Fundoscopy Made Easy

Fundoscopy Made Easy
2010
Apr. 15
2010

WONG YEE MING
Medical Student, 5th Year, 2010/2011
National University of Malaysia.
© 2010 by medicalpblukm.blogspot.com
1st edition, June 2009
2nd edition, July 2009
3rd edition, April 2010
This is an open project meant to be shared in any form of publication,

regardless of being reproduced, stored in a retrieval system, or transmitted, in
any form or by any means, electronic, mechanical, photocopying, recording or
otherwise from the author at kong1ming2@gmail.com. Credits should be
given to medicalpblukm.blogspot.com.
The author welcomes and appreciates feedbacks and reviews of this project in the effort to
improve this book in the spirit of information sharing, as well as notifications of usage of this
project in any form. Feel free to e‐mail the author at kong1ming2@gmail.com.
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Acknowledgements
The 3rd edition of this Fundoscopy Made Easy reflects a continued
improvement on the previous editions. The changes that have been made are
largely from comments and suggestions by students, as well as review by a
senior lecturer and ophthalmologist Dr. Then Kong Yong who have taken time
to tell us what they like about the book and how it can be further improved.
We understand that this book is far from being perfect, and the flaws are
corrected as time goes by, which is why we try to incorporate the comments,
suggestions and feedback into this improvised edition.
Specifically, we owe our thanks to the following reviewers: doctors, students
and faculty who spent considerable time to provide us with correction,
suggestions, improvements and to make this possible. They were gladly the
source of inspiration in the continuation of this project to its 3rd edition:
Dr. Then Kong Yong

Senior Lecturer
Ophtalmology Consulting Specialist (Cornea)
University Kebangsaan Malaysia Medical Center
Kuala Lumpur, Malaysia
Jeffrey Lee Soon Yit, MS

Lee Cun Coon, MS

Boey Ching Yeen, MS

2010
Table of Contents
Preface................................................................................. 6
The Tool – Direct Ophthalmoscope ....................................... 7
Note from the Author .......................................................... 9
The Fundus Mapping........................................................... 10
Fundoscopy Steps ............................................................... 12
1. Optic Disc Abnormalities ................................................. 14
2. Macular abnormalities .................................................... 21
3. Retinal Vessels Abnormalities ........................................ 26
4. Retinal findings .............................................................. 28
Credits: ............................................................................... 36
EXTRAS: Systematic Ophthalmic Examination ................... 37
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Preface
This open project book is intended for medical students who are newly
exposed to the use of the direct ophthalmoscope. Over the years, basics in
fundoscopy has form an essential part of the medical field. However, little has
been written specifically to teach the younger generation on how to appreciate
through the eyes of the fundoscope. For what the mind does not know, the
eyes could not see. And yet, the eyes hold the 8th wonder of the world, being
the only place in our bodies where we can look in awe at the living pulses of the
blood vessels in our bodies. But first, we as students would need to be exposed
and taught of the ways of the fundoscope, and what we can see and expect.
We need to be guided in our pursue of perfection, and to tell us that, there is
more than meets the eye.
Being one of the many medical students who had struggled from such
experience, this book is written with medical students in mind, to help them to
master the fundamentals. That is, before they could proceed to appreciate the
abnormalities and pathology in the eyes which would never fail to mesmerize
those who could see it. We are incredibly grateful to everyone who made this
book a reality.
Wong Yee Ming
Kuala Lumpur, 2010
2010
The Tool – Direct Ophthalmoscope
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Apertures and Filters

There are various apertures and filters in the indirect
ophthalmoscope, but beginners may require only a certain few.
However, here is a general breakdown of the use of each aperture
and filter:
Small Aperture: For easy view of fundus through the undilated

pupil. Always start with this while looking at the fundus.
Large Aperture: Standard aperture for dilated pupil and general

examination of the eye, particularly the red reflex.
Sm Micro Spot Aperture: Allows easy entry into very small,

undilated pupils.
Slit Aperture: Helpful in determining various elevations of
lesions, particularly tumors and edematous discs.
Fixation Aperture: The pattern of an open center and thin lines
permits easy observation of eccentric fixation without masking
the macula.
2010
Note from the Author

