visual
Journal of
Matching fundus
photographs of classmates.
An informal competition
to promote learning
and practice of direct
ophthalmoscopy among
medical students
Jørgen Krohn1,2, Bård Kjersem2 and Gunnar Høvding1,2
1
Department of Clinical Medicine, Section of Ophthalmology, University of Bergen, Bergen, Norway
2
Department of Ophthalmology, Haukeland University Hospital, N-5021, Bergen, Norway
Purpose: To present a new approach for
teaching direct ophthalmoscopy to medical
students.
Methods: At the University of Bergen, four
consecutive classes of fourth-year medical
students complete a required 9-week
ophthalmology course every year. In the
present project, one fundus photograph was
taken of each student. The photographs
were randomly numbered, printed on A4
glossy photo paper, and displayed on
the classroom wall. Each student was
given a form to fill in the fellow students’
names matching the number of the fundus
photographs. They were encouraged to
practise direct ophthalmoscopy on their
classmates outside formal teaching hours.
At the end of the course, they returned the
filled-in forms, and those with the highest
number of correct matches between the
fundus photographs and fellow students
received a reward.
Results: Between 2011 and 2013, 239
students completed their ophthalmology
course. Of these, 220 students (92%)
voluntarily participated in the project.
communication
in medicine
Email: jorgen.krohn@helse-bergen.no
The mean score was 70% correct
matches between fundus photographs
and fellow students (range 7 - 100%).
The students’ course evaluations were
overall positive.
Conclusions: We recommend the use of
peer fundus photographs in the context
of a learning competition as a simple,
inexpensive, and effective way to improve
teaching of direct ophthalmoscopy.
It should be a priority for all ophthalmologists
involved in university-based education to
improve the ophthalmic knowledge and
examination skills of medical students. With
the tremendous growth in medical information
and technology, however, the constraints of
time have made it necessary to eliminate some
of the subjects covered during medical school
and residency.1 Despite the rising prevalence
of age related eye diseases and diabetic
retinopathy, medical schools throughout the
world continue to reduce the time allocated
for ophthalmic education, thus diminishing
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dic Within the ophthalmology curricula, relatively
less time for teaching and practising eye
examination skills has also been reported.3,4
In particular, the task of teaching direct
ophthalmoscopy has been made more difficult
ORIGINAL ARTICLE
by the limited availability of suitable patients,
due to shorter stays and increased morbidity
of hospitalised patients, and the busy time
schedule during ambulatory visits.
Under the arguments that indirect
ophthalmoscopy has largely replaced direct
examination and that direct ophthalmoscopy,
even in the hands of experienced
ophthalmologists, has been found to be of
limited diagnostic value,5,6 the objective
of teaching direct ophthalmoscopy to
medical students is a subject of controversy.7
Nevertheless, the ability to perform
ophthalmoscopy remains important in general
practice and other medical specialities.
When compared to the equipment required
for indirect examination, a standard direct
ophthalmoscope offers several advantages
such as being readily available and portable,
inexpensive, and allowing high magnification
of the fundus even through undilated pupils.
Various methods, like the use of plastic
canisters and simulation mannequins, have
been developed to aid medical students to
learn direct ophthalmoscopy.8–15 Although
such simulation models complement clinical
education and are useful for teaching the
basic principles of ophthalmoscopy, they
cannot by any means replace the challenges
and experiences of examining a living
person. There are a few previous reports
on ophthalmoscopy teaching based on the
recognition of peer fundus photographs
within small groups of medical students.16,17
Likewise, the identification of peer optic
nerve photographs has been used for
an objective assessment of the students’
ophthalmoscopy skills.18,19 In this paper,
we present a learning-by-doing approach
for teaching direct ophthalmoscopy among
fellow medical students by letting them
compete in matching fundus photographs
of the whole class during their entire
ophthalmology course.
