THE OPHTHALMOLSCOPE The direct ophthalmoscope is used by many specialties and it is important for

students to master its intricacies. It is turned on midway through the instrument by depressing this green button
and moving it clockwise. To change the aperture you move the wheel on the back of the ophthalmoscope. If the
pt’s pupils are dilated the largest aperture should be used. Use the smallest to look in an undilated eye.
Other things found by moving this wheel are a blue filter for use with fluoroscein stain to detect aberrations in
the corneal surface.
A slit which is said to allow you to assess depth – if the image seen on the retina is not straight then you can
assume it is falling on an uneven surface suggesting pathology.
A grid which can be used for estimating measurements, by asking the pt to look at the centre you can assess
where their position of fixation is relative to the grid.
Just above this wheel there is a switch. Turn it left to see the green filter. This neutralises red colours and so
haemorrhages will appears black in colour. It can be useful when looking at microaneurysms etc.
To the right Neutral density