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Techniques in Ophthalmology 3(3):138–140, 2005  2005 Lippincott Williams & Wilkins, Philadelphia


Pearls on Indirect Ophthalmoscopy

Robert S. Wirthlin, MD and Tara A. Young, MD
Jules Stein Eye Institute UCLA
David Geffen School of Medicine
Los Angeles, CA

n INTRODUCTION adequate field of view and image magnification. The 28-D

Inspection of the ocular fundi is an essential part of lens is effective at obtaining an image through a small
pupil and also gives a wider field of view; however, its
a complete eye examination. This allows for an assess-
magnification may often be insufficient to identify subtle
ment of the retina as well as detection of ocular manifes-
or minute pathology, such as small retinal breaks. The
tations of systemic diseases. For the ophthalmologist,
VolkTM 2.2 Pan Retinal lens is a popular lens that pro-
indirect slit-lamp biomicroscopy and indirect ophthal-
vides the field of view of a 28-D lens with greater mag-
moscopy are the two most important tools in carrying
nification. Also available are 14-D and 15-D lenses,
out this task. This article reviews the basics of indirect
ophthalmoscopy and offers practical techniques for im- which provide higher magnification but may be more dif-
proving examination skills. ficult to use due to the longer working distance. They
may be used for detailed examination of the optic nerve,
macula, or inspection of isolated lesions. This may be of
n HISTORICAL CONSIDERATIONS particular benefit in patients who are unable to position
at a slit lamp. Table 1 summarizes the basic optical spec-
The development of the indirect ophthalmoscope marked ifications of several handheld lenses.
a turning point in the field of ophthalmology and to the
advancement of vitreoretinal surgery in particular. Since
its introduction by Schepens in the 1950s, it has become n PATIENT PREPARATION
the standard for proper examination of the retina.1 After assessment of visual acuity, visual field, pupillary
function, intraocular pressure, and the anterior segment,
PRINCIPLES examination of the ocular fundi begins with pharmaco-
n logical dilation. Initial instillation of topical anesthetic
The indirect ophthalmoscope consists of a headset with drops such as proparacaine HCl 0.5% increases pene-
a binocular view box and an adjustable light source. tration of subsequently administered topical mydriatic
The light is focused on an angled mirror then reflected agents. This increases the speed and degree of dilation.4,5
into the patient’s eye. Light passes through the pupil A combination of phenylephrine 2.5% plus tropicamide
and reflects off the fundus. This is then focused with 1% effectively achieves dilation in most patients.6 Repeat
a handheld, plus aspheric lens into an image. The image instillation of dilating drops is sometimes necessary. En-
is inverted, reversed (real), and located above the plane sure that the pupil is completely and widely dilated be-
of the lens. The view box of the indirect ophthalmoscope fore proceeding with the examination.
contains prisms that optically reduce the interpupillary
distance resulting in a binocular, stereoscopic image.3
• Develop a systematic and consistent step-wise ap-
proach when examining both eyes and all quadrants
n LENS SELECTION of the retina.
There are several handheld double aspheric lenses avail- • Stand opposite the area of the fundus to be
able. Those most commonly used are the 28-diopter (D) examined.
lens and the 20-D lens. The 20-D lens provides both an • Warn the patient that the bright lights will be in-
tense, that scleral depression may be uncomfort-
Address correspondence and reprint requests to Tara A. Young, MD, able, and that vision will return momentarily
Jules Stein Eye Institute UCLA, 100 Stein Plaza UCLA, Los Angeles, after the examination.
CA 90095-7000.

