Fundoscopy (Ophthalmoscopy) – OSCE Guide

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Fundoscopy (ophthalmoscopy) frequently appears in OSCEs and you’ll be expected to pick up the relevant clinical signs using your examination skills. This guide provides a step-by-step approach to assessing the anterior eye and performing fundoscopy. It also includes a video demonstration.


Introduction

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

Example explanation

“I will be using a magnifying tool called an ophthalmoscope to look at the front and back of your eyes with the lights off.”

“To do this, I’ll need to get quite close to your face. I’ll place a hand on your forehead to prevent us from bumping into each other.”

“I’ll also be using some eye drops to dilate your pupils and to highlight any problems. The dilating drops will cause your vision to be temporarily blurry and you’ll be more sensitive to light, so you’ll not be able to drive for several hours afterwards.”

Gain consent to proceed with the examination.

Position the patient sitting on a chair.

Wash your hands.

Ask if the patient has any pain before proceeding.


Gather equipment

  • Ophthalmoscope
  • Mydriatic eye drops
  • Fluorescein eye drops

Inspect the external eye

To inspect the external eye, ask the patient to focus on a fixed object in the distance (e.g. light switch) and use the light of the fundoscope to carefully examine the eyelids, eyelashes, conjunctiva, sclera, cornea, iris and pupil.

General inspection

Inspect the eye for signs of pathology:

  • Eyelids: note any lumps (benign or malignant), oedema, cellulitis and entropion/ectropion.
  • Eyelashes: inspect for loss of eyelashes (can be associated with malignant lesions) or trichiasis (inturning of the eyelashes).
  • Diffuse conjunctival injection (redness): dilated inflamed blood vessels across the majority of the conjunctiva. Typically associated with bacterial, viral and allergic conjunctivitis.
  • Circumciliary injection: dilated inflamed blood vessels affecting the conjunctiva in a circular pattern around the cornea suggesting intraocular inflammation. Typically associated with keratitis, acute angle-closure glaucoma and uveitis.
  • Discharge: watery discharge is typically associated with allergic conjunctivitis, viral conjunctivitis or normal physiological production (e.g. reaction to a corneal abrasion/foreign body). Purulent discharge is more likely to be associated with bacterial conjunctivitis.
  • Hyphema: an inferior settled layer of blood in the anterior chamber typically occurring as a result of trauma.
  • Hypopyon: an inferior settled layer of ‘pus’ (white cells and debris) in the anterior chamber. Typically associated with severe corneal ulcers or endophthalmitis, but can also occur secondary to anterior uveitis.
  • Periorbital erythema and swelling: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis (posterior to the orbital septum).
  • Pupillary abnormalities: can include abnormal size, shape and asymmetry (see below).
  • Foreign bodies: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical features include redness, pain, watering and a ‘foreign body sensation’.
  • Corneal abrasion: redness, pain, watering and photophobia are common clinical features. Epithelial defects can be very hard to see with the naked eye but stain brightly with fluorescein drops and a cobalt blue light.
  • Corneal ulcer: typical clinical features include pain, watering, photophobia and a staining epithelial defect with associated haziness (infiltrates). The infiltrate may appear fluffy and irregular.

Inspect the pupil

The pupil is the hole in the centre of the iris that allows light to enter the eye and reach the retina.

Assess pupil size

  • Normal pupil size varies between individuals and depends on lighting conditions (i.e. smaller in bright light, larger in the dark).
  • Pupils are usually smaller in infancy and larger in adolescence.

Assess pupil shape

  • Pupils should be round, abnormal shapes can be congenital or due to pathology (e.g. posterior synechiae associated with uveitis).
  • Peaked pupils in the context of trauma are suggestive of globe injury.

Assess pupil symmetry

  • Note any asymmetry in pupil size between the pupils (anisocoria). This may be longstanding and non-pathological or relate to actual pathology. If the pupil is more pronounced in bright light this would suggest that the larger pupil is the abnormal pupil, if more pronounced in dark this would suggest the smaller pupil is abnormal.
  • Examples of asymmetry include a large pupil in oculomotor nerve palsy and a small and reactive pupil in Horner’s syndrome.

