Ophthalmoscopy

MODERATER:DR BHARTI NIGAM

• 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
 HISTORY OF OPHTHALMOSCOPE
 Three basic principles described by Hermann von
Helmholtz
 Patient and observershould be made emmetropic
 Retina of the patientshould be sufficiently illuminated
 Optical alignment of light source and observer’s pupil
• System of lens focusing light on
a 45 degree mirror with hole.
• Mirror reflect light in diverging
beam then illuminate patient,s
eye.
• Light reflected from illuminated
retina of the patient ,then
passes back through the hole to
observer,s eye.
• Image of blub is formed just
below the hole,so the reflection
does not interfere with viewing
 Ophthalmoscopic methods of examination
are-

(1)Distant direct ophthalmoscopy

(2)Direct ophthalmoscopy
(3) Indirect ophthalmoscopy
 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.
 Application of distant direct
ophthalmoscopy
• To diagnose opacities in the refractive media
• To differentiate between a mole and a hole of
the iris.
• To recognize detached retina or a tumour
arising from the fundus
 Parallactic
displacement

Behind the At the pupil In front of the pupil

pupil the opacity is opacity moves
opacity moves stationary opposite to
with with examiner,s examiner,s motion.
examiner,s motion.
motion.
 Direct opthalmoscopy
• Direct ophthalmoscope is a hand
held instrument used to examine
the fundus.
• It is used monocularly.
• It can be used to examine central 7
to 10 degree of retina.
• It gives a magnification of 15x which
makes the 1.5mm disc appear much
larger.
 Optical principle

• We assume that anterior focal point of the

subject (Fs) coincide with the anterior focal
point of the observer (Fo)
• Image on the examiner,s retina is always
inverted …..seen as erect
Also, the image size varies with the refractive
state of the patient,s eye.
• The image being smaller in
hypermetropia,and larger in myopia than in
emmetropia
• The formula for Magnification achieved by a
loupe
Dioptric power of the loupe
• Magnification
• is If ascribe dioptric power of 60+ D to the
patient,s emmetropic eye, the magnification
of the direct ophthalmoscope is 15x.
 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.
 Types

• Head mounted

• Spectacle mounted
 Principal of indirect
To make the eye highly myopic by placing a
strong convex lens in front of patientseye
The emergent rays forms areal inverted
image between the lens and observer’s
eye
 Optical system of bio
• Binocularity is achieved by artificially
reducing the observer’s IPD to
approximately 15mm by the help of
prisms/mirrors
 Emmetropia
Emmetropic eye, rays from fundus are
parallel, brought to a focus by the
condensing lens
Image formed at the principal focus of the
lens
Hence, size of image remains the same, no
matter the position of lens.
 Myopia
Rays are convergent
Image formed in front of theeye
Final image by condensing lenswithin its
own focal length
Image is smaller when lens is nearer to
anterior focus of the eye and larger when
away
 Hypermetropia
Rays divergent and appear to come from
behind the retina
Image by condensing lens in front of its
principle focus
Image is larger when lens is nearer to the
anterior focus of the eye and smaller when
away.
 Relative position of images
In Emmetropia: - at the principal focus
In Myopia: - Nearer to the lens than its
principal focus
In Hypermetropia: - Farther away from the
principal focus
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.
 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
 Fundus Drawing

• Place chart upsidedown

• Draw what you
 AMSLER’S CHART
Concentric Circle
• Innermost – Equator
• Middle – Ora Serrata
Outermost – Pars plana

Radial lines to describe

the location of fundus
finding in clock hours

Posterior pole – in the 1st

circle
 ORIENTATION
Ora serrata on charthas a
larger circumference than
the equator, while actually
the equatorhas a greater
circumference

Centre of thechart:
Optic nerve [O]
Fovea [+]
COLOUR CODING
Background/periphery Vitreous
Pigmentation changes Asteroid hyalosis, floate
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 notchin
systemic hypertension in glaucoma
Bifurcations: embolisms, Anterior ischaemic opt
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