Before you conduct a direct fundoscopy, be realistic in your aims and
know that practice makes perfect. Nothing beats experience in
fundoscopy, even if you are a genius. But of course, do know your
fundoscopy steps prior to the examination. You might not want to
blind your volunteering patient with your initially wobbly techniques!
Now, I’m sure most of you medical students would have been too
enthuasistic on looking at the fundus, having seen many pictures in
the books. Do note that fundoscopy pictures in the books are taken
with indirect ophthalmoscope which have a wider view. Therefore,
tracing is required in direct fundoscopy before you get a full picture
of the fundus.
A view of indirect fundoscopy of a normal fundus (on the left) with a highlighted
area of focus of direct fundoscopy in the box(on the right).
With this in mind, do not panic if you do not find the optic disc on
your first try. All you need is a clear and calm mind, and this book is
here to guide you for an enjoyable experience in your use of
fundoscopy.
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The Fundus Mapping
The major landmarks of the fundus:

1. Optic disc
• the point where the optic nerve enters the retina. This is the
blindspot area of your eyes. In the optic disc is a cup which is
usually present.
• normal vertical cup disc ratio : 0.1‐0.3
o (pathological changes are suspected if > 0.6)
• the cup is usually at/ near the central of the optic disc, while
the crowding of vessels are always on the nasal side of the
optic disc.
• this knowledge is useful to identify which side is the eye(left or
right).In most pictures from indirect fundoscope, the optic disc
is shown on the nasal aspect, making it easier to identify them.
2010
2. Macula
• the pigmented area of the retina which is rich in cone
photoreceptors and is responsible for clear detailed
vision.
3. Fovea
• a small rodless area of the macula that provides acute
vision.
• the foveal light reflex should be seen particularly in a
young healthy adult as a rim of light around the fovea.
4. Vessel branches
• There are 4 main branches of vessels from the optic disc.
Each branches off into different directions, mainly
superonasally, superotemporally, inferonasally, and
inferotemporally.
• In the normal variation, the macula is devoid of retinal
vessels, thus it is supplied from the branches of
superotemporal and inferotemporal vessels.
• One should remember the embryonic development of
retinal vessels which arise from the optic disc, towards
the nasal aspect at 8 months of gestation and temporally
at 10 months (approximately 1 month neonatally). This is
important to understand the concept of retinopathy of
prematurity!
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Fundoscopy Steps
Fundoscopy should be done optimally in a dark or dimmed room.
Such preference is essential to keep the pupil as dilated as possible.
Alternatively, topical drops can be given to dilate the eyes if there is
no contraindications.
1. Fundoscopy should be done on the same side for the patient
and you, as the examiner. This being said, the examiner should
hold the fundoscope with his right hand, while his right eye
should be examining the patient’s right eye. This would avoid
both of you rubbing noses! Do remember to rest your other
(free) hand on the patient’s forehead, also to prevent you two
from knocking heads!
2. Start about an arm’s length away with the illuminated lens disc
at +4.00 ‐ +10.00 d (usually green positive) lens using the large
aperture. However, this may also depends on whether you are
wearing your glasses, so do experiment to get used to it.
3. Illuminate both of the patient’s eyes to enable you to observe
the red reflex of the patient and to examine for any media
opacities (cataract, corneal scars, large floaters).
4. Select “0” on the illuminated lens disc and start with the small
aperture as you approach the patient while fixing the “red
reflex” pupil as your target. Remember to ask the patient to
look straight at a distance to maintain pupil dilation.
5. Tilting slightly at 15‐25o lateral to the patient, move forward as
you direct the light beam into the pupil. The optic disc should
be within view as you are about 1‐2 inches from the patient’s
eye. remember that the optic disc is slightly towards the nasal
aspect of the fundus.
6. Do not panic if you do not see the optic disc initially. Look for a
nearby retinal blood vessels. You’ll most likely find the optic
disc by tracing at either one “end” or the other of the vessel.
This is due to the developmental fact that retinal vessels branch
from the optic disc to the peripheral retina.
2010
7. The optic disc may not be focused as you see it, as