Inspect the eyelids

  • Assess lid position: ptosis can be a sign of Horner’s syndrome (often very subtle ptosis) and oculomotor nerve palsy (can vary from partial to complete ptosis).
  • Assess the lid margins: crusting and inflamed lid margins are associated with blepharitis.
  • Inspect the pupils
    Inspect the pupils
Causes of red eye

Below is a non-exhaustive list of causes of red eye, with their associated clinical features.

Painless red eye:

  • Conjunctivitis: diffuse conjunctival injection (unilateral or bilateral), discharge, swollen conjunctiva (chemosis) and debris. Bacterial conjunctivitis typically has more purulent discharge than viral or allergic conjunctivitis.
  • Subconjunctival haemorrhage: a flat, bright red patch on the conjunctiva with sharply defined borders and normal conjunctiva surrounding it.
  • Episcleritis: sectoral area of subconjunctival injection (unilateral). The subconjunctival injection in episcleritis is superficial and, as a result, moveable with a swab (using topical anaesthesia) pressed gently on the conjunctiva.
  • Dry eye: caused by deficiencies in tear production and maintenance secondary to conditions such as blepharitis (obstruction of meibomian glands). Clinical features include diffuse conjunctival injection (unilateral or bilateral), inflamed lid margins with crusting and matted eyelashes.

Painful red eye:

  • Scleritis: deep pinkish localised conjunctival injection (unilateral), visual acuity may be reduced, minimal watery discharge, photophobia and a tender globe (causing the patient to wake at night). Symptoms tend to progressively worsen and individuals commonly have other connective tissue diseases.
  • Uveitis: circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, reduced visual acuity, watery discharge, photophobia and pain are common clinical features.
  • Corneal abrasion: eye redness, pain, watering and photophobia are common clinical features. Epithelial defects can be very hard to see with the naked eye but stain brightly with fluorescein drops and a cobalt blue light.
  • Corneal ulcer: typical clinical features include pain, watering, photophobia and a staining epithelial defect with associated haziness (infiltrates). The epithelial defect may appear fluffy, irregular and apparent even without a slit lamp.
  • Acute angle-closure glaucoma (AACG): typical clinical features include significant pain leading to vomiting, circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a mid-dilated unreactive pupil.
  • Foreign bodies: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical features include redness, pain, watering and a ‘foreign body sensation’. Foreign bodies may be hidden under the top and bottom of the eyelid.

Ophthalmoscope overview

Parts

  • Viewing window: this is where you look through to observe the eye.
  • Filter switch: allows you to select a light filter (e.g. blue cobalt light).
  • Aperture dial: adjust the size of the light beam.
  • Diopter dial: adjusts the lens used to view the eye.
  • Diopter power display: shows the current lens being used.
  • Rheostat: adjusts the intensity of the light beam.
  • On/off switch: turns the device on and off.

Aperture size (beam size)

  • Micro aperture: used for viewing the fundus through very small undilated pupils.
  • Small aperture: used for viewing the fundus through an undilated pupil.
  • Large aperture: used for viewing the fundus through a dilated pupil and for the general examination of the eye.
  • Slit aperture: can be helpful in assessing contour abnormalities of the cornea, lens and retina as it makes elevation easier to see.

Filter

  • Cobalt blue filter: used to look for corneal abrasions or ulcers with fluorescein dye.
  • Red-free filter: used to look at the centre of the macula and other vasculature in more detail.
  • Practitioner side of the ophthalmoscope
    Practitioner side of the ophthalmoscope

Prepare to perform fundoscopy

1. It is essential to darken the room for the examination. Make sure the patient is positioned seated prior to turning out the lights to avoid accidents.

2. Dilate the patient’s pupils using short-acting mydriatic eye drops such as tropicamide 1%.  You will be unable to monitor pupil reactions once dilating drops have been applied, furthermore assessing vision, colour vision, double vision and visual fields will be less accurate once drops are instilled.

