1. 9/19/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 1
Ophthalmoscopy

2. Why?
 Ophthalmoscopy is performed:
 Trauma around or of the eye itself
 Routine diabetic check
 As part of a neurological examination
 Deteriorating vision
 Symptoms associated with visual problems
 Headaches
 Dizziness
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The ophthalmoscope
 Viewing
aperture
 Lens
wheel
 Lens
indicator
 Rheostat
 Mask dial
interposes
various sized
and shaped
masks, use
 large for general
viewing
 small for
fovea/macula
 coloured filters
may also be
included

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Holding the ophthalmoscope 1
 Have the lens value(s) set to
“0”
 Select a wide white light filter
 Hold instrument in right hand,
held to right eye to look in
patient’s right eye
 Hold the instrument with the
index finger resting on the
focusing wheel and the thumb
on the rheostat
 Limit the brightness of the
beam using thumb - too bright
a beam is uncomfortable

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Preliminaries
 Explain the procedure to the
patient
 Inspect the external eye for any
abnormalities
 Use a mydriatic or dim the lights
to dilate the pupils
 Ask the person to fix their gaze
on a distant object
 Place your free hand on the
forehead of the patient - this
sets the distance from which to
approach and avoids clashes of
head as you get nearer. Also
the thumb can be used to hold
the upper eyelid open

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Holding the ophthalmoscope 2
 The instrument MUST be
held close to the examiner’s
eye nestled against the
supraorbital ridge or against
glasses if worn
 Look through the aperture
with one eye and close the
other, or leave open if you
prefer

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Direction of approach
 Use the viewing eye to
direct the beam of light onto
the patient’s eye from 0.5 - 1
metre (arms length)
 Approach from an angle of
15-20° to the line of gaze
 Approach on the same level
as the equator of the
patient’s eye
 This approach directs the
beam towards the optic disc,
an important landmark
Fixed gaze
Angle of
approach
Optic disc

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15 to 20 degrees from point of gaze
Your eyes should be at
the same level as the
patients
Ophthalmoscope light beam

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Ophthalmoscopy
 Note the appearance of
the external eye
structures
 Note the red reflex -
use this to guide you in
closer to the pupil
 When close to the eye,
use the focusing wheel
to fine tune your focus
on the retinal structures

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Correct approach should bring you
on or near to the optic disc
Patient’s
right eye
Patient’s
left eye
Superior nasal
Inferior nasal
Superior temporal
Inferior temporal
Superior temporal
Inferior temporal

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The view of retina
 The circled area opposite
shows the likely area that is
illuminated on first
visualising the retina
 To view the rest of the
structures move the area of
illumination by adjusting
head-eye-instrument
inclination
 If you still have difficulty
seeing structures, try and
find a blood vessel and turn
the focus wheel until the
lines of the vessel become
clear
LEFT
MEDIAL LATERAL

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Examination of the vessels
 Once a vessel is found
you should follow the
length of the vessel as far
as possible to look for
abnormalities
 Vessels branch into the
four quadrants of the eye:
superior nasal and
temporal and inferior
nasal and temporal.
 The quadrants can be
used to describe where
an abnormality lies
Inferior Nasal Inferior Temporal
Superior TemporalSuperior Nasal
Optic Disk
LEFT EYE

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The retinal vessels
 If you miss or lose the optic
disc: any branching of vessels
form a “V”, the point of the “V”
always points towards the
optic disc
 The main vessels branch out
in four directions (see arrows)
 Veins are uniform and
burgundy in colour
 Arteries have a central pale
line and two outer red walls

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The macula
 The macula is lateral
to the optic disc (about
11/2 disc diameters
away)
 Few blood vessels are
seen here
 To view the macula
move your light beam
in the direction of the
temples

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Viewing the fovea
 The fovea is a depression in
the centre of the macula and is
the point of central vision, with
maximum concentration of
cones.
 This is best viewed at the end
of the examination
 Reduce the intensity of the
light and ask the person to look
directly into the light
 Now examine the other eye,
remember to swap
ophthalmoscope to the other
hand

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The retina - what to note
 Optic disc
 Sharpness
 Colour
 Optic cup
appearance
 Arteries and veins
 tortuous or straight
 width and colour
 the light reflex along
the arterioles
 appearance of the
AV crossing
 Peripheral fundus
 follow each of the 4 main
retinal vessels out for 3-4
disc diameters
 haemorrhages
 exudates
 choroidal changes
 scarring
 new vessel formation
 Culturally based variability in the
colour of the iris and in retinal
pigmentation = darker irises are
correlated with darker retinas.

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Ophthalmoscopy - summary
 Introduce yourself
 Explain procedure
 Wash hands
 Check identity of patient
 Gain informed consent
 Ask subject to fix vision on
distant object
 Dim lights, warn patient
you will be close to the face
 Hold instrument to eye with
index finger on lens dial
 Approach from shallow
angle (15-20 degrees)
 Approach on the same
level as the equator of
subject’s eye
 Note & comment on red
reflex
 Note & comment on
anterior structures of the
eye
 Focus on retina and
Identify optic disc
 Follow blood vessels into 4
quadrants
 observe macula and fovea