hypermetropic patients require more “plus” (green numbers)
lenses for clear focus of the fundus while myopia patients
require more “minus” (red numbers).
8. Examine the optic disc for (the 4C’s):
• color (pink, pale, hyperemia, etc)
• contour (margin, shape, elevation, etc)
• cup‐disc ratio (compare the vertical diameters)
• caliber of vessels (normal AV ratio around 2:3)
‐ the AV ratio mentioned is measured from the width of
the vessels before the 3rd bifurcation from the origin on
the optic disc..
9. Follow each vessel as far to the periphery as you can and look
for any abnormalities such as venous dilatation, AV nipping,
etc.
10. To examine the periphery, ask the patient to:
• Look up for examination of the superior retina
• Look down for inferior retina
• Look temporally for temporal retina
• Look nasally for nasal retina.
11. Lastly, locate the macula which is approximately 2 disc
diameters temporally from the optic disc, between the
superotemporal and inferotemporal vessels. Or you can ask
the patient to look at the light of the ophthalmoscope, which
would put the macula in good view. Look for abnormalities.
Red filter facilitates the view of macula.
12. For the examination of the left eye, the same procedure can
be repeated, but with left hand and left eye on the left side.
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1. Optic Disc Abnormalities

Disc Swelling
i. Disc swelling is a sign, not a diagnosis.
ii. It is essential to test the optic nerve function in all cases of
disc swelling.
iii. Tests for optic nerve function includes:
1. Visual acuity
2. Pupil response
‐ direct reflex
‐consensual reflex
‐ relative afferent pupillary defect (RAPD)
3. Visual field
4. Color vision (Red desaturation)
iv. Important causes of optic disc swelling(Disc edema) may
include:
• Optic Neuritis
• Papilloedema
• CRVO
• AION
*The term ‘papilloedema’ is usually reserved for bilateral disc
swelling (as it is a result of increased intracranial pressure). Thus,
check the other eye for optic disc swelling before coming to a
conclusion of papilloedema!
*Cases of unilateral papilloedema are very rare.
2010
v. Papilloedema vs Optic Neuritis

Papilloedema Optic Neuritis
Definition Passive swelling of Inflammation of the optic
the optic disc nerve.
secondary to 2 ypes of optic neuritis:
increased intracranial a. Papillitis
pressure. Optic disc is swollen
Eg. Space Occupying b. Retrobulbar neuritis
lesion, meningitis, Normal appearance
beingn intracranial of disc
hypertension (BIH)
Unilateral/ Usually Bilateral Usually Unilateral
Bilateral
Pain on eye No Yes
movement (Rectus contraction pulls
on optic nerve sheath)
Visual Transient obscuration Reduced
Acuity – mostly normal until
late stage
Pupil Normal, no RAPD Positive RAPD in unilateral
reaction cases
Visual field Enlarged blind spot Central or paracentral
scotoma
Color vision Usually normal Red desaturation
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Quick Reference: Causes of disc swelling:

Unilateral Bilateral
Vascular: eg. AION, CRVO or Raised intracranial pressure:
diabetic papillopathy SOL, hydrocephalus, Benign
Intracranial Hypertension (BIH)
Inflammatory: “papillitis”, eg. Malignant hypertension
uveitis, sarcoidosis, viral, SLE
Demyelination: MS‐ may become Diabetic papillopathy

bilateral
Hereditary: Leber’s Hereditary Infiltrative papilloedema:
Optic Neuropathy lymphoma
Infiltrative: tumors such as Toxic: ethambutol,
retinoblastoma, lymphoma chloramphenicol uremia
Infective: Toxoplasmosis, herpes,
Lyme’s disease
2010
Optic Atrophy (Figure 1.1)

Optic atrophy is the final common morphologic endpoint of any
disease process that causes a loss of optic nerve fibers at the optic
nerve head.
Optic atrophy is actually a misnomer; in the strict histologic
definition, atrophy refers to involution of a structure resulting from
prolonged disuse.
• Clinical Findings:
a. Poor visual acuity
(Severity depending on degree of optic atrophy)
b. Reduced Color Vision
c. Visual field defect (depending on cause)
d. Positive RAPD (unilateral cases)
e. Pale optic disc
Figure 1.1 Optic Atrophy

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Common Causes of Optic Atrophy
a. Pressure/ Traction: Glaucoma, Papilloedema

b. Hereditary: Autosomal dominant optic atrophy, autosomal
recessive optic atrophy, Leber’s hereditary Optic Atrophy
c. Vascular: Central Retinal Artery Occlusion, Antrior ischemic
optic atrophy (acute phase)
d. Retinal dystrophy: Cone dystrophy, Retinitis Pigmentosa
e. Nuttritional/Toxic: Vitamin B deficiency
f. Inflammatory: Sarcoidosis, polyarteritis nodosa
g. Demyelination: Multiple Sclerosis
h. Compresive: Optic nerve glioma or meningioma
2010
Glaucomatous optic neuropathy (Figure 1.2)

