FUNDUS EXAMINATION. Dr Cesar Carrillo
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1 FUNDUS EXAMINATION Dr Cesar Carrillo October, 2014 Vien%ane/NOC **Disclaimer** The images contained in this presenta4on are not my own, they can be found on the web
2 Normal Fundus
3 Funduscopy Techniques/ instruments Direct Ophthalmoscopy Monocular Indirect Ophthalmoscopy Headband Binocular Indirect Ophthalmoscopy (BIO) Fundus Biomicroscopy Fundus Contact Lens
4 Direct Ophthalmoscopy First proposed by Jan Evangelista Purkinge in 1827 Invented by Charles Babbage in 1847 First used clinically by Herman Helmholtz 1851
5 Direct Ophthalmoscopy Advantages Portable Easy to use Upright image Magnification 15x Can use w/o dilation Disadvantages Small field of view Lack of stereopsis Media opacities can degrade image
6 Direct Ophthalmoscopy Examiner s sight hole Focus adjustment wheel Light spot size and filter selector On-off and brightness control knob The instrument handle
7 Direct Ophthalmoscopy: Basic skills
8 Direct Ophthalmoscopy: Basic skills Viewing ocular media Observe red reflex Look for media opacities Cataracts Corneal scars Large floaters
9 Direct Ophthalmoscopy: Basic skills Proper position for central fundus viewing Right eye to right eye Left eye to left eye Don t rub noses
10 Direct Ophthalmoscopy: Basic skills Proper position for peripheral fundus viewing
11 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
12 Viewing the Optic Nerve Head Observe: Size, shape, color, margins Cup to disc ra4o (C/D) horiz & Vert Neurore4nal rim (ISN T rule) Disc hemorrhages, nerve fiber layers defects Peripapillary atrophy
13 Blood Vessel Evaluation Observe: Vessel diameter Shape/tortuosity Color Crossings Light reflex Artery/Vein (A/V) ratio: after 2nd bifurcation
14 Hypertensive Retinopathy Normal crossing Direction change Banking or nipping
15 Scheie classification I.Thinning of retinal arterioles relative to veins II. Obvious arteriolar narrowing w/ focal areas of attenuation III: Stage II + CWS, exudates & hemorrhages IV: Stage III + swollen optic disk 15
16 Arteriolosclerosis Increased light reflex (1/2) Copper wire arterioles Silver wiring arterioles Whitish appearance w/continuing sclerosis Increased A/V crossings
17 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
18 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
19 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
20 Indirect Ophthalmoscopy Monocular or binocular Monocular: Provides re4na assessment without pupil dilata4on Higher use in the past when fewer countries allowed optometrist to use mydria4c drugs
21 Monocular Indirect Ophthalmoscopy Manufacturer: Welch Allyn Increased field of view & magnifica4on Increased working distance Hand held but less portable
22 Monocular Indirect Ophthalmoscopy Advantages Allows a five 4mes greater area View beyond the equator Can be used with children Monocular clinicians Disadvantages Monocular= 2D Image is inverted Rela4vely low magnifica4on 5x Limited view of peripheral and macula
