FUNDUS EXAMINATION
Dr Cesar Carrillo
October, 2014 Vien ane/NOC **Disclaimer** The images contained in this presenta on are not my own, they can be found on the web Normal Fundus Funduscopy Techniques/ instruments • Direct Ophthalmoscopy • Monocular Indirect Ophthalmoscopy • Headband Binocular Indirect Ophthalmoscopy (BIO) • Fundus Biomicroscopy • Fundus Contact Lens Direct Ophthalmoscopy
• First proposed by Jan Evangelista Purkinge in 1827 • Invented by Charles Babbage in 1847 • First used clinically by Herman Helmholtz 1851 Direct Ophthalmoscopy
• Advantages • Disadvantages – Portable – Small field of view – Easy to use – Lack of stereopsis – Upright image – Media opacities can – Magnification ≈ 15x degrade image – Can use w/o dilation Direct Ophthalmoscopy
• Examiner’s sight hole • Focus adjustment wheel • Light spot size and filter selector • On-off and brightness control knob • The instrument handle Direct Ophthalmoscopy: Basic skills Direct Ophthalmoscopy: Basic skills • Viewing ocular media – Observe red reflex – Look for media opacities • Cataracts • Corneal scars • Large floaters Direct Ophthalmoscopy: Basic skills • Proper position for central fundus viewing • Right eye to right eye • Left eye to left eye • Don’t rub noses… Direct Ophthalmoscopy: Basic skills • Proper position for peripheral fundus viewing Direct Ophthalmoscopy: Exam technique • Be systematic • Start at optic disc & work radially • Observe: – Optic disc: size, rim, cup,hemorrhage – Vessels: course & caliber, AV ratio, light reflex, crossings/banking – Macula – Peripheral fundus Viewing the Optic Nerve Head
• Observe: – Size, shape, color, margins – Cup to disc ra o – (C/D) horiz & Vert – Neurore nal rim (ISN’T rule) – Disc hemorrhages, nerve fiber layers defects – Peripapillary atrophy Blood Vessel Evaluation
• Observe: – Vessel diameter – Shape/tortuosity – Color – Crossings – Light reflex – Artery/Vein (A/V) ratio: after 2nd bifurcation Hypertensive Retinopathy
Normal crossing
Direction change
Banking’” or “nipping Scheie classification
II. Obvious III: Stage II + I.Thinning of arteriolar CWS, exudates IV: Stage III + retinal arterioles narrowing w/ & swollen optic relative to focal areas of disk veins attenuation hemorrhages
15 Arteriolosclerosis
• Increased light reflex (1/2) • “Copper wire” arterioles • “Silver wiring” arterioles – Whitish appearance w/continuing sclerosis • Increased A/V crossings Periphery
• Ask the patient to look into various positions of gaze • Look in the same direction as the patient • Systematically examine the retina with a moderately wide beam of light Macula
• Use the smallest aperture • This observation is performed at the end (light uncomfortably bright) • You can either move the light in this direction or ask the patient to look directly into the light Macula
• Lies about 2DD (disc diameters) temporal to the optic disc • Should be avascular • May appear darker red than surrounding retina • Should see bright foveal reflex on younger patients Indirect Ophthalmoscopy
• Monocular or binocular • Monocular: Provides re na assessment without pupil dilata on Higher use in the past when fewer countries allowed optometrist to use mydria c drugs Monocular Indirect Ophthalmoscopy • Manufacturer: Welch Allyn • Increased field of view & magnifica on • Increased working distance • Hand held but less portable Monocular Indirect Ophthalmoscopy Advantages Disadvantages • Allows a five mes • Monocular= 2D greater area • Image is inverted • View beyond the • Rela vely low equator magnifica on 5x • Can be used with • Limited view of children peripheral and macula • Monocular clinicians Why do we dilate pupils? Binocular Indirect Ophthalmoscopy • Quick and thorough assessment of the entire fundus • Headband BIO + 20D aspheric condensing lens Binocular Indirect Ophthalmoscopy Fundus abnormali es in the peripheral re na missed with direct or indirect monocular ophthalmoscopy: • Re nal holes • Tears and re nal detachments • Intrare nal haemorrhages • Exudates and infarcts • Neovascularisa on • Re nal degenera ons • Vitreore nal trac on • Naevi and tumours Binocular Indirect Ophthalmoscopy Advantages: Disadvantages: • Wide field of view (en re • Requires more skills fundus, periphery and vitreous) • Decreased magnifica on (3x) • Provide stereopsis • Requires dila on • Simultaneous viewing of eight • Inverted image disc diameters (35°) • Pa ent should be placed in a • Easy localiza on of lesions supine posi on (large field of view) • Poten al light toxicity with • Improved view through media prolonged exposure opaci es • Pa ent ametropia does not affect the view Binocular Indirect Ophthalmoscopy