Materials and methods
The project was initiated at the Section
of Ophthalmology at the University of Bergen,
where four consecutive classes of
14
fourth-year medical students (with
approximately 30 students per class) each
year complete a required 9-week
ophthalmology course.
During the first week of the course,
all students received two hours of formal
group instruction on the principles of
ophthalmoscopy and how to use a direct
ophthalmoscope. During this session, they
had one eye dilated with 1% tropicamide
to facilitate practising on each other. They
were also informed about our project of
using peer fundus photographs for further
ophthalmoscopy training throughout the
ophthalmology course. Although this
would be run as a competition among
the classmates, it was emphasised that
participation was voluntary and that their
performance would have no bearing on later
evaluations or their final course grade. A
single 40-degree colour fundus photograph,
centred at the optic disc, was taken of one
randomly selected eye of each participating
student, using a Canon CF-60 Dsi fundus
camera system equipped with a Canon EOS-1
mark II camera (Canon Inc., Tokyo, Japan).
Within the next few days, the photographs
were labelled with random identification
numbers to maintain anonymity, printed on
A4 high quality glossy photo paper at 300
dpi (Figure 1), and displayed together on the
classroom wall (Figure 2). Each student was
then given a pre-numbered form to fill in the
fellow students’ names matching the number
of the printed fundus photographs on the
wall. They were strongly encouraged to train
and practise direct ophthalmoscopy on their
classmates during the entire ophthalmology
course, both between the course sessions
and outside the formal teaching hours in the
afternoon and evening. As all the students
had key access to the classroom with the
wall-mounted fundus photographs and
several ophthalmoscopes, they could easily
practise direct ophthalmoscopy on each
other, with or without the use of mydriatics,
and fill in the pre-numbered forms also after
regular teaching time (Figure 3). Because
the project was designed as a competition
and meant to enhance individual learning,
the students were asked not to share their
results. Close to the end of the 9-week
ophthalmology course, they were requested
to return the filled-in forms to the teacher
for review and assessment. On the last
day of the course, the three students with
the highest scores (i.e. number of correct

Figure 1. Fundus photograph of one of the students labelled with a random identification number
and printed on A4 high quality glossy photo paper.
matches between each fundus photograph
and a specific fellow student) received
diplomas and free cinema ticket vouchers as
a recognition of their achievement.
If more than three students made the same
top score, the winners were selected among
the top scorers by random draw. All the
participating students were also allowed
to keep their own fundus photographs. The
project was performed in accordance with
institutional guidelines and governmental
ethics regulations.
Figure 2. A collage of the students’ fundus photographs mounted on the classroom wall.
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ORIGINAL ARTICLE
Results
Our project of using peer fundus photographs
for ophthalmoscopy training was first
introduced in the fall of 2011, and has since
then been implemented in every academic
semester (fall, winter, spring, and summer).
Between August 2011 and June 2013, a total
of 239 fourth-year medical students, belonging
to 8 different classes, completed their
ophthalmology course in our department.
Of these, 220 students (92%; 142 women
15
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ORIGINAL ARTICLE
Figure 3. Medical students practising direct ophthalmoscopy by matching the fundus photographs to
the correct eye of their classmates. This unarranged picture was taken unexpectedly after regular
teaching hours.
and 78 men) voluntarily participated in the
project.
The students were remarkably enthusiastic
about the competition and very active in
training and practising direct ophthalmoscopy
on one another, both between and after
the formal teaching sessions. Among the
participating students, the mean score
was 70% correct matches between fundus
photographs and fellow students (median
74%; range 7 - 100%). Thirty percent of the
students scored 100%, 19% scored between
100 and 75%, 23% scored in the range from
75 to 50%, and 28% of the students scored
below 50%. In all the classes taking part in the
project, the students’ course evaluations were
overall positive, particularly regarding the use
of peer fundus photographs in the context of a
learning competition.