Findings:
a. Increased Cup/Disc ratio (Normal: 0.1‐0.3) (Abnormal > 0.6)
b. Nasalization/Bayonetting of vessels in the optic disc
Bayoneting – double angulation of vessels as it “climbs” from the the cup of the optic
disc
Nasalization‐displacement of the vessels from center to the nasal aspect of the cup
in the optic disc.
c. Lamellar dots (multiple gray dots scattered on cup of optic disc)

‐caused by exposure of lamina cribosa due to loss of neuroretinal tissue (seen in
advanced glaucomatous stage)
d. Very deep cup

*not all enlarged cup means glaucoma
Figure 1.2 Glaucoma
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Optic Disc Neovascularization (Figure 1.3)

• Disorganized arcades of vessels seen on optic disc
• Can be shaped as fronds, with thin and fragile vessels
• Neovascularization may involve just the peripheral as well, and
may assume the shape of a “seafan”
• Common causes of disc neovascularization:
1. Advanced Diabetic Retinopathy
2. Central Retinal Vein Occlusion
3. Ocular Ischemic Syndrome
Figure 1.3 New vessels formation on optic disc

Notice the disorganized tiny vessels on the nasal side of the optic disc, forming a massive
frond‐like stuctures.
2010
2. Macular abnormalities
Macular edema
• Result of increased fluid and protein deposits within the

neuroretina in the macula.
• Swelling may distort the central vision, as the macula is near
the center of retina.
• May be differentiated into cystoid and non‐cystoid.
*It is hard to differentiate between cystoid and non‐cystoid with a direct
ophthalmoscope, hence hard exudate seen around the macular region is usually used as
an indicator of macular edema.
Figure 2.1 ‐ Left: Hard exudate formation around the macula (Non‐cystoid)
Right: Thickening of fovea associated with microcyst (Cystoid)
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• Causes of macular edema may include:

i. Retinal vascular disease (Background diabetic
retinopathy, retinal vein occlusion)
ii. neovascularization
iii. retinitis pigmentosa
iv. age‐related macular degenration (ARMD)
v. hypertensive choroidopathy, malignant arterial
hypertension
vi. iatrogenic (eye surgery, eg: retinal detachment surgery,
retinal cryotherapy)
2010
Stellate Maculopathy (Figure 2.3)
• Retinal hard exudates forming a macular star

• Frequently associated with optic disc swelling
• Causes:
o Hypertension – bilateral
o Papilloedema – bilateral (may be assymetrical)
o Neuroretinitis (usually unilateral)
o Capillary angioma, may be on the optic disc or at the
periphery, is associated with macullar star.
Figure 2.2 Macular Star
Diabetic Maculopathy
• Poor near vision, not corrected by Plus lenses

• Usually assymetrical
• The commonest cause for poor vision in diabetes patients is
macular edema especially in NIDDM.
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Cherry Red Spot (Figure 2.4)
• An obvious red round spot of the fovea surrounded by a

concentric area of pale retinal background.
• Causes: Central retinal artery occlusion (acute phase), and GM2
gangliosidoses particularly Tay‐Sachs disease.
Figure 2.4: Cherry Red Spot in

central retinal artery occlusion(left) and Tay‐Sachs disease(right)
Note the much paler background of the retinal in CRAO
*In CRAO, giant cell arteritis (GCA) should be considered in patients

older than 65 years, but do not ignore in younger patients.
2010
*Central Serous Retinopathy (Of interest) – Figure 2.5
• Localized detachment of sensory retina at the macula

secondary to focal RPE defects.
• Self‐limiting, usually affecting young/middle‐aged men with
Type A personality.
• Sub‐retinal fluid around macula (elevation as indicated by the
“climb” by vessels on macula.
Figure 2.5 Central Serous Retinopathy
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3. Retinal Vessels Abnormalities

Normal Artery to Venous (A‐V) ratio is 2:3
Reduced in:
• Aging
• Hypertension
• Old CRAO (due to attenuated arterioles)
Retinal Vasculitis (Figure 3.1)
• Vasculits may affect veins (periphlebitis) or arteries