Binocular Indirect Ophthalmoscopy Procedure: 1. Dilate the patient eyes 2. Recline the patient 3. Adjust the headband 4. Adjust the eyepieces and mirror vertically so the spot of light is in the upper half of the field of view 5. Adjust the illumination intensity Binocular Indirect Ophthalmoscopy 6. Dim the room lights 7. Ask the patient to look straight up to the ceiling 8. Align the two reflections from the condensing lens with middle of pupil 9. Gradually pull the lens directly toward you until the fundus details fill the entire lens 10. Examine the fundus in a systematic way (clockwise) Binocular Indirect Ophthalmoscopy • Fundus image viewed in condensing lens is real, reversed and inverted • Superior is inferior, nasal is temporal and temporal is nasal • To draw a lesion mentally reverse and invert the image as seen in the lens, or • Place the examination form upside down and draw exactly what you see Binocular Indirect Ophthalmoscopy Binocular Indirect Ophthalmoscopy Fundus Biomicroscopy Non –Contact Fundus Lens • The indirect biomicroscope lens is not intended to take the place of the binocular indirect ophthalmoscopy, but allows you to view an area stereoscopically and with higher magnification than with the binocular indirect ophthalmoscope Fundus Biomicroscopy
• Field of View & Mag: – FOV
Field of View Lens Magnifica on (Sta c/ View Other Dynamic) 13mm working distance; high Volk 60D 1.15x 68 ̊/81 ̊ indirect mag ideal for detailed ONH and macula
8mm working distance; good Volk 78D .93x 81 ̊/97 ̊ indirect compromise b/ w FOV and mag
7mm working distance; ideal Volk 90D .76x 74 ̊/89 ̊ indirect for small pupil examina on Lens specifications
Field of View Lens Magnifica on View Other (Sta c/Dynamic) Op mal small pupil capability through a Volk SuperPupil® XL .45x 103 ̊/124 ̊ indirect pupil as small as 1 - 2mm
Wide field, pan Volk Super re nal examina on .57x 103 ̊/124 ̊ indirect Vitreofundus® and small pupil capability (3-4mm)
High resolu on with Volk Digital Wide .72x 103 ̊/124 ̊ indirect a wide field of view Field® (past vortex) Ideal for op c disc Volk Digital 1.0x 1.0x 60 ̊/72 ̊ indirect measurements and macula Lens specifications
Imaging Lens® slit lamp photos High resolu on, high Volk Digital High 1.30x 57 ̊/70 ̊ indirect magnifica on Mag® imaging of the central re na Ocular Wider field of Instruments view compared .77x 98 ̊/155 ̊ indirect Osher to a classic 78D MaxField® 78D lens Wide field, pan re nal Ocular examina on Instruments .50x 120 ̊/173 ̊ indirect and small pupil MaxField® 120D capability (2mm) Slit Lamp Aspheric Biomicroscopy Indirect Fundus Lenses • Clinically, if the pupil is fully dilated, the magnification is set on low, and there is good patient cooperation, this can be accomplished with any of these lenses Simple Magnification
• Emmetropic eye is considered to be 60 Diopters
• MAGNIFICATION = POWER OF THE EYE / POWER OF THE CONDENSING LENS • MAG. = 60D / 90D • MAG. = .666 X MAGNIFICATION OF SLIT LAMP • MAG. = .666 Times 10X • MAG. = 6.66 X (ETC.) Slit Lamp Aspheric Biomicroscopy procedure 1. Adjust patient in the slit lamp 2. Align illumination and microscope (10x) 3. Explain procedure to the patient. Open slit width 2-3 mm, low illumination 4. Focus on the centrally retroilluminated pupil. Then pull the slit lamp back approximately 2 inches 5. With the lens between your thumb and index finger place the lens and your index finger against the patients brow Slit Lamp Aspheric Biomicroscopy procedure 6. If the light is going into the patients pupil you are ready to look through the slit lamp. The more the pupil is dilated and the closer the lens is to the patient's eye the larger the field of view 7. If you have told the patient to look in the direction of the top of your ear the optic nerve head should be coming into view 8. To reduce reflection tilt the lens slightly or place the illumination slightly out of click Slit Lamp Aspheric Biomicroscopy procedure 9. Once you have located the structure you are wanting to evaluate; you can increase mag (16 X or higher). Look for venous pulsation when viewing the disc 10. To view superior fundus lens must be tilted in toward the cheek and the top out toward the Examiner Slit Lamp Aspheric Biomicroscopy procedure
