Direct Ophthalmoscopy

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Direct Ophthalmoscopy

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1. Direct Ophthalmoscopy Judy Tong, O.D., F.A.A.O. Ocular Health Procedures I Spring 2010-11

2. Introduction

3. Advantages Ease in performance Comfort Dilation not necessary Ease in documentation Less expensive Disadvantages No stereopsis Close distance Small field Limited illumination Refractive error

4. Ophthalmoscopes Direct Hand held direct ophthalmoscope PanOptic Fundus contact lens Hruby lens Indirect Binocular indirect (BIO) Monocular indirect (MIO) 60D, 78D, 90D…

5. Principles

6. Image Virtual and erect Ease in orientation Ease of documentation

7. Field of View (FOV) 10º or 2DD Limited by Peripheral light rays Expanded by Decreasing working distance Maximizing pupil dilation Decreasing myopia

8. Magnification Depends on refractive powers of the patient and the doctor; axial lengths, compensating lenses 15X = 60/4 Refractive error Aphakes Hyperopes Myopes

9. Area of Fundus Visible 50-70% when dilated What about the remaining 30-50% of the retina?

10. Brightness 1/2 - 4 watts Limited Media opacities

11. Working Distance 1 - 2 cm Very close Think Altoids!!!

12. Stereopsis None What about observing elevation or depression?

13. Features Wide aperture Bull’s eye fixation target – visuoscope Filters Red free RNFL, blood vessels, choroidal lesions Cobalt blue Abrasions, foreign bodies, infiltrates, CL, GAT

14. Preparation Patient education Alignment Dim room lights Fixation

15. Tong’s DO Dance Technique 7 steps to distance ophthalmoscopy 1) Turn DO on to moderate setting 2) Hold DO in right hand to be used with right eye 3) Dial in lens up to +3.00 D with right index finger 4) Look through aperture with right eye 5) Stand at arm’s length (30-40 cm) 6) Shine light toward patient’s right eye 7) Evaluate all quadrants Repeat for left eye

16. What to look for while dancing… Orange-red fundus reflex Black spots Localization While focused at plane of lens Against motion - in front of lens Cells, flare, hyphema No motion - at plane of lens Mittendorf dot, PSC, vacuoles With motion - behind lens Vitreous hemorrhage, asteroid hyalosis

17. DO Dancing

18. Anterior Segment Evaluation 6 steps to evaluate from the lids to the retina 1) Dial in approximately +20.00D to evaluate lids and lashes 2) Reduce + to evaluate conjunctiva and cornea 3) Further reduce + to evaluate iris 4) Continue to reduce + to evaluate lens 5) Then vitreous 6) All the way back to the retina

19. You’re on your own Review 10 layers of retina Retinal vasculature

20. #1 Media Normal Orange-red reflex Clear, no opacity

21. Abnormal Fundus Reflex Bright red Hemorrhage

22. Abnormal Fundus Reflex White Arterial occlusion Coloboma Retinoblastoma

23. Abnormal Fundus Reflex Yellow Tumor Retinoblastoma

24. Abnormal Fundus Reflex Blue/Black Choroidal melanoma

25. Abnormal Fundus Reflex Green Retinal detachment

26. #2 Optic Nerve Head Margin Distinct 15 degree nasal 360 eval starting at 12 o’clock15 degree nasal 360 eval starting at 12 o’clock

27. Indistinct Margin Disc edema Increased cerebral spinal fluid Compressive force Causes HTN, DM, AION, CRVO, PTC, meds Swelling, inflammation, infiltrationSwelling, inflammation, infiltration

28. Characteristics of True Disc Edema Vessel obscuration Rim tissue hyperemia Hemorrhages Absence of SVP

29. True Disc Edema True swelling = vessel obscuration, rim tissue hyperemia, hemorrhages at the OHP, (-) SVPTrue swelling = vessel obscuration, rim tissue hyperemia, hemorrhages at the OHP, (-) SVP

30. True Disc Edema

31. True Disc Edema

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