(periarteritis)
• Active vasculitis is characterized by fluffy white haziness
(cuffing) of the vessels column.
Figure 3.1 Examples of retinal vasculitis

2010
Common Causes of Major Changes in Vascular Caliber

Arterial attenuation Venous dilatation and/or
• Systemic hypertension tortuosity
• Retinal artery occlusion • Retinal vein occlusion
• Diffuse retinal disease • Non‐proliferative diabetic
(Retinitis pigmentosa) retinopathy
Combined venous and arterial • Hyperviscosity syndrome
dilatation and tortuosity • Ocular ischemic syndrome
• Retinopathy of prematurity • Inherited venous beading
• Retinal capillary
hemangioma
• Retinal racemose
hemangioma
Figure 3.3
Figure 3.2
Arterial attenuation in advanced retinitis Venous beading and dilatation along with new
pigmentosa vessels formation on disc (Proliferative Diabetic
Retinopathy)
Figure 3.4
Arterial and venous tortuosity in racemose
hemangioma
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4. Retinal findings
Retinal hemorrhages
i. Superficial
Flame shaped hemorrhages (Figure 4.1)
• bleeding near the surface of retina in nerve fiber
layer
• follows nerve fiber, giving flame‐shaped appearance
• located usually in relation to optic nerve head or
posterior pole, seldom in peripheral retina where
nerve fiber layer is thin.
• causes: retinal vein occlusion, diabetic retinopathy,
optic nerve disease (acute papilloedema, anterior
ischemic optic neuropathy), retinal periphlebitis
Figure 4.1 Flame‐shaped hemorrhage
Notice the unidirectional smudge‐smear like of the hemorrhage, forming the characteristic
flame appearance.
2010
ii. Deep
Dot and blot hemorrhages (Figure 4.2)
• bleed from deep retinal capillaries
• dot hemorrhages are small round and with uniform
density
• blot hemorrhages are larger, with irregular shape and
density, forming an irregular patch of bleeding, and
darker in color
• dots and blots are mostly found in the peripheral retina
where retinal nerve fiber is usually thinner
• causes: retinal vein occlusion, non‐proliferative diabetic
retinopathy, ocular ischemic syndrome
Figure 4.2 A clear cut dots and blots hemorrhage appearance
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Preretinal Hemorrhage (Figure 4.3)

Also known as: Subhyaloid hemorrhage
• Bleeding on the surface of retina, between the retina and

hyaloid membrane of vitreous
• Usually solitary and located at the posterior pole
• Well defined margin with vessels sometimes seen crossing
BELOW the hemorrhage area. (Not over the hemorrhage)
• Initally round but later settle with gravity, giving the “boat‐
like” apperance due to pooling of the blood.
• Causes: Proliferative retinopathy, retinal artery
macroaneurysm, wet ARMD, choroidal neovascularization,
trauma
Figure 4.3 Preretinal hemorrhage

A round preretinal hemorrhage (left) with vessels seen crossing below it. The picture on the
right show a large preretinal hemorrhage which settled into a boat‐like appearance or
pooling of blood.
2010
Subretinal Hemorrhage (Figure 4.4)
• Bleeding between the photoreceptors and retinal pigment

epithelium
• Usually large and bright red with indistinct margin
• Vessels are clearly seen ABOVE the hemorrhage (not below the
hemorrhage)
• Causes: choroidal neovascularization, retinal tear, Coat’s
disease, sickle cell anemia, blunt trauma
Figure 4.4 Subretinal hemorrhage

Note that the vessels are crossing above the hemorrhage area.
Key Points
Retinal hemorrhage Superficial: Flame‐shaped
Deep: Dots and blots
Preretinal hemorrhage Blood vessels cross BELOW the hemorrhage area
Subretinal hemorrhage Blood vessels cross ABOVE the hemorrhage area
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Cotton Wool Spots ( Figure 4.5)
• Represents microinfarction of the nerve fiber layer of the retina

• Consist of axoplasmic debris
• small, white, superficial lesions with indistinct margin, giving it
a fluffy appearance of cotton wool .
• Causes: Retinal vein occlusion, non‐proliferative diabetic
retinopathy, vasculitides (SLE, scleroderma), hypertensive
retinopathy, AIDS microvasculopathy, microembolic retinal
artery occlusion
Figure 4.5 Cotton Wool Spots