3. Ask the patient to look straight ahead for the duration of the examination (asking the patient to fixate on a distant target such as a light switch can cause confusion if you then obstruct the view of this target).


Assess the red reflex

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the red reflex adjust the diopter dial to correct for your refractive error so that you can see the patient and their eye clearly from a distance:

  • If you have normal visual acuity, you can set the diopter dial to 0.
  • If you have a refractive error but are planning to wear glasses/contact lenses that correct this when using the ophthalmoscope you can also set it to 0.
  • If you have a refractive error and are not going to wear your glasses/contact lenses you should adjust the diopter dial to match your prescription (e.g. -2).

How to assess for the red reflex

1. Look through the ophthalmoscope, shining the light towards the patient’s eye at a distance of approximately one arm’s length.

2. Observe for a reddish/orange reflection in each pupil, caused by light reflecting back from the vascularised retina.

Causes of an absent red reflex

Absence of the red reflex in adults is often due to cataracts in the patient’s lens blocking the light. Other causes include vitreous haemorrhage and retinal detachment.

Absence of the red reflex in children can be due to congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma.

The presence of a white reflex (leukocoria), regardless of whether the red reflex is partly visible suggests the presence of one of the pathologies mentioned previously.

  • Assess for the red light reflex
    Assess for the red light reflex

Assess the anterior segment of the eye

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the anterior surface of the eye adjust the diopter dial to a high green number (e.g. 10 or 15) which changes the ophthalmoscope into a magnifying glass.

How to assess the anterior segment of the eye

1. Stand to the side of the patient and place your hand on the patient’s forehead to prevent an accidental collision.

2. Approach the eye and assess the anterior segment using the ophthalmoscope:

  • Fluorescein dye can be applied as an eye drop which will stain and fluoresce yellow under the blue cobalt light filter of the ophthalmoscope if there is damage to the corneal or conjunctival epithelium (e.g. an abrasion).
  • Look for white opacities on the cornea which may be suggestive of a corneal ulcer.
  • Assess the anterior segment of the eye
    Assess the anterior segment of the eye

Assess the fundus

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the fundus, adjust the diopter dial so that it is the net result of yours and the patient’s refractive error:

  • If you and the patient have normal visual acuity, set the dial to 0 (e.g. 0 + 0 = 0).
  • If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive error of 0 and add the patient’s refractive error to this (e.g. 0 + -2 = -2).
  • If the patient has a refractive error and you have normal visual acuity set the dial to the net refractive error. An example of this would be (your refractive error of 0) + (patient’s refractive error of -2) = a setting of -2.
  • If the patient has a refractive error and you have a refractive error set the dial to the net refractive error. An example of this would be (your refractive error of +3) + (patient’s refractive error of -2) = a setting of +1.
  • If things appear out of focus during the assessment, simply adjust the diopter dial until things look sharper.

Assess the optic disc

1. If you are assessing the patient’s right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the hand not holding the ophthalmoscope onto the patient’s forehead to prevent accidental collision between yours and the patient’s face.

2. Approaching from a 45-degree angle slightly temporal to the patient, move closer whilst maintaining the red reflex.

3. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches point like arrows towards the optic disc).

4. Once you identify the optic disc assess its characteristics including the contour, colour and the cup (“3Cs”):

  • Contour: the borders of the optic disc should be clear and well defined. If the borders appear blurred it may suggest the presence of optic disc swelling (papilloedema) secondary to raised intracranial pressure.
  • Colour: a healthy optic disc should look like an orange-pink doughnut with a pale centre. The orange-pink colour represents well-perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of optic neuritis, advanced glaucoma and ischaemic vascular events.
  • Cup: the cup is the pale centre of the orange-pink doughnut mentioned previously. The pale colour of the cup is due to the absence of neuroretinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as the “cup-to-disc ratio“. A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally considered normal. An increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can occur in glaucoma.
  • Perform fundoscopy
    Perform fundoscopy

