By Dr-Wedad Bardisi

It is an instrument about the size of a small

flashlight with several lenses that can

magnify up to about 15 times.

This type of ophthalmoscope is most

commonly used during a routine physical

examination

An indirect ophthalmoscope constitutes a light

attached to a headband, in addition to a small

handheld lens. It provides a wider view of the

inside of the eye. Furthermore, it allows a

better view of the fundus of the eye, even if the

lens is clouded by cataracts.

An indirect ophthalmoscope can be either

monocular or binocular

Establish good Doctor- Patient relationship.

Take his permission.

Explain what are you going to do and why.

Examine the eye generally by inspection for any obvious abnormalities like ptosis, exophthalmous, conjunctivitis, scleritis, swellings or ptyrigium which can mechanically impairs the direct ophthalomoscopy.

Shine torsh light to both eyes to look for the

red reflex so to exclude cataract which may

impairs the procedure.

Inspect the size of the pupils.

If it is small you need to darken the room,

if this fails to dilate the pupil sufficiently,

then use mydriatic, for example ,

mydrilate(1% cyclopentolate), can be

installed. This should never be done in the

unconscious patient and must always be

recorded in the patient notes.

Do not use mydriatics in a patient with glaucoma.

Rememberto revese the effect of medriatic at the

end of the examination by installing 2%

pilocarpine.

Ask the patient to fixate on a distant target.

If the patient wears glasses with a substantial

correction, It some times facilitate the

examination to perform it with the patients

glasses in place.

The optic disc is examined to assess its

shape, colour and clarity.

The temporal margin of the disc is slightly

paler than the nasal margin. The

physiological cup varies in size but seldom

extends to the temporal and never to the

nasal margins of the disc.

The blood vessels are not obscured as they cross the disc , nor they are elevated.

The vessels are examined next, the arteries are narrower than the veins and a brighter in color.

They posses a longitudinal pale streak as a consequence of light reflecting from their walls.

The retinal veins should be closely inspected

where they enter the optic disc.

In approximately 80% of individuals the veins

pulsate. This pulsation ceases when CSF

pressure increase, therefore the presence of

this retinal venous pulsation is very sensitive

index of normal intracranial pressure.

The fundus is examined for the presence of

haemorrhage or exudates, the position of

which are best shown by a diagram in the

patient notes.

Clinical application

Optic atrophy

Papilloedema

Retinal artery and vein occlusion.

Hypertensive retinopathy

Diabetic retinopathy

Glaucoma

It is useful to characterize the changes in

the optic nerve head that occur in

papilledema as being mechanical or

vascular in nature.

1. Blurring of the optic disc margins

2. Filling-in of the optic disc cup

3. Anterior extension of the nerve head (3D

= 1mm of elevation)

4. Edema of the nerve fiber layer

5. Retinal and/or choroidal folds.

1. Venous congestion of arcuate and peripapillary

vessels

2. Papillary and retinal peripapillary hemorrhages

3. Nerve fiber layer infarcts (cotton-wool spots)

4. Hyperemia of the optic nerve head

5. Hard exudates of the optic disc

Papilledema is classified as:

A. Early

B. Fully developed

C. Chronic

D. Late

Early papilledema:

1-Disc hyperemia

2- Disc swelling

3-Blurring of the disc margins

4-Blurring of the nerve fiber layer

Fully developed papilledema:

1.Gross elevation of the optic nerve head

2. Engorged and dusky veins appear.

3. Peripapillary splinter hemorrhages and sometimes

choroidal folds arise

4. Retina striae

In chronic papilledema:

1. Fewer hemorrhages occur.

2. The optic disc cup is obliterated completely.

3. Less disc hyperemia is seen.

4. Hard exudates occur within the nerve head.

5. Optociliary shunts can start showing.

In late disc edema:

1-Secondary optic atrophy occurs

2-Disc swelling subsides

3-Retinal arterioles are narrowed or sheathed

4-The optic disc appears dirty gray and blurred,

secondary to gliosis

5-Retinochoroidal vein shunts(or Optociliary) may be

seen

Headache.

Brief transient obscurations of vision.

Less commonly, blurred vision, constriction of

visual fields, dyschromatopsia, and/or diplopia.

Cause for concern exists if the headache is particularly severe or associated with nausea and vomiting or a sense of pressure around the ears..

Papilledemashowing blurred disc margins and dilated tortuous vessels

.

Age related macular degeneration (AMD) is one of the most common

causes of poor vision after age 60.

The specific cause is unknown, AMD seems to be part of aging.

Age is the most significant risk factor for developing AMD.

Heredity, blue eyes, high blood pressure, cardiovascular disease,

and smoking have also been identified as risk factors.

AMD accounts for 90 percent of new legal blindness in the US.

Nine out of 10 people have dry AMD which

results in thinning of the macula.

Dry AMD takes many years to develop.

Currently no treatment

The wet form of AMD occurs much less

frequently (one out of 10 people) but is more

serious.

