Dr.

MAMTA
Dept of ophthalmology
RNT Medical college, Udaipur
 Ophthalmoscopy is a clinical examination of
the interior of the eye by means of an
ophthalmoscope.
 It is primarily done to assess the state of
fundus and detect the opacities of ocular
media.
 The ophthalmoscope was invented by von
Helmholtz in 1850.
 temporal
nasal
DISC: LOCATION –nasal to geometric axis

DIAMETER – 1.5mm [1 disc diameter]

COLOR – Pale pink
SHAPE – Circular
EDGES – Regular
TERMINATION OF ALL
LAYERS EXCEPT NFL

CUP: C/D ratio – 0.3 to 0.5

 RETINAL SYSTEM :
CENTRAL RETINAL ARTERY
AND
CENTRAL RETINAL VEIN
Arterioles
Venules
Capillaries

 CILIARY SYSTEM : POST.CILIARY ARTERIES

Choriocapillaries
 Specialised region of retina
 Diameter – 5.5 mm
 Location – 2 DD - temporal margin of disc
 Color – Yellow; deep pigmented
 4 zones : Foveola -0.35 mm
Fovea -1.50 mm
Parafovea
Perifovea
 Retinal vessels
 Cilioretinal artery
 Ophthalmoscopic methods of examination
are-

(1)Distant direct ophthalmoscopy

(2)Direct ophthalmoscopy
(3) Indirect ophthalmoscopy
Parts-
◦ Light source
◦ Eyepiece
◦ Lens rack and power dial
◦ Aperture selector
◦ Filter selector
◦ On/off and brightness control
◦ Power handle
 For a good view of fundus the pupil should be
dilated by instilling few drops of short acting
mydriatic drug (e.g. combination of
tropicamide and phenylephrine )

 The subject should be examined in sitting or

lying down position.
 Examination room should be semidark.
 keep the eye as still as possible.
For examining right eye of the patient,

 Examiner should stand on right side of the

patient.
 Hold the instrument in his right hand.
 Use examiner’s right eye.

If examining left eye, stand on left side, hold

instrument in left hand use left eye.
 Viewing should begin about half meter away
from the eye.
 First see the “Red reflex”
 Initially the lens power in the instrument
should be set to zero, and if refractive error
present in patient or examiner, e.g. if the
patient is myopic then set the (-ve )lens, if
the examiner or patient is hypermetropic
then set the lens to (+ve) lens. If both
patient & examiner have refractive error
then sum together their powers.
 Rotate the lens dial until the optic disc is focused
clearly.
(Red numbers/negative numbers in myopia or
short-sightedness.
Green numbers/positive numbers in hyperopia or
far-sightedness.)

 Examine the optic disc for:

Shape – normally round or slightly oval

Clarity of the outline-clear outline or rim
Colour-pale pink contrast to rich red of rest of
fundus.
 Examine the macula last.

 To locate the macula, focus on the disc, then

move 2 disc diameters temporally. The
macula is darker in colour than the
surrounding fundus, and devoid of blood
vessels.

 May also ask the patient to look at the light,

this automatically puts the macula into full
view.
 It should be performed routinely before the
direct ophthalmoscope, as it gives a lot of
useful information.
 It can be performed with the help of a self-
illuminated ophthalmoscope or a simple plain
mirror with a hole at the centre.
Procedure- The light is thrown into patients
eye sitting in a semi-darkroom, from a
distance of 20-25 cm and the features of the
red glow in the pupillary area are noted.
 1. To diagnose opacities in the refractive
media- any opacity in the refractive media is
seen as a black shadow in the red glow.
 2. To differentiate between a mole and a
hole of the iris- a small hole and mole on the
iris appears as a black spot on oblique
illumination
 3. To recognise detached retina or a tumour
arising from the fundus is seen as a greyish
reflex.
 It is the most commonly practised method for
routine fundus examination.
 It works on the basic optical principle of glass
plate ophthalmoscope introduced by von
helmholtz.
 A convergent beam of light is reflected into
the patients pupil. The emergent rays from
any point of the patients fundus reach the
observers retina through the viewing hole in
the ophthalmoscope.
 The emergent rays from the patients eye are
parallel and brought to focus on the retina of
the emmetropic observer when
accommodation is relaxed.
 In hypermetropic patient,the emergent rays
will be divergent and with the help of convex
lens can be brought to focus on the observers
retina.
 In myopic patient,the rays will be convergent
and use concave lens for focus on the
observers retina.
Focussed Convergent Parallel Divergent Reflected
on retina light light light light
source

Corrective lens is
placed along pathway Convergent Divergent
light, if subject light, if subject
myopic hypermetropic
 The image is erect, virtual and about 15 times
magnified in emmetropes.
 Technique- should be performed in a semi-
darkroom with the patient seated and looking
straight ahead , while the observer standing
or seated slightly over to the side of the eye
to be examined by the observer with his or
her right eye and left with the left.
 The observer should reflect beam of light
from the ophthalmoscope into patients pupil.
Once the red reflex is seen the observer
should move as close to the patients eye as
possible.
 Once the retina is focused the details should
be examined systematically starting from
disc,blood vessels, the four quadrant of the
general background and the macula.
Monocular Indirect Ophthalmoscopy
It consists of-
 Illumination rheostat at its base,
 Focusing lever for image refinement,
 Filter dial with red free and yellow filters,
 Forehead rest for proper observer head
positioning, and
 Iris diaphragm lever to adjust the illumination
beam diameter.
 Optics- an internal relay lens system re-
inverts the initially inverted image to a real
erect one, which is then magnified. This
image is focusable using the focusing lever.
Indications are-
 Need for an increased field of view
 Small pupils
 Uncooperative children
 Patients intolerance of bright light of
binocular indirect ophthalmoscope.
 Extent of view- although vitreous base views
are possible with monocular IO, its greatest
effectiveness extends anteriorly to the
peripheral equatorial region.
 Advantage- field of view similar to IO and,
 Erect real image similar to DO.
 Disadvantage –are lack of stereopsis,
 Limited illumination and,
 Fixed magnification.
 It is very popular method for examination of
posterior segment introduced by Nagel in
1864.
 PRINCIPLE- To make the eye highly myopic by
placing a strong convex lens in front of
patients eye so that the emergent rays from
an area of the fundus are brought to the
focus as a real,inverted image between the
lens and the observers eye.
 An inverted reverse real image
 Magnification = 2 to 4 X
 Field of view = 40 to 50 degrees
 Optimal working distance = 40 to 50 cms
 Good illumination & stereopsis
 Ease of use with scleral indentor
 Lenses from 14 to 30 D range
 CHARACTERISTICS- Magnification of image
depends upon the dioptric power of convex
lens, position of the lens in relation of the
eyeball and refractive state of eyeball.
 About 5 times magnification is obtained with
+13 D lens.
 With a stronger lens,image will be smaller,
but brighter and field of vision will be more.
(1) Dark room
(2) source of light and concave mirror or self
illuminated indirect ophthalmoscope
(3) Convex lens
(4) pupils of the patient should be dilated.
 The patient is made to lie in the supine
position, with one pillow on a bed or couch
and instructed to keep both eyes open.
 The examiner throws the light into patients
eye from an arms distance.
 In practise, Binocular ophthalmoscope with
head band or that mounted on the spectacle
frame is employed most frequently.
 Keeping his or her eyes on the reflex, the
examiner then interposes the condensing
lens in the path of beam of light, close to the
patient eye, and then slowly moves the lens
away from eye until the image of retina is
clearly seen.
 The examiner moves around the head of the
patient to examine different quadrants of the
fundus.
 He or she has to stand opposite to clock hour
position to be examined.
 By asking the patient to look in extreme gaze,
and using of scleral indenter, the whole
peripheral retina up to ora serrata can be
examined.
 Scleral indentation- helps in making prominent
the barely perceptible lesions, done with the
depressor placed on patients lid.
 Examiner should move the scleral depressor in a
direction opposite to that in which he or she
wishes the depression to appear.
 Scleral depressor should be rolled gently and
tangentially over the eye surface.
 The temporal part of upper lid is sufficiently lax
so depressor can be placed inferiorly in the
horizontal meridian.
 -Thimble scleral
depressor

-Pencil type depressor

-Cotton tipped applicator

To examine periphery between equator and ora serrata by creating a

mound to view.

Start superonasal superior ,superotemporal,

Inferotemporal, inferior, inferonasal
 FUNDUS DRAWING-
 The image seen with IO is vertically inverted and
laterally reversed; top of the retinal chart is
placed towards the foot end of the patient
[i.e.upside down]
 Fundus drawing is made on a special Amsler
chart,which has 12 clock hours marked and has
three concentric circles made on it-
 Innermost circle,middle circle and outermost
circle represents to the equator,the ora serrata
and,the midpoint of pars plana respectively.
-Technique is difficult and can be mastered by
hours of practice.
-Magnification is less compare to DO.
-It is impossible with very small pupil.
-Patient is usually more uncomfortable with
intense light of IO and with scleral
indentation.
-Reflex sneezing can occur on exposure to
bright light.
 Advantages of Indirect system
• Image not affected by the patients refractive power

• In eyes with nystagmus

• Delivery of LASER

• Binocular examination of fundus up-to the periphery

• Large field of view allow for the panoramic view

• Better Resolution

• Use in operating room for cryo/scleral buckling

• Better view in presence of media opacities

• Increased illumination

• Reduced distortion
Background/periphery Vitreous
Pigmentation changes Asteroid hyalosis, floater
in retinitis pigmentosa haemorrhages
Retinal tears,
detachments
Retinal nerve fibre layer
Dropout in glaucoma,
myelination at disc margi

Vessels Fovea
Haemorrhages ARMD, drusen,
Optic disc
in diabetes, macular holes
vessel occlusion, Myopic crescent
hypertension in myopia
Crossings: nipping in Cupping and notching
systemic hypertension in glaucoma
Bifurcations: embolisms, Anterior ischaemic opti
branch occlusions neuropathy in diabetes
Vessel walls: sheathing in Swelling and blurred
systemic hypertension, leakage margins in papilloedem
and neovascularisation in diabetes. and optic neuritis
 (1) Hruby lens biomicroscopy
 (2) Contact lens biomicroscopy
 (3) Indirect fundus biomicroscopy
 Hruby lens is a planoconcave lens with
diopteric power 58.6D, which neutralizes the
optical power of normal eye (60D) and forms
a virtual,erect image of the fundus.
 This lens provides a small field with low
magnification and cannot visualize the
fundus beyond equator.
 It combines stereopsis, high illumination and
high magnification with the advantages of slit
beam.
 Modified Koeppe lens, i.e. posterior fundus
contact lens can be used to examine the
posterior segment, provides a virtual and
erect image.
 Goldmanns three-mirror contact lens, consist
of a central contact lens and three mirror
placed in the cone,each with different angles
of inclination.
 With this, the central as well as peripheral parts
of the fundus can be visualized.
 It also provides a virtual and erect image.
 By flat central portion can see posterior
vitreous and pole.

 Angled mirror - 73 deg - Peripheral fundus

67 deg - Pars plana
59 deg - Gonioscopy

 Eliminates total internal reflection by

replacement with cornea – goldmann contact lens
interface.
 Also known as non-contact fundus biomicroscopy,
most commonly used lenses are +78D and +90D,
which are mostly double aspheric lenses, so it does
not matter which side is held towards the patient.

 Optics similar to IO, thus a real, inverted image is

formed between the condensing lens and objective
lens of slit-lamp.

 Magnification provided by fundus non-contact lenses

is calculated by dividing power of the eye by the
power of lens, e.g. +90D lens provides a
magnification of 60/90=0.75X,i.e. a minification of
the image.
 However, the Magnified image seen because of
the magnification provided by the slit-lamp.
 Magnifying knob to 10X or 16X.
 Field of view high powered lens provides larger
field of view but lesser magnification.
 Drawing the slit lamp biomicroscopic view:
Done on an inverted fundus chart and paper
is turned as patients gaze direction changes in
respective clock hour meridian.
 Performing indirect slit lamp biomicroscopy
 Evaluating fundus :
Provides wide field 130 degree and
high power lens

A real inverted magnified image is

formed

It is used in both posterior fundus

examination and also
Laser pan retinal photo
Coagulation.
THANK YOU