Assess the retina

5. Methodically assess each quadrant of the retina and the associated vascular arcades in a clockwise or anticlockwise fashion looking for evidence of pathology:

  • Superior temporal (ST)
  • Superior nasal (SN)
  • Inferior nasal (IN)
  • Inferior temporal (IT)
  • Assess each quadrant of the retina
    Assess each quadrant of the retina
Types of retinal pathology
  • Arteriolar narrowing: subtle, with generalised arteriolar narrowing with typical copper or silver wire appearance. Most commonly associated with the early stages of hypertensive retinopathy.
  • Arteriovenous nipping/nicking: areas of focal narrowing, and compression of venules at sites of arteriovenous crossing. The typical appearance involves bulging of retinal veins on either side of the area where the retinal artery is crossing. Most commonly associated with grade 2 hypertensive retinopathy.
  • Dot and blot haemorrhages: arise from bleeding capillaries in the middle layers of the retina and may look like microaneurysms if small enough. They are most commonly associated with diabetic retinopathy.
  • Flame haemorrhages: larger haemorrhages with a flame-like appearance caused by rupture of pre-capillary arterioles or small veins in the retinal nerve fibre layer. Most commonly associated with grade 3 hypertensive retinopathy, thrombocytopaenia, retinal vein occlusion and trauma.
  • Cotton wool spots: appear as small, fluffy, whitish superficial lesions and represent infarcts of the neuro-retinal layer. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
  • Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking microaneurysms. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
  • Neovascularisation: formation of new blood vessels that appear as a net of small curly vessels, with or without associated haemorrhages. They may be located on the optic disc or elsewhere on the retina. They are most commonly associated with advanced proliferative diabetic retinopathy.
  • Pan-retinal photocoagulation: the primary treatment for proliferative diabetic retinopathy. Clinically it is seen as clusters of pale burn marks on the retina which have been created by the laser used in the treatment process.
  • Branch retinal vein occlusion: blockage of one of the four retinal veins, each of which drains about a quarter of the retina. Typical signs include flame haemorrhages, dot and blot haemorrhages, cotton wool spots, hard exudates, retinal oedema, and dilated tortuous veins.

Assess the macula

6. Finally, inspect the macula by asking the patient to briefly look directly into the light of the ophthalmoscope. The macula is found lateral (temporal) to the optic nerve head and is yellow in colour. The central part of the macula, the “fovea” is about the same diameter as the optic disc and appears darker than the rest of the macula due to the presence of an additional pigment.

  • Assess the macula
    Assess the macula
Types of macula pathology
  • Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking microaneurysms. They are most commonly associated with diabetic retinopathy, grade 3 hypertensive retinopathy  and retinal vein occlusions.
  • Drusen: yellow-white flecks scattered around the macular region representing remnants of dead retinal pigment epithelium. Most commonly caused by age-related macular degeneration.
  • Cherry-red spot: associated with central retinal artery occlusion which typically presents with sudden profound visual loss.

Assess the other eye

Repeat assessment of the anterior segment, red reflex and fundus on the other eye. You will need to approach the patient from the opposite side and hold the ophthalmoscope in your other hand.


To complete the examination

Explain to the patient that the examination is now finished.

Thank the patient for their time.

If mydriatic drops were instilled, remind the patient they cannot drive for the next 3-4 hours until their vision has returned to normal.

Wash your hands.

Summarise your findings

Further assessment and investigations

All of the following further assessments and investigations are dependent on the patient’s presenting complaint and in most cases, none of them would need to be performed:

  • Amsler chart: to assess for central visual loss and distortion which is commonly associated with macular degeneration.
  • Cranial nerve examination: to further assess for evidence of cranial nerve pathology (e.g oculomotor nerve).
  • Blood pressure: if there are concerns about hypertensive retinopathy.
  • Capillary blood glucose: if there are concerns about diabetic retinopathy.
  • Retinal photography: to better visualise any abnormalities noted on fundoscopy.

