Fundoscopy & Otoscopy Flashcards
1
Q
What is the fovea?
A
the darker area which is in the centre of the macula
this has the highest density of cone receptors and therefore provides the clearest vision
2
Q
What is the definition of the lens?
A
a transparent, biconvex structure situated behind the iris and pupil
this allows the eye to focus objects onto the retina
3
Q
What is the definition of the cornea?
A
a transparent layer to the anterior of the eyeball
this is responsible for refraction of the light entering the eye
4
Q
What is the definition of the pupil?
A
central aperture within the iris
this constantly changes in size in response to the sphincter and dilator pupillae muscles
5
Q
What is fundoscopy?
A
fundoscopy involves using a fundoscope / ophthalmascope to shine a light through the pupil towards the back of the eye (retina / fundus) to examine its surface
you should see an upright image of a small portion of the retina approx 15x magnification of its actual size
6
Q
What is the purpose of fundoscopy?
A
- it can be used to assess the health of the eye, and also other systems within the body
- visualisation of the retina and vessels in the back of the eye can give us clues as to the general health of the patient including their cardiovascular, neurological and endocrine health
7
Q
What are the indications for fundoscopy?
A
- head injury
- eye injury
- as part of complete neurological examination to assess for papilloedema
- chronic disease monitoring (diabetes / hypertension)
- to assess health of the eye and retina
- assess for possible infections such as CMV, endocarditis and candidaemia
8
Q
When explaining the procedure to the patient, what is it important to include?
A
- you will need to get close to them in this examination
- it shouldn’t hurt but may be uncomfortable, please let us know if it becomes too much
- explain fixing gaze and find appropriate point to look at, this will make the exam easier to perform
- you can blink
9
Q
After explaining the examination, what is it important to do?
What might you choose to use and why?
A
- once you have explained the procedure, give the patient the chance to consent and answer any questions
- you may choose to use mydriatic drops (check 5Rs and allergies) and this should be explained fully to the patient
10
Q
What should the environment be like for fundoscopy?
A
- a darkened room to maximise the diameter of the pupil
- position for you and the patient - you should be upright and eye level to one another
11
Q
What eye should you use to examine the patient’s eye?
How should the ophthalmoscope be held?
A
- you should use your right eye to examine the patient’s right eye and vice versa to avoid facial contact
- hold the ophthalmoscope in a way that allows you to use your index finger to adjust the lens wheel as required
- adjust the brightness and aperture mask prior to commencing examination, in order to maximise patient comfort
12
Q
What should be looked for when inspecting the eyes at the beginning of the inspection?
A
- any discharge or foreign bodies
- symmetry of the eyes and eyelids
- surrounding skin including any erythema, oedema or skin abnormalities
13
Q
What is the red reflex and how can it be found?
A
- direct beam of light onto patient’s eye from around 1 foot away and from an angle of 15-20o
- move slowly in towards patient’s eye as this directs the beam towards the optic disc
- look for red reflex and use it to guide you closer to the pupil
- the red reflex is a red/orange reflection of the light off the retina
- the red reflex should be round and clear
- opacities or change in colour could indicate vitreous haemorrhage, cataracts or debris
14
Q
How do you use the fundoscope to see the anterior structures in the eye?
What should you comment on when doing this?
A
- place hand on patient’s forehead
- approach from 15-30 degrees on the same level as the equator of subject’s eye, directing the beam of light into the pupil (use red reflex to guide you)
- focus on the anterior segment of the eye and comment on any abnormalities
- comment on the pupils - shape, symmetry and size
15
Q
What do you do once you have a vessel in focus?
A
- you should adjust the focussing wheel as you get closer to the patient
- once you have a vessel in focus, follow the branching vessels as though they were arrows pointing towards the disc
- follow these “arrows” to locate the disc
16
Q
What structures are evident at the back of the eye?
What should you identify and comment on?
A
- focus on the retina
- identify and describe the optic disc
- follow blood vessels into 4 quadrants, commenting on vessels and spaces between
- seek to identify the macula and fovea
- comment on all the above
17
Q
What are each of the quadrants of this eye?
Is this a left or right eye?
A
it is a right eye
this is because the optic disc is in the medial position
18
Q
What 4 aspects are involved in the systematic examination of the retina?
A
- background
- disc
- vessels
- fovea and surrounding macula area
19
Q
What is looked for when examining the background of the retina?
A
- any microaneurysms or haemorrhaging
- this includes blot, dot and flame haemorrhages
- hard exudate - such as lipids, proteins & other debris
-
cotton wool spots
- these are also known as soft exudates
- they show areas of ischaemia / infarcts
20
Q
Where is the macula and fovea found and what should it look like?