23 Why do we dilate pupils?
24 Binocular Indirect Ophthalmoscopy Quick and thorough assessment of the entire fundus Headband BIO + 20D aspheric condensing lens
25 Binocular Indirect Ophthalmoscopy Fundus abnormali4es in the peripheral re4na missed with direct or indirect monocular ophthalmoscopy: Re4nal holes Tears and re4nal detachments Intrare4nal haemorrhages Exudates and infarcts Neovascularisa4on Re4nal degenera4ons Vitreore4nal trac4on Naevi and tumours
26 Binocular Indirect Ophthalmoscopy Advantages: Disadvantages: Wide field of view (en4re fundus, periphery and vitreous) Provide stereopsis Simultaneous viewing of eight disc diameters (35 ) Easy localiza4on of lesions (large field of view) Improved view through media opaci4es Pa4ent ametropia does not affect the view Requires more skills Decreased magnifica4on (3x) Requires dila4on Inverted image Pa4ent should be placed in a supine posi4on Poten4al light toxicity with prolonged exposure
27 Binocular Indirect Ophthalmoscopy
28 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
29 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)
30 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
31 Binocular Indirect Ophthalmoscopy
32 Binocular Indirect Ophthalmoscopy
33 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
34 Fundus Biomicroscopy Field of View & Mag: FOV <indirect but >direct varies w/lens & slit lamp mag Inverted image Stereopsis Dilated pupil Requires skill
35 Slit Lamp Aspheric Biomicroscopy Indirect Fundus Lenses double aspheric lens +90D, +78D, +60D, super field, etc magnification increases as power of the lens decreases slit lamp biomicroscope permits variable magnification which neutralizes this magnification problem
36 Lens specifications Lens Volk 60D Volk 78D Volk 90D Magnifica%on 1.15x.93x.76x Field of View (Sta%c/ Dynamic) 68 /81 81 /97 74 /89 View Other indirect 13mm working distance; high mag ideal for detailed ONH and macula indirect 8mm working distance; good compromise b/ w FOV and mag indirect 7mm working distance; ideal for small pupil examina4on
37 Lens specifications Lens Magnifica%on Volk SuperPupil XL.45x Volk Super Vitreofundus Volk Digital Wide Field Volk Digital 1.0x.57x.72x 1.0x Field of View (Sta%c/Dynamic) 103 / / / /72 View Other indirect Op4mal small pupil capability through a pupil as small as 1-2mm indirect Wide field, pan re4nal examina4on and small pupil capability (3-4mm) indirect High resolu4on with a wide field of view (past vortex) indirect Ideal for op4c disc measurements and macula
38 Lens specifications Imaging Lens slit lamp photos Volk Digital High 1.30x Mag Ocular Instruments Osher MaxField 78D.77x Ocular Instruments.50x MaxField 120D 57 /70 98 / /173 indirect High resolu4on, high magnifica4on imaging of the central re4na indirect Wider field of view compared to a classic 78D lens indirect Wide field, pan re4nal examina4on and small pupil capability (2mm)
39 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
40 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.)
41 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
42 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
43 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
44 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
45 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
46 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
47 Slit Lamp Aspheric Biomicroscopy procedure Interpreta%on The image provided in each of the above lenses is inverted and laterally reversed Clinical Pearls Pa4ent 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
48 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
49 Viewing the Optic Nerve Head
50 Contact Fundus Lens
51 Contact Fundus Lens Clinical uses Enhancing view of macula 1) Edema in diabe4c, ARMD, or POHS 2) Epire4nal membrane 3) Macular hole 4) Cystoid macular edema Dilated fundus examina4on in an uncoopera4ve or photophobic pa4ent To obtain a more magnified view of a peripheral re4nal lesion noted during BIO
52 Contact Fundus Lens Contraindica4ons: Severe corneal trauma Penetra4ng ocular injury Severe anterior segment infec4on Hyphema
53 Contact Fundus Lens Lens Magnifica%on Volk Fundus 20mm (with flange) 1.44x Ocular Instruments Yannuzzi Fundus Lens.93x Ocular Instruments Fundus Diagnos4c Lens Central lens of 3- mirror1.93x Volk High Resolu4on Centralis Volk Equator Plus Volk High Resolu4on Wide Field Field of View (Sta%c/ Dynamic) 25 / x 74 /88 Flange helps provide stability of lens on cornea Flange helps provide stability of lens on cornea The flat front surface of this contact lens provides a direct image of the posterior pole 15mm contact diameter; No flange op4on is ideal for use on infants or pa4ents with narrow palpebral fissures direct 0.5x Other direct 1.06x 1.08x direct 3 mirrors: (Volk 60 /66 /76 ) (Ocular Instruments 59 / 67 /73 ) 0.44x View direct High magnifica4on and resolu4on of posterior pole Lens of choice in eyes with poor dila4on (can be used in pupils as small as 3mm) Extreme peripheral re4nal examina4on indirect 114 /137 indirect 160 /165 indirect
54 Contact Fundus Lens Requires physical contact w/eye Viewed w/ Biomicroscope Advanced dx & surgery Field of view & Mag vary w/lens design
55 3 Mirror gonio fundus lens
56 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)
57 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)
58 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
59 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 Pa4ent s gaze can be altered in order to maximize view of given area
60
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