - pale burn marks on retina to treat diabetic retinopathy

Question 6

Step 3 - fundal assessment

-retina

Answer 6

4 quadrants between vessels
-veins darker than arteries

Dot, blot hemorrhages - diabtetic retinopathy
Flare hemorrhage - rupture of vessels
-HTN, retinal vein occlusion, trauma

Cotton wool spots (slightly diffuse edges), hard exudates (well defined edges) - retinal infarcts
-HTN, DR

Question 7

Step 3 - fundal assessment

• preparation
• macula

Answer 7

Ask patient to look briefly into the light => macula is temporal to optic disc

Normal fovea - darker circle, same size as optic disc
Macula - yellow

Hard exudate (infarcts) - HTN, DR 
-often found with hemorrhages
Drusen - DryAMD
-not often found with hemorrhages
Cherry red spot - central retinal artery occlusion

Question 8

Step 4

-assessment of other eye

Answer 8

Repeat with other eye but CHANGE HANDS

Question 9

Completion of examination

Further investigations

Answer 9

Explain that the examination has finished, thank them for their time

If tropicamide used => remind them they cannot drive for 3-4hrs until vision has returned to normal

Hx
Visual acuity
Visual fields
Cranial nerve examination

Macular degeneration - Amsler chart to assess for central visual loss, distortion in AMD
HTNR - BP
DR - capillary blood glucose