11. To view the inferior retina have the patient look down. You will have to use your middle or ring finger to retract the upper lid. Tilt the top of the lens toward the patient and the bottom out towards you Slit Lamp Aspheric Biomicroscopy procedure 12. To view the nasal or temporal retina you will need to have the patient look in the direction you are wanting. Rotate the microscope and illumination system as a unit in the opposite direction to the patient's gaze allowing you to get slightly farther into the periphery. The lens is held so it is always perpendicular to the light source Suggested procedure 1. Optic nerve head (cup) 2,3,4,5,6,7. scan superior and inferior vessels out as far as you can and back to the optic nerve head. Have the patient look as far in all directions and see the extent of the retina you are able to view 8. With the red-free filter in place find the macula-foveal areas and foveal reflex Slit Lamp Aspheric Biomicroscopy procedure Interpreta on • The image provided in each of the above lenses is inverted and laterally reversed Clinical Pearls • Pa ent’s gaze can be altered in order to maximize view of given area • Each lens has its own unique working distance to allow for maximal performance Indications for non-contact fundus lens
1. Papilledema diagnosis (Nerve head evaluation) 2. Detection of drusens of the nerve head (pseudopapiledema) 3. Detection of optic nerve head neovascularization (diabetic retinopathy) 4. Evaluation of optic nerve size, cup, rim, hemorrhages (glaucoma) 5. Detection of optic nerve atrophy (optic neuritis, trauma) 6. Detection of cystoid macular edema (pseudophaquia, diabetes, trauma, etc) 7. Detection of central serous retinopathy 8. Detection of chorioretinal lesions (uveitis, holes, RD) 9. Evaluating nerve fiber layer of the retina (glaucoma) 10. Vitreoius evaluation (posterior vitreous detachment, syneresis) 11. Specific macular problems (ARMD, holes, hemorrhages, scars, pseudoholes, etc)
48 Viewing the Optic Nerve Head Contact Fundus Lens Contact Fundus Lens Clinical uses • Enhancing view of macula 1) Edema in diabe c, ARMD, or POHS 2) Epire nal membrane 3) Macular hole 4) Cystoid macular edema • Dilated fundus examina on in an uncoopera ve or photophobic pa ent • To obtain a more magnified view of a peripheral re nal lesion noted during BIO Contact Fundus Lens
Contraindica ons: • Severe corneal trauma • Penetra ng ocular injury • Severe anterior segment infec on • Hyphema Contact Fundus Lens
Field of View (Sta c/ Lens Magnifica on View Dynamic) Other Volk Fundus 20mm (with Flange helps provide 1.44x 25 ̊/30 ̊ direct flange) stability of lens on cornea Ocular Instruments Flange helps provide .93x 36 ̊ direct Yannuzzi Fundus Lens stability of lens on cornea The flat front surface of Ocular Instruments this contact lens provides .93x 36 ̊ direct Fundus Diagnos c Lens a direct image of the posterior pole 15mm contact diameter; 3 mirrors: (Volk 60 ̊/66 ̊/76 No flange op on is ideal 1.06x ̊) Central lens of 3-mirror1 direct for use on infants or 1.08x (Ocular Instruments 59 ̊/ pa ents with narrow 67 ̊/73 ̊) palpebral fissures High magnifica on and Volk High Resolu on 1.08x 74 ̊/88 ̊ indirect resolu on of posterior Centralis® pole Lens of choice in eyes with Volk Equator Plus® 0.44x 114 ̊/137 ̊ indirect poor dila on (can be used in pupils as small as 3mm) Volk High Resolu on Wide Extreme peripheral re nal 0.5x 160 ̊/165 ̊ indirect Field examina on Contact Fundus Lens
• Requires physical contact w/eye • Viewed w/ Biomicroscope • Advanced dx & surgery • Field of view & Mag vary w/lens design 3 Mirror gonio fundus lens Contact Fundus Lens
Set Up 1. Prepare disinfected lens by cleaning of debris and fingerprints (soap and water, or cleansing solution can be used) 2. Place 2‐3 drops of buffering solution into lens well (Goniosol , Refresh Celluvisc, or Genteal Gel). Lenses without a flange may require less or no buffering solution 3. Anesthetize patient’s cornea(s) Contact Fundus Lens Procedure 1. Instruct patient to look up 2. Obtain lower lid control (may not be necessary if using a lens without a flange) 3. Insert the lower portion of the lens/flange into the patient’s inferior cul‐de‐sac 4. Push the lens downward and rotate the lens onto the cornea. Upper lid control can be obtained if necessary. 5. Instruct the patient to look at your fixation target (knob, ear, etc) Contact Fundus Lens Procedure 6. Pull back on the slit lamp joystick in order to obtain a focus on the desired target. 7. Lens removal a) Carefully break suction between lens and tear interface b) Lenses without a flange will have less or no suction and lens can be gently pulled directly away from the eye 8. Lavage if necessary based on buffering solution used 9. Disinfection of used lens with glutaraldehyde high‐level disinfection Contact Fundus Lens Interpretacion Interpreta on • Direct view: view seen is how it appears anatomically • Indirect view: view is inverted and laterally reversed Clinical Pearls Pa ent’s gaze can be altered in order to maximize view of given area