References

  1. James Heilman, MD. Adapted by Geeky Medics. Allergic conjunctivitis. Licence: CC BY-SA. Available from: [LINK].
  2. Adapted by Geeky Medics. Bacterial conjunctivitis. Licence: Public domain. Available from: [LINK].
  3. FiP. Adapted by Geeky Medics. Subconjunctival haemorrhage. Licence: CC BY-SA. Available from: [LINK].
  4. Imrankabirhossain. Adapted by Geeky Medics. Episcleritis. Licence: CC BY-SA. Available from: [LINK].
  5. Kribz. Adapted by Geeky Medics. Scleritis. Licence: CC BY-SA. Available from: [LINK].
  6. Adapted by Geeky Medics. Blepharitis. Licence: Public domain. Available from: [LINK].
  7. Jonathan Trobe, M.D. Adapted by Geeky Medics. Anterior uveitis. Licence: CC BY. Available from: [LINK].
  8. Jonathan Trobe, M.D. Adapted by Geeky Medics. Acute closed-angle glaucoma. Licence: CC BY. Available from: [LINK].
  9. EyeMD (Rakesh Ahuja, M.D.). Adapted by Geeky Medics. Hypopyon. Licence: CC BY-SA. Available from: [LINK].
  10. Tripp on Flickr. Adapted by Geeky Medics. Pre-septal cellulitis. Licence: CC BY 2.0. Available from: [LINK].
  11. Waster. Adapted by Geeky Medics. Miosis. Licence: CC BY. Available from: [LINK].
  12. Evan Herk. Adapted by Geeky Medics. Foreign body. Licence: CC BY-SA. Available from: [LINK].
  13. James Heilman, MD. Adapted by Geeky Medics. Corneal abrasion. Licence: CC BY-SA. Available from: [LINK].
  14. Yoanmb. Adapted by Geeky Medics. Corneal ulcer. Licence: CC BY SA. Available from: [LINK].
  15. Jonathan Trobe, M.D. Adapted by Geeky Medics. RAPD. Licence: CC BY. Available from: [LINK].
  16. Adapted by Geeky Medics. Red eye reflex. Licence: Public domain. Available from: [LINK].
  17. Imrankabirhossain. Adapted by Geeky Medics. Cataract. Licence: CC BY-SA. Available from: [LINK].
  18. Adapted by Geeky Medics. Retinoblastoma. Licence: Public domain. Available from: [LINK].
  19. Adapted by Geeky Medics. Retinal detachment. Licence: Public domain. Available from: [LINK].
  20. Yandle on Flickr. Adapted by Geeky Medics. Normal fundus. Licence: CC BY 2.0. Available from: [LINK].
  21. Jonathan Trobe, M.D. Adapted by Geeky Medics. Papilloedema. Licence: CC BY. Available from: [LINK].
  22. Frank Wood. Adapted by Geeky Medics. Hypertensive retinal disease. Licence: CC BY. Available from: [LINK].
  23. Adapted by Geeky Medics. Cotton wool spots. Licence: Public domain. Available from: [LINK].
  24. National Eye Institute. Adapted by Geeky Medics. Pan-retinal photocoagulation. Licence: Public domain. Available from: [LINK].
  25. Ku C Yong, Tan A Kah, Yeap T Ghee, Lim C Siang and Mae-Lynn C Bastion. Adapted by Geeky Medics. Licence: CC BY. Retinal branch occlusion. Available from: [LINK].
  26. National Eye Institute. Adapted by Geeky Medics. Pan-retinal photocoagulation. Licence: Public domain. Available from: [LINK].
  27. Adapted by Geeky Medics. Drusen. Licence: Public domain. Available from: [LINK].
  28. National Eye Institute. Adapted by Geeky Medics. Macular oedema. Licence: Public domain. Available from: [LINK].
  29. Achim Fieß, Ömer Cal, Stephan Kehrein, Sven Halstenberg, Inez Frisch, Ulrich Helmut Steinhorst. Adapted by Geeky Medics. Cherry red spot. Licence: CC BY. Available from: [LINK].

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