In the meantime, high-intensity reading

lamps, magnifiers and other low-vision aids

help people with AMD make the most of

remaining vision.

is the loss of some or most of the fibers of the optic nerve.

loss of vision , colour vision.

Causes

Optic atrophy can be congenital or acquired

anterior ischemic optic neuropathy or

posterior ischemic optic neuropathy.

optic neuritis

Tumour

diabetes mellitus, trauma, glaucoma, or

toxicity (caused by methanol, tobacco, or

other poisons).

It is also seen in vitamin B12 deficiency and

Paget's disease of the bone.

Toxoplasmosis is a common parasitic infection. When contracted by a pregnant woman, toxoplasmosis can pose serious risks to the unborn baby.

Simple precautions can reduce the chance of infection.

Pregnant women should avoid handling litter

boxes and eating raw meat because the

parasite may originate in cat feces or

undercooked meat.

If acquired during the first trimester of

pregnancy, the infection can be devastating

to an infant.

Central retinal vein occlusion (CRVO) blocks the main vein in

the retina.

The blockage causes macular oedema, vision becomes

blurred.

Floaters due to blood in the vitreous.

Retinal vein occlusions commonly occur with glaucoma,

diabetes, age-related vascular disease, high blood pressure,

and blood disorders.

CRAO usually occurs in people between the ages of 50 and 70.

The most common medical problem associated with CRAO is

arteriosclerosis.

Carotid artery disease is found in almost half of the people with

CRAO.

The most common cause of CRAO is a thrombosis. Sometimes

CRAO is caused by an embolus.

Central retinal artery occlusion (CRAO) blocks the central artery

in retina, the ligh.

The first sign of CRAO is a sudden and painless loss of vision.

Loss of vision can be permanent without immediate

treatment.

Irreversible retinal damage occurs after 90

minutes, but even 24 hours after symptoms begin,

vision may still rarely be saved.

The goal of emergency treatment is to restore

retinal blood flow

Back ground diabetic retinopathy

Microaneurysms: these are usually the earliest visible change in retinopathy seen on exam with an ophthalmoscope as scattered red spots in the retina where tiny, weakened blood vessels have ballooned out.

Hemorrhages: bleeding occurs from damaged blood vessels into the retinal layers. This will not affect vision unless the bleeding occurs in or near the Macula

Hard Exudates: caused by proteins and lipids from the blood leaking into the retina through damaged blood vessels. They appear on the ophthalmoscope as hard white or yellow areas, sometimes in a ringlike structure around leaking capillaries. Again vision is not affected unless the macula is involved.

Arteriosclerotic changes

◦ Arteriolar narrowing that is almost always bilateral.

Grade I - 3/4 normal caliber

Grade II - 1/2 normal caliber

Grade III - 1/3 normal caliber

Grade IV - thread-like or invisible

◦ Arterio-venous crossing changes (aka "AV nicking") with venous constriction and banking

◦ Arteriolar color changes

Copper wire arterioles are those arterioles in

which the central light reflex occupies most

of the width of the arteriole.

Silver wire arterioles are those arterioles in

which the central light reflex occupies all of

the width of the arteriole.

◦ Vessel sclerosis.

Ischemic changes (e.g. "cotton wool spots")

Hemorrhages, often flame shaped.

Edema

◦ Ring of exudates around the retina called a "macular

star"

Papilledema, or optic disc edema, in patients with

malignant hypertension

Visual acuity loss, typically due to macular involvement

A 23 year old man had had intermittent odourless discharge from his right ear for two years since experiencing sudden earache while diving on holiday.

He felt he was deaf in that ear and had recently noticed some high pitched tinnitus on the right, although his ear was currently dry.

What does otoscopy of his right tympanic membrane show?

There is a perforation of the posterosuperior

quadrant of the tympanic membrane.

No cholesteatoma is visible, and the intact

long process of the incus and stapes head

can be seen through the perforation

A 5 year old girl had multiple attacks of otitismedia, was falling behind in her schoolwork, and was mispronouncing words. Her teacher felt she was not paying attention in class and her parents noticed that she turned up the television volume to unacceptably loud levels. The picture above shows the otoscopicappearances. What is the likely diagnosis?

The tympanic membrane is intact but is dull

and a golden colour.

This child has otitis media with effusion (glue

ear). If this is persistent she may benefit from

the insertion of ventilation tubes (grommets

A 28 year old woman had put up with an intermittent foul smelling discharge from her ear for over 10 years.

Topical antibiotics controlled her symptoms for only a few weeks. She had suddenly become very deaf in the affected ear and had asked for a specialist opinion. What do the otoscopic findings suggest?

There is a large mass of infected squamousepithelium and keratin behind the pars flaccida - a cholesteatoma.

This can cause infective complications such as meningitis and may erode into the labyrinth or facial nerve.

The cholesteatoma therefore needs to be removed.

The operation entails exploring the mastoid to identify the fundus of the sac, removing the disease, and grafting the surgical defect.