Discussion
Ophthalmoscopy is essential for diagnosis
and treatment of many eye diseases, as well
as a number of other severe and sometimes
life-threatening medical conditions. Although
direct ophthalmoscopy is a relatively simple
procedure, efficient and proper use of the
ophthalmoscope requires instruction, training,
and above all practice. Several studies have
shown that medical students and residents do
not trust their abilities and skills in performing
direct ophthalmoscopy.20,21 Gupta et al20 also
found that the majority of medical students are
interested in additional training, and that
self-confidence was significantly greater
16
among those practising outside formal
teaching sessions.
Our approach to help students develop and
practise the skills of direct ophthalmoscopy
offers several advantages to both faculty and
students. As the students spend a considerable
amount of time learning for themselves outside
the context of formal classroom teaching,
additional resources can be devoted to more
traditional clinical education and lectures.
Peer physical examination also has the benefit
of protecting patients from the discomfort of
being examined by inexperienced learners.
In addition, the students can easily share
information on how the ophthalmoscopic
examination was performed and experienced,
point out each other’s mistakes, and correct
them. Such peer-assisted learning has been
shown to improve the students’ clinical
examination skills.22 For classes with few
students, the competition can be made more
challenging by including peer iris photographs
for penlight examination of the anterior
segment, or fundus photographs not belonging
to the classmates to increase the total number
of images to be considered.
We were surprised by the enthusiasm
with which the students engaged in the
project. Despite the repetitive and rather
tedious task of matching about 30 fundus
photographs to the correct eye of their
classmates, they were remarkably committed
and excited about the project and very active
in performing ophthalmoscopy throughout
the 9-week ophthalmology course. We
mainly attribute this to the competitive and
interactive nature of the learning method.

Although competitions may create a level
of anxiety and students are more motivated
when they cooperate rather than compete
with their peers,23 we believe that this kind
of competition, run in an informal and
friendly atmosphere, promotes the students’
learning process. It is, however, important to
point out to the students that participation is
completely voluntary and does not have any
impact on their final course grade or other
assessments. Another concern when students
are examined during training of clinical skills,
is the rare event of finding an unexpected
abnormality or disease.24 The students should
therefore be informed that all the fundus
photographs are screened for possible eye
diseases before display, and if something
unusual is found, they will be notified and
examined before they decide whether or not
to proceed in the project. Among the 220
students who have participated so far, all had
normal fundus photographs except for two
students with small patches of myelinated
retinal nerve fibres.
The main disadvantage of the presented
learning method is that the students examine
healthy subjects without ocular pathology.
On the other hand, to search for fundus
abnormalities is obviously meaningless
if the examiner is incapable to handle an
ophthalmoscope. Our method enables the
students to develop the necessary motor
skills and to use the corrective lenses in
the ophthalmoscope to get a clear view
of the fundus in eyes with a wide range
of refractive errors. Thereby, they learn to
recognise the normal anatomic variations of
the optic disc, retinal vessels, macula, and
general background of the fundus, and thus
to distinguish normal from abnormal. They
also develop the skills to judge and memorise
what they see during ophthalmoscopy, which
are particularly valuable if they in future
clinical practice should want to compare their
ophthalmoscopic findings with images of
specific eye fundus diseases.
At the end of our ophthalmology course,
all students undertake a mandatory written
and oral examination, where the latter
includes clinical examination of patients
with various eye diseases. Although we have
not objectively evaluated the effectiveness
of our learning method, it is our clear
impression that the students’ ability to perform
ophthalmoscopy and reach a correct diagnosis
during the examination of real patients has
improved significantly after introduction of
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the present project. Based on our mme u
experiences over the last two years, we dic
therefore recommend the use of peer fundus
photographs in the context of a learning
competition as a simple, inexpensive, and
effective way to improve the teaching of direct
ORIGINAL ARTICLE
ophthalmoscopy to medical students.
Declaration of interest
None.
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DOI: 10.3109/17453054.2014.884551
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