2010
Hard Exudates ( Figure 4.6)
• Leakage of high protein and lipid due to break in blood retinal

barrier
• Yellowish glistening intraretinal lesion, usually with a well‐
defined margin.
• Commonly seen in any conditions that are associated with
chronic vascular leakage , such as::
1. Diabetic retinopathy
2. Hypertensive retinopathy
3. Choroidal neovascularization
Figure 4.6 Hard Exudates

Notice the picture on the right where a circinate ring is being formed.
*In fundus with massive hard exudates, check the patient’s lipid profile
for hypercholesteremia. It is essential to control the cholesterol level as
well!
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Drusen (Figure 4.7)

• Drusens are yellowish deposits external to neuroretina and
retinal pigment epithelium.
• It may be well‐defined and small (hard) or ill‐defined (soft).
• Drusen may be discrete or confluent (coalesce with one
another) and usually are the hallmarks of age‐related change.
• Drusens can occur anywhere, in the peripheral retina or macula,
but those occuring at the macula are the ones with clinical
significance as they may be related to central visual loss..
• Association: Age‐related macular degeneration (ARMD),
autosomal dominant drusens (ADD
Figure 4.7 Drusens on the macular area

2010
Tigroid retina /fundus (Figure 4.8)
• A normal fundus to which a deeply pigmented choroid gives

the appearance of dark polygonal areas between the choroidal
vessels, especially in the periphery. Causes: Highly myopic eyes
or racial variations.
• Sometimes, it refer to the lacking pigment so that underlying
choroid vessels are visible as irregular stripes. Causes: albinism
• The dark stripes at the background resemble the tiger stripes,
which therefore give rise to its name: Tigroid fundus
Figure 4.8 Tigroid fundus
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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. E‐Medicine specialties: Ophthalmology,
http://emedicine.medscape.com
5. Digital Reference of Ophthalmology, Edward S. Harkness Eye
Institute. http://dro.hs.columbia.edu/index.htm
6. Prof. Dr Che Muhaya Hj Mohamad. Ophthalmology Checklist for
Undergraduates. Universiti Kebangsaan Malaysia (National
University of Malaysia)
7. Dr Zaid Shalchi. Eyes Made Easy.http://eyesmadeeasy.net
8. Dr Faridah Hanom Annuar, our supervisor who had inspired us to
work hard and was always there to guide us in our lessons.
2010
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, check
for counting fingers and hand movement.Then, 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.
*Vision should be checked with and without glasses and pinhole

glasses.
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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.
2010
Next would be the Anterior Segment which consist of cornea,

anterior chamber, pupil/iris and the lens.
3. Cornea
• Looks at the size(normal adult diameter 10‐13mm) and
shape of the cornea which should be round and equal size.
• Sharp and pointy cornea is suggestive of keratoconus.
• The cornea should be clear and avascular.
(A generalized cloudy cornea is suggestive of corneal
edema)
• Look out for any sutures or scar especially at the superior
cornea for signs of previous cataract surgery.
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!
• Pupillary reflex may be examined, the direct light reflex,
consensual light reflex and relative afferent pupillary defect.
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6. Lens
• Check for the eye’s 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.
• Also, check for the presence of cataract if the red reflex is
absent. The cataract can be anterior subcapsular, posterior
subcapsular, nuclear sclerosis or cortical cataract.
Note: There are a total of 4 light reflexes from the eye media
when the light is shone thorugh the media (cornea and lens).
However, only 1 can be obviously seen as you manouver the light
source in a circular motion.
Summary:
External Eye Examination:

Lids + conjunctiva + Anterior Segment
= Lids + conjunctiva + (Cornea + Anterior Chamber + Pupils/Iris + Lens)
Anterior Segment Examination:
Cornea + Anterior Chamber + Pupils/Iris + Lens
2010
Principles of RAPD (Relative Afferent Pupillary Defect)
RAPD
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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 range of
vision, otherwise you may cause 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 light reflex can be observed while
doing the extraocular test, which can rule out pseudosquint if
present.
This method use a different pathway but applies the same
principles as the bisected H.
Pathway for the “Union Jack” extraocular movement test
The actions of the IIIrd, IVth and VIth nerves on the eye movements of the right
eye. III= Oculomotor, IV=trochlear, VI= abducent
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*Note:
• Test for accomodation as well by bringing the target to around

