Lecture 2: Fundus Biomicroscopy and Fundus Findings

Question 1

(T or F) It is ok to dilate a pt with an anterior chamber IOL but you may need to use the highest strength of dilating drops (Tropicamide 1% and Phenylehrine 10%)

Answer 1

False, dont do it! (2 more contraindications of dilation is plateau iris and small angles)

Question 2

In order to bill for a complete comprehensive exam, can the dilation portion be skipped?

Answer 2

only in 2 exceptions 1) patient refuses and 2) medically contraindicated

Question 3

What are the billing codes for a comprehensive exam for both a new pt and an existing pt?

Answer 3

new=92004

existing=92014

Question 4

Can you bill for a comprehensive exam and use undilated 90 in place of dilated fundus assessment?

Answer 4

yes, to bill for a comprehensive exam you must include a fundus assessment. This can be done with the undilated 90, but this is not preferred. explain to your pt the benefits of the dilated view.

Question 5

What are the 3 tools for examining the retina?

Answer 5

1) direct ophthalmoscope
2) fundus biomicroscopy (undilated 78/90/3M)
3) Binocular indirect ophthalmoscope (BIO)

Question 6

(T or F) Direct ophthalmoscopy gives the Dr. an upright view, while BIO gives the Dr. an inverted and reversed view of the fundus.

Answer 6

True (Goldmann 3- mirror contact Hruby lens and 3M rectangle/trapezoid mirrors are inverted)

Question 7

What is the difference between Direct ophthalmoscopy and binocular indirect ophthalmoscopy?

Answer 7

With direct, the image of the pt’s retina is formed onto the observers retina. With indirect, the pt’s retinal image becomes an aerial image in between the BIO and the condensing lens

Question 8

The 90D lens is prefferred for ______ and the 78D is prefferred for _____ and ______

Answer 8

90D-undilated views, 78D-glaucoma suspects and diabetic retinopathy

Question 9

The “super 66” and the “digital high mag” are similar to the:

A) 20D lens
B) 78D lens
C) 90D lens

Answer 9

B) 78D lens

(super 66=higher mag, larger diameter, but same FOV as 78D) (digital high mag=higher mag, same diameter, same FOV as 78D)

Question 10

The “super 90” and the “digital wide field” are similar to the:

A) 20D lens
B) 78D lens
C) 90D lens

Answer 10

C) 90D lens

super 90=same mag, and greater FOV than 90D) (digital high mag “ultimate 90”=same mag, greater FOV than 90D

Question 11

(T or F) Lens magnification increases as lens power decreases

Answer 11

true

Question 12

You are examining OS and superior-temporal arcades. The view is lost as you reach the outer limit of the lens. What is the corrective maneuver?

A) move your lens to the right
B) move your light to the right
C) move your lens to the left
D) move your light to the left

Answer 12

C) move your lens to the left. Why does this work? because your views are inverted and reversed (always move your lens in the direction of your scans)

Question 13

Which of the following is INCORRECT?

A) Long posterior ciliary nerves are at 3 and 9 O’clock
B) Long posterior ciliary nerves are also at 8 and 12 O’clock
C) Short ciliary nerves are seen between 10 and 2 O’clock
D) Short ciliary nerves are also seen at 4 and 6 O’clock

Answer 13

B) Long posterior ciliary nerves are also at 8 and 12 O’clock

Question 14

(T or F) Long posterior ciliary nerves (LCN) represent the anatomical horizontal meridians and divide the retina into superior/inferior, while the short ciliary nerves (SCN) represent the vertical meridians and divide the retina into nasal/temporal

Answer 14

True

Question 15

What is the junction between the retina and ciliary body?

Answer 15

Ora Serrata (nasal Ora appears serrated)

Question 16

What divides the anterior and posterior retina?

Answer 16

equator

Question 17

There are at least ____ to ____ vortex veins (ampulla) located in the ___, ___, ___, and ___ O’clock meridians

Answer 17

4 to 6….1,5,7,11 O’clock (vortex ampulla are located just posterior to the Ora)

Question 18

What is the angle of inclination for the following goldman universal 3-mirror?

A) D-shaped
B) Rectangle shaped
C) trapezoid shaped

Answer 18

A) D-shaped=60=for undilated views of the angle, or when dilated can view pars plana
B) Rectangle shaped=66=equator to Ora
C) trapezoid shaped=76*=equator to mid-periphery

(all views are inverted, however, H-ruby is center and view is upright used to view posterior pole)

Question 19

(T or F) Hruby has a smaller FOV than BIO

Answer 19

False, its larger

Question 20

(T or F) Avg vertical disc diameter is 1500 micrometers. This may be greater in a myope and less in hyperope (in ametropes with >5D)

Answer 20

True (also, a normal optic disc has an oval shape)

Question 21

How can you measure the size of the optic nerve?

Answer 21

With DO: use 5* aperature size or medium aperature size. If disc falls within spot, its smaller than avg and if disc falls outside spot, its larger than avg

With slit lamp: Adjust vertical height of beam to fit the inner edges of the disc margin and scleral ring, Read the measurement off the slit lamp scale. Conversion factor: 66=1x, 78D=1.2x, 90D=1.33x (with volk lenses, nikons would be slightly different)

Question 22

Which ethnicity has the largest Optic disc size?
A) Caucasians
B) Hispanics
C) Asians
D) African Americans

Answer 22

D) African Americans

(Caucasians, Hispanics, Asians, African Americans are in order from smallest to largest)

Question 23

ONH C/D is always recorded:

A) vertical/horizontal
B) horizontal/vertical
C) temporal/nasal
D) nasal/temporal

Answer 23

B) horizontal/vertical

Question 24

When viewing the ONH, you will see a “circle inside a circle”. Which one of the following is true concerning the circles:

A) The inside circle is the cup, outside circle is the disc
B) The inside circle is the disc, outside circle is the cup
C) neither is true because cups and discs are found in the macula and not in the optic nerve.

Answer 24

A) The inside circle is the cup and the outside circle is the disc

Question 25

What are the 5 “R”’s of optic nerve evaluation?

Answer 25

Rim (size and color), Retinal (nerve fiber layer), Ring (scleral ring for ON diameter), Region (of the papillary for atrophy PPA), Retinal (and/or optic nerve hemorrhages)