With this, the book has come to an end of the basics of fundoscopy. The author did not touch on certain aspects such as fibrosis in retinal detachment but nevertheless important once you have grasp the basics in this book. This book does not intend to replace any textbook in fundoscopy teachings, thus readers are advised to read up more from recommended Ophthalmology textbooks. Last but not least, enjoy your fundoscopy experience!!

Credits:

1.Jack J.Kanski. Clinical Ophthalmology A Systematic Approach. 6th edition 2007.

2.Jack K Kanski, Ken K Nischal. Ophthalmology – Clinical Signs and Differential Diagnosis. 1999

3.Jane Oliver, Lorraine Cassidy. Opthalmology at a Glance. 2005.

4.Prof. Dr Che Muhaya Hj Mohamad. Ophthalmology Checklist for Undergraduates. Universiti Kebangsaan Malaysia (National University of Malaysia)

5.Dr Faridah Hanom Annuar

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EXTRAS: Systematic Ophthalmic Examination

In a systemic ophthalmic examination, there are 5 essential components to perform, which includes:

1.Visual Acuity

2.External Eye Examination

3.Extraocular Movements

4.Visual Field Test

5.Fundoscopy

Visual Acuity

There are 2 aspects of the visual acuity which should be tested for, namely the distance and the near vision.

Distance vision should be formally done with a Snellen Chart or its equivalent for pediatric cases, at 6 meter. If the acuity is too poor, let the patient try reading at 5 meters instead. For worse cases, try shining a pentorch from the peripheral retina, to test for light perception. In cataract, light perception is usually preserved.

Near vision can be tested with a Test Chart at 15 inches or 33cm away from the eyes.

External Eye Examination

From general inspection, look for any ptosis, symmetry of the face particularly the eyelids or any obvious changes which have include discoloration of the sclera or a serious red eye. This can be done as soon as your patient steps into the clinic!

1.Lids

The upper lid should cover around 1mm of the upper limbus. Lower lid should cover just at the lower limbus.

Palpebral aperture should be normal and look at the lashes for possible malalignment for trichiasis. A normal lash should be pointing anteriorly and laterally.

Look for the margins for lumps, bumps and any pigmentation.

2.Conjunctiva

The conjunctiva consist of the palpebral, fornix and bulbar conjunctiva. Inspect each side closely.

look for any papillae, follicles, dilatation of vasculature (injection) or subconjunctiva hemorrhage.

Next would be the Anterior Segment which consist of cornea, anterior chamber, pupil/iris and the lens.

3.Cornea

Looks at the shape of the cornea which should be round and equal size. A sharp and pointy cornea is suggestive of keratoconus.

The cornea should be clear and avascular.

Look out for any sutures or scar especially at the superior cornea for signs of previous cataract surgery.

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4.Anterior chamber

Inspect the content of the anterior chamber, whether if it is clear, hypopyon or hyphaema.

Shine a torch perpendicular to the limbus from the lateral aspect and observe the shadow to gauge the depth of anterior chamber. A deep anterior chamber should have no shadow at the medial iris.

5.Pupils/Iris

The pupils should be equal, round and central. The color of the iris should be same for both eyes, otherwise it would be heterochromis iridis.

Look out for any previous scars suggestive of peripheral iridectomy or iridotomy!

6.Lens

Check for red reflex if possible. Shining a torch at the lens may show a dislocated lens or sometimes an intraocular lens in the anterior chamber.

Shine a light at the cornea through the pupil. Pseudophakic patients may reveal an obvious double light reflex, a second glistening reflex.

*Note: There are a total of 4 light reflexes from the eye media when the light is shone thorugh the media. However, only 3 is seen at most usually, and only 1 is obvious as you manouver the light source in a circular motion.

Extraocular Movement

Extraocular movement is only done in certain patients most of the time. It is not aroutine examination, thus you won’t see such examination done in a patient on diabetic retinopathy follow up.

Indications for such a test include:

•Symptoms of double vision (diplopia)

•Strabismus

•Patients with also neurological problems

•History of trauma to the orbit

There are 2 methods to test for extraocular movement:

i.Bisected H

The typical H shape drawn in the air with a target object (pentop or finger). Be sure to not exceed the patient’s visual field, otherwise you may course a physiological nystagmus!

Bisected H pathway for extraocular movement

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ii.“Union Jack”

This is a test using a pentorch with the light directed at both eyes. With this, the corneal reflex can be observed while doing the extraocular test, which can rule out pseudosquint if present. This method use a different pathway but applying the same principles as the bisected H.

Pathway for the “Union Jack” extraocular movement test

*Note:

•Test for accomodation as well by bringing the target to around 20 cm from the patient’s eyes and observe the pupil constriction.

•remember to gently pull up the eyelid as the patient looks at the bottom to have a clear view of the eyeball positions.

•Always ask the patient if they see any double vision during the extraocular movement test.

•Know the muscles involved in each eyeball movement and the supplyiong cranial nerves.

The muscles movements are: Abduction adduction, elevation depression, intorsion, extorsion.

Visual Field Test

This can be done with a confrontation test (1 meter apart) with a white neuropin. Peripheral vision utilizes rods which is predominant in peripheral retina, thus it detects black and white, not color.

Remember to bring the neuropin all the way to the center from the peripheral. You might miss a scotoma defect if you stop at the peripheral once the patient sees the target!

Blind spot should also be tested with a red neuropin. This is due to the fact that the blind spot is enlarged in disc edema. As the macula is near to the optic disc (blind spot area in your eye), color acuity is the best, thus red pin is used instead of white.

Move around the blind spot once you found it. Move up or down to check if it is enlarged, and make sure that the reason the patient can’t see the target is not because it is beyond his visual field’s limit!

Fundoscopy

Fundoscopy is the last part of the examination, and it has been described in the early section of the book. Thus, I am sure you would have no difficulty in doing this.

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