20 cm from the patient’s eyes and observe the pupil
constriction and eye convergence.
• remember to gently pull up the eyelid as the patient looks
down to have a clear view of the eyeball positions.
• Observe for the smoothness(smooth pursuit) of the eye
movement as it follows the moving target. They can be smooth
or jerky.
• Always ask the patient if they see any double vision during the
extraocular movement test.
• If there is limitation of the eye movement, you may try
occluding the normal eye. That way, you may test if the defect
is vergence or version.
• Know the muscles involved in each eyeball movement and the
supplying cranial nerves.
The eye muscle movements are:
Abduction‐adduction
Elevation‐depression
Intorsion – extorsion
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Visual Field Test

• This can be done with a confrontation test (1 meter apart and
on the same level with the patient) with a white neuropin.
Peripheral vision utilizes rods which is predominant in
peripheral retina, thus it detects black and white, not color
vision.
• Make sure the patient could see in each eye before testing for
visual field.
• Remember to bring the neuropin all the way to the center from
the peripheral. You might miss a scotoma defect or a central
visual defect !
• 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!
Red pin is also used to test for optic nerve

function by checking for red desaturation in
all 4 quadrants of the visual field.
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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2010
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Fundoscopy Made Easy

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Fundoscopy Made Easy

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Fundoscopy Made Easy

Fundoscopy Made Easy

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Dr. Then Kong Yong

Jeffrey Lee Soon Yit, MS

Lee Cun Coon, MS

Boey Ching Yeen, MS

The Tool – Direct Ophthalmoscope

Apertures and Filters

Small Aperture: For easy view of fundus through the undilated

Large Aperture: Standard aperture for dilated pupil and general

Sm Micro Spot Aperture: Allows easy entry into very small,

Note from the Author

The Fundus Mapping

The major landmarks of the fundus:

7. The optic disc may not be focused as you see it, as

1. Optic Disc Abnormalities

v. Papilloedema vs Optic Neuritis

Quick Reference: Causes of disc swelling:

Demyelination: MS‐ may become Diabetic papillopathy

Optic Atrophy (Figure 1.1)

Figure 1.1 Optic Atrophy

Common Causes of Optic Atrophy

a. Pressure/ Traction: Glaucoma, Papilloedema

Glaucomatous optic neuropathy (Figure 1.2)

c. Lamellar dots (multiple gray dots scattered on cup of optic disc)

d. Very deep cup

Figure 1.2 Glaucoma

Optic Disc Neovascularization (Figure 1.3)

Figure 1.3 New vessels formation on optic disc

• Result of increased fluid and protein deposits within the

• Causes of macular edema may include:

Stellate Maculopathy (Figure 2.3)

• Retinal hard exudates forming a macular star

Figure 2.2 Macular Star

• Poor near vision, not corrected by Plus lenses

Cherry Red Spot (Figure 2.4)

• An obvious red round spot of the fovea surrounded by a

Figure 2.4: Cherry Red Spot in

Note the much paler background of the retinal in CRAO

*In CRAO, giant cell arteritis (GCA) should be considered in patients

*Central Serous Retinopathy (Of interest) – Figure 2.5

• Localized detachment of sensory retina at the macula

Figure 2.5 Central Serous Retinopathy

3. Retinal Vessels Abnormalities

Retinal Vasculitis (Figure 3.1)

• Vasculits may affect veins (periphlebitis) or arteries

Figure 3.1 Examples of retinal vasculitis

Common Causes of Major Changes in Vascular Caliber

Figure 4.1 Flame‐shaped hemorrhage

Figure 4.2 A clear cut dots and blots hemorrhage appearance

Preretinal Hemorrhage (Figure 4.3)

• Bleeding on the surface of retina, between the retina and

Figure 4.3 Preretinal hemorrhage

Subretinal Hemorrhage (Figure 4.4)

• Bleeding between the photoreceptors and retinal pigment

Figure 4.4 Subretinal hemorrhage

Cotton Wool Spots ( Figure 4.5)

• Represents microinfarction of the nerve fiber layer of the retina

Figure 4.5 Cotton Wool Spots

Hard Exudates ( Figure 4.6)

• Leakage of high protein and lipid due to break in blood retinal

Figure 4.6 Hard Exudates