A
- it is lateral to the optic disc
- it is slightly pigmented and has no border
- it is responsible for the central and sharpest vision
- the foveal pit in the centre of the macula sometimes has a glistening appearance due to the light reflex
- this is seen more commonly in young people
- the fovea loses the light reflex as people get older
21
Q
What should be checked for during examination of the macula?
A
- hard exudates that are creamy in colour
- haemorrhaging
- proliferation / neovascularisation
- ideally nothing should be in the macula area as it is avascular due to the rods and cones
22
Q
What should the outline of the optic disc look like?
A
- in a normal state, it is well-defined and sharp
- there may be a white scleral ring, a dark pigmented ring or a stippled choroidal ring surrounding the optic disc
23
Q
What is the colour of the optic disc like?
How does this change in oedema and atrophy?
A
- it is creamy yellow/orange-pink in colour compared to the rest of the retina
- temporal margin is slightly paler than the nasal margin
- in atrophy of the optic nerve, the disc becomes white/greyish
- in oedema of the optic disc, it becomes pinker and resembles the colour of the surrounding retina
24
Q
What should the vessels of the retina look like?
A
- branching of vessels forms a “v” that always points towards the optic disc
- main vessels branch in 4 directions
- veins are uniform and burgundy in colour
- arteries have a central pale line and 2 red outer walls
- they are narrower than veins and a brighter colour due to light reflecting from their walls
25
What should be noted about the features of the vessels in the retina?
* the calibre (**_width_** of blood vessels)
* whether they are **_curvilinear_** (not too tortuous or straight)
* the points where the **vessels cross** to check for **_arteriovenous nipping_**
26
What are all the key points to mention about the optic disc in summary?
* sharp margins
* blind spot
* it is round / oval
* it is yellow / orange to creamy pink
* the cup to disc ratio should be \< half
27
What are key points to mention about the vessels of the retina in summary?
* **_AV ratio_** - arteries are 2/3 the size of veins
* **_AV crossing_** - no indentation
* **no arterial light reflex**
28
What are the key points to mention about the background of the retina in summary?
* the colour should be **red to purple**
* there should be **no exudates or haemorrhages**
29
What are key points to mention about the macula in summary?
* it is located **temporal** to the optic disc (lateral)
* there are **no vessels** around the macula
* it may be **pigmented**
30
Why might a diminished red reflex be present?
What can cause this?
if there is **_any opacity_** between the **_cornea_ and the _retina_**, the reflex will be changed dependent upon the nature and depth
* **vitreous haemorrhage**
* **brown or white reflex** with **cataract**
31
What is papilloedema?
What does the optic disc look like?
**_swelling_ of the optic disc**
* there is **elevation** or **obscuring of the vessels** at the disc margin
* there is a **blurred or absent disc margin**
32
What typically causes papilloedema?
* congestion of the optic disc due to **_raised intracranial pressure_** is often **bilateral**
* it can also be caused by **_malignant hypertension_** when **BP \> 180/110 mmHg**
33
What is the cup of the optic disc?
What is a normal cup-to-disc ratio and what happens in cupping?
* the cup is the **pale, central part** of the disc
* a normal cup-to-disc ratio is **_0.3_**
* the cup occupies 1/3 of the size of the disc
* cupping can occur due to **glaucoma**
34
What types of vessel abnormalities need to be looked out for?
* abnormal crossing / AV nipping
* arterial diameter being \< half of vein diameter
* copper wiring
* increased tortuosity of vessels
35
When do haemorrhages occur?
What determines the shape of the haemorrhage?
haemorrhages occur when **weakened capillary walls** or **microaneurysms** rupture
the **depth** of the haemorrhage determines its shape
36
Where are "flame" and "splinter" haemorrhages found?
* they occur in the **nerve fibre layer**
* they get their shape from the tracking of blood along the nerve fibre
37
Where are round / oval "dot" and "blot" haemorrhages found?
* they occur within the **inner layer of the retina**
* the cells are so compactly arranged that the haemorrhage cannot spread
38
When do exudates occur?
they occur when weakened capillary walls or microaneurysms rupture
39
What causes a hard exudate?
What does it look like?
deposits of **_lipid and protein_** which leak from surrounding capillaries
they are **_yellow, waxy looking_** and have **more defined edges** than cotton wool spots
40
What is a soft exudate?
What does it look like?
* these are **nerve fibre layer infarctions**
* areas of **_ischaemia_** resulting from **occlusion of retinal arteries** and **swelling of the local nerve fibre axons**
* they are **_white_** with a **_"fluffy" appearance_**
41
What is shown in these photos?
macular degeneration
42
What is otoscopy?
the clinical examination of the **_ear canal_** and **_tympanic membrane_**
this usually is by means of a **hand-held auriscope** (also known as an otoscope) providing **illumination** and **magnification**
43
What are the main indications for otoscopy?
* hearing loss
* tinnitus
* discharging ear
* vertigo and dizziness
* lump or swelling in the neck
* facial pain
* facial palsy
* ear pain
* head injury
* undiagnosed cause for temperature
44
What is the definition of otorrhoea?
this is **discharge from the ear** and may originate from the ear canal or the middle ear
it is a symptom and a sign, but not a diagnosis
45
What potential things may come out of a discharging ear?
* debris
* wax (cerumen)
* mucus
* pus
* blood
* CSF
46
What might cause debris to come out of a discharging ear?
debris can accumulate from **dermatological conditions**
or some **infections** such as candida, or some from **external debris** such as sand or dirt
47
What is earwax and how is it normally produced?
* it is a normal secretion of the **ceruminous glands**
* it is slightly **acidic**, which gives is bactericidal qualities
* the **epithelium** in the ear is **migratory** and it travels radially out from the eardrum and along the ear canal
* this means that the ear is **_self-cleaning_** and removal of earwax is not usually necessary
48
What can unnecessary cleaning of earwax lead to?
When does it need to be removed and why?
* the earwax can be pushed into the ear and **accumulate**
* removal is only necessary if it accumulates and becomes **impacted**
* this can cause **hearing loss, pain** and **vertigo**
49
Where does mucus in ear discharge usually originate from?
it often originates from the **middle ear,** due to infection of the middle ear mucosa
50
What does pus in the ear discharge suggest?
this is indicative of infection
51
What are possible causes of blood in ear discharge?
* tympanic rupture
* trauma
* infection
52
Why might there be CSF in ear discharge?
this is clear fluid that usually is present after a head injury
it would test positive for glucose
53
What is involved in the external inspection of the ear prior to examination?
* compare the pinnae for **symmetry**
* observe **pinnae, conchal bowl, mastoid** and **pre-auricular areas** for any skin abnormalities, scars, trauma, discharge, redness and swelling
* remember to **move the pinna back** and inspect behind it
54
What is the next stage after inspection of the ear?
a gross hearing test
this includes:
* whisper test
* Webbers test
* Rinnes test
55
What are the stages involved in using the otoscope?
* check that light is working and apply single use ear piece
* ensure patient and examiner are sat comfortably and at the same height
* pull the pinna upwards and backwards to straighten the external auditory meatus
* hold the otoscope like a pen, with the examiners little finger resting against the patient's cheek to reduce risk of trauma
* position otoscope at the external auditory meatus, so that patient can alert to any pain or discomfort prior to advancing it
* advance the otoscope under direct vision through the lens
* examine the external auditory meatus
56
What is shown in this photo?
this is the tympanic membrane
57
What should the tympanic membrane look like on examination?
What is it important to look for?
* it should appear **_relatively flat_**, **_pearly grey_** and **_translucent_**
* examine the **_margin_** as **perforations** and **pathologies** can be present there
* look for **perforations, scarring, bulging, retraction** and **erythema**
* note any abnormalities and the position and size of them
58
What is the pars tensa?
the largest section of the tympanic membrane
59
What is the pars flaccida?
the superior part of the tympanic membrane
it is thinner and the fibrous layer is missing
60
What is used as a geographical marker when visualising the tympanic membrane?
the handle and lateral process of the malleolus
61
What is the cone of light?
the cone of light is also known as the light reflex
this should appear in the **_anterior inferior quadrant_** of the tympanic membrane
absence or distortion may indicate **_increased inner ear pressure_**
62
What potential additional examinations / investigations may be performed after otoscopy?
* lymph node examination
* cranial nerve examination
* audiometry
* vital signs
* culture of any discharge
* biopsy of lesions
* imaging
* referral to ENT
63
What are gouty tophi and why might they be present on the ear?
**nodular masses of urate crystals**
they are deposited in the **soft tissue**, particularly on the ear and hands
they are a late sign of **_hyperuricaemia_**, particularly in patients with **gout**
64
What is shown in this image?
otitis media
the membrane is bulging, there is erythema and visible blood vessels
65
What is shown in this image?
**_otitis media with effusion_**
there is a **bulging** tympanic membrane
**fluid** is visible, which is indicative of an effusion
66
What is shown in this image?
**perforated tympanic membrane**
there are visible **blood vessels** and **erythema**
67
What is cholesteatoma?
What can happen if it becomes infected?
* an abnormal, **sac-like accumulation** of **_keratin_** and **_keratinizing squamous epithelium_** within the **middle ear** or **mastoid air cell spaces**
* can become infected and **erode the bony structures of the middle and inner ear**, causing potential life-threatening complications and infections
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