138 Techniques in Ophthalmology

Indirect Ophthalmoscopy

TABLE 1. Handheld lenses fundus will be overlooked. It also allows for a frame-
Field of Image Working work for recalling and recording observations.1
Lens View Mag. Distance One approach consists of first visualizing the poste-
14D 36/43 4.30 3 75 mm rior pole and then tracking the retinal vessels peripher-
20D 46/60 3.13 3 50 mm ally while the patient looks straight ahead. To do this,
2.2 Pan Retinal 56/73 2.68 3 40 mm the examiner’s head, body and hand must move together
28D 53/69 2.27 3 33 mm to maintain proper alignment. After examining in this
40D 69/90 1.67 3 20 mm
manner, attention is then directed to the retinal periphery.
To view the total extent of the peripheral fundus, the
examiner must stand opposite the area to be viewed. For
Warn the patient that the bright lights will be intense, example, the examiner must stand on the same side as the
that scleral depression may be uncomfortable, and that eye when viewing the nasal periphery and the opposite
vision will return momentarily after the examination. side to examine the temporal periphery. Turning the
This is especially important for patients in whom binoc- patient’s head toward the examiner makes it easier to
ular indirect funduscopy is being performed for the first visualize the temporal periphery without bumping into
time. The room lights are dimmed and the patient placed the patient’s nose.
comfortably in a supine position. When examining the periphery the patient’s pupil
appears elliptical. This may prevent the passage of both
the illumination and observation beams. It may be nec-
essary to tilt the head and/or increase the illumination in-
n TECHNIQUE tensity to obtain an image.
The head set of the binocular indirect ophthalmoscope is Moving the lens side to side induces a prism effect
first adjusted so that it fits comfortably by tightening or that may allow more peripheral visualization. It also may
loosening the two headbands as necessary. Next the in- improve identification of small retinal breaks by enhanc-
terpupillary distance is set by moving the eyepieces until ing the contrast between the retinal discontinuity and the
the light, directed at the examiner’s outstretched hand, is underlying choroid.
The light intensity is set at a low level initially and
increased as necessary during the examination. Lighting
must be sufficient to provide adequate illumination for
examination without causing undue discomfort. The su- n SCLERAL DEPRESSION
perior retinal periphery is examined first because it is the To examine the peripheral retina in detail it is necessary
least light sensitive for the patient. to perform scleral depression. This is especially impor-
A bright red reflex appears when the examiner aligns tant in patients who present with posterior vitreous de-
his viewing axis with the patient’s pupil. The handheld tachment or retinal detachment in whom small retinal
lens is then placed over the patient’s eye and adjusted un- breaks near the ora serrata may otherwise be missed. Of-
til an image is identified. The light of the indirect, the ten a dynamic examination with simultaneous depression
condensing lens, the patient’s pupil, and the retina must is necessary to visualize small retinal tears.
fall on one line. The examiner’s head and lens are moved There are several types of scleral depressors avail-
and rotated together all in a line and pivoted at the able. A thimble-type depressor that is placed on one
patient’s pupil. of the fingers has the advantage of freeing both hands
The examiner’s arm must be extended fully. The lens for manipulation of the patient’s lids. A longer straight
is held between the thumb and index finger. The third and depressor can also be used. These are advantageous
fourth fingers are used to stabilize the hand on the pa- because many have both a broad platform and narrow,
tient’s cheek and steady the lens. The opposite hand may rounded end. They also have a convenient pocket clip.
be used to retract the patient’s lids. If these instruments are not available, a cotton-tip
The most convex surface of the lens must face the ex- applicator can be used; however, it is more difficult
aminer. The opposite surface is marked on most lenses by to move this instrument along the lid and depress
an unpainted edge and this must face the patient. Tilting posteriorly.
the lens slightly reduces bothersome glare from the lens Scleral depression helps to identify retinal breaks by
surfaces. enhancing the contrast between the break and adjacent
A systematic routine is important for several reasons. retina—the indented choroid and retinal pigment epithe-
A standard approach improves examination efficiency. lium (RPE) appear darker than non-indented areas and
Further, it decreases the likelihood that a portion of the darker still than intact retina. Breaks in the retina appear

Volume 3, Issue 3 139

Wirthlin and Young

like a dark spot. Indented retina is less translucent and to look down and the indentation is visualized by the
therefore darker.7 indirect ophthalmoscope.
Postoperative patients with unstable wounds must not
undergo scleral depression. Care must be taken in patients
with filtering blebs as the scleral depressor could cause
a bleb leak. In cases of trauma where there is a hyphema
Scleral depression can be painful. Instillation of a second or possibility of globe rupture, scleral depression may be
round of topical anesthesia may sometimes be beneficial deferred.
to provide deeper anesthesia of the ocular surface in
patients who are difficult to examine. Applying only the
minimal amount of pressure necessary to see the inden- CONCLUSION
tation is important.
The patient is instructed to look down while the Indirect ophthalmoscopy and scleral depression are im-
scleral depressor is positioned vertically at 12 o’clock. portant techniques for a comprehensive eye examination.
The patient is then asked to look up and the indentation Mastery of these techniques requires time and practice.
of the depressor is identified with indirect ophthalmos- Ophthalmologists at all stages of their careers may ben-
copy. If the indentation is not identified, the fundus is efit from a conscious effort to improve their examination
first scanned from anterior to posterior as the location skills by more accurate observation of the ocular fundi.
may be more posterior then anticipated. If it is still not
identified, the depressor is advanced posteriorly until
the indentation comes into view. Anterior-posterior and n REFERENCES
lateral correcting movements are then made until the in-
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Principles and Practice of Ophthalmology. Philadelphia:
and the indentation followed simultaneously with coordi-
WB Saunders; 2000.
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ophthalmoscopy. Highlights Ophthalmol. 2005;256:179–
is opposite that suggested by the image with indirect
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140 Techniques in Ophthalmology