Direct and Indirect

Ophthalmoscopy
Dr Saurya Pahadi
First Year Resident
Department of Ophthalmology
LEARNING OBJECTIVES
 INTRODUCTION
 DIRECT OPHTHALMOSCOPE PARTS
 DISTANT DIRECT OPHTHALMOSCOPE AND ITS APPLICATIONS
 DIRECT OPHTHALMOSCOPE – OPTICS, IMAGE FORMED
 MONOCULAR INDIRECT OPHTHALMOSCOPE- OPTICS,INDICATIONS, ADVANTAGES
AND DISADVANTAGES
 BINOCULAR INDIRECT OPHTHALMOSCOPE – PARTS. OPTICS, IMAGE FORMED,
ADVANTAGES AND DISADVANTAGES
 DIFFERENCE BETWEEN DIRECT AND INDIRECT OPHTHALMOSCOPE
Introduction
 Ophthalmoscope is an instrument for viewing the retina and associated
tissues— the ocular fundus
 Consists of 3 essential elements: a source of illumination, a method of
reflecting the light into the eye, and an optical means of correcting an unsharp
image of the fundus

 Four methods:

 Distant direct ophthalmoscopy

 Direct ophthalmoscopy

 Monocular Indirect ophthalmoscopy

 Binocular Indirect Ophthalmoscopy

History

 Charles Babbage invented the 1st direct ophthalmoscope in 1848

 Hermann Von Helmhotz revolutionised it in 1850
 Ruete designed the first monocular indirect ophthalmoscope in 1852
 Charles Schepens invented the modern day Binocular indirect
ophthalmoscope in 1946
Direct Ophthalmoscope
 Distant Direct Ophthalmoscope
 Done routinely before direct ophthalmoscopy

 Distance 20-25cm

 Red glow in pupillary area noted

Applications:

 To diagnose opacities in refractive media

 To differentiate between a mole and hole of Iris

 To recognize detached retina or tumour arising from fundus

 Direct Ophthalmoscopy- Optics
When both the examiner and patient are EMMETROPIC:

 Rays of light coming from the patients retina exit parallel with zero vergence

 focussed into the examiners retina through viewing hole in the ophthalmoscope
In myopic patient:
 Emergent rays will be convergent

 Brought focus on observer’s retina with help of Concave lens

 Here, a minus lens is dialed in, to overcome the extra plus power “error lens” inside the patient’s
eye

 Those 2 lenses create a Galilean telescope effect, increasing magnification and decreasing the
field of view.
In Hypermetropic patient:

 Emergent rays from illuminated area of retina will be divergent

 Brought to focus on observer’s retina with help of Convex lens

 Here the image will be magnified less than 15× because of the reverse Galilean telescope
created by the minus power error lens inside the patient’s eye and the plus lens of the direct
ophthalmoscope
Characteristics of the Image Formed
 Erect

 Virtual

 15×

(As eyes acts as a simple magnifier approx. magnification at reading distance

25cm using simple formula =1/4 of power i.e, for emmetropic eyes Refractive
power is 60D ; magnification(60/4)=15x)

 Field of view –7°

Monocular Indirect Ophthalmoscopy
 It consists of

- Illumination rheostat at its base,

- Focusing lever for image refinement

- Filter dial

- Iris diaphragm lever to adjust the illumination beam diameter

-Forehead rest for proper observer head positioning

Optics

 An internal relay lens system re-inverts the initially inverted image to a real erect
one, which is then magnified

 This image formed is focusable using focusing lever

Indications

 Need for an increased field of view

 Small pupil

 Uncooperative children

 Basic Fundus screening

 Patients intolerance to bright light of binocular indirect

ophthalmoscope
ADVANTAGES

 Increased field of view similar to binocular indirect ophthalmoscopy

 Erect imaging similar to direct ophthalmoscopy

DISADVANTAGES

 Limited illumination

 Lack of stereopsis

 Fixed magnification
INDIRECT OPHTHALMOSCOPE
 Optics of indirect ophthalmoscopy
 Make eye highly myopic by placing strong convex lens in front of patient’s eye

 Emergent rays from area of fundus brought to focus as real inverted image between lens
& observer’s eyes

 Binocularity is achieved by decreasing IPD( from 60mm to 15 mm)

 Requires dilated pupils

 Here, the patient’s retina, the aerial image, and the examiner’s

retina are all conjugate to each other.

 Conjugate planes

 The main purpose of the condensing lens – besides forming the aerial image,

 to make the faceplate of the indirect ophthalmoscope conjugate to the patient’s cornea,

 so that the bright illumination light passes at a different place through the cornea, to avoid reflections back
from the cornea into the examiner’s eyes

Therefore, in indirect ophthalmoscopy, the light pathway is separated from the observation pathway by imaging
the faceplate on the cornea with the condensing lens, so that the aerial image of the retina can be seen.
 Image characteristics
 Real

 Inverted

 Magnified
Magnification depends on:
1.Diopteric power of lens
2.Position of lens in relation to eyeball
3.Refractive state of eyeball
Emmetropic eye
 Rays from fundus are parallel and brought to focus by condensing lens
 Image is formed at the principal focus of lens
 Hence , size of image remains the same no matter the position of the
lens
 Myopic eye
 Rays are convergent
 Image formed in front of the eye
 Final image by condensing lens within its own focal length
 Image is smaller when lens is nearer to the anterior focus of the eye and
larger when away
Hypermetropic eye

 Rays are divergent and appear to come from behind the retina
 Image by condensing lens is infront of its principal focus
 Image is larger when lens is nearer to the anterior focus of the eye and smaller when
away
 Factors affecting field of view
 Power of condensing lens
 Patients pupil size
 Distance at which the condensing lens is held from the eye

Field of view is inversely propotional to magnification and directly propotional

to power of lens
Advantages

 Large field of retina visible

 Less distortion of image

 Easy visualization of retina anterior to equator(retinal holes; degeneration)

 Useful in hazy media due to bright light & optical property

 Easier to examine patient with high spherical & astigmatic refractive error
Disadvantages

 Magnification less

 Difficult in small pupil

 Uncomfortable to patient( intense light & scleral indentation)

 Requires extreme practice in both technique & interpretation

Comparison
REFERENCES

 AMERICAN ACADEMY OF OPHTHALMOLOGY – SECTION 3 (CLINICAL OPTICS)

 OPTICS AND REFRACTION-A.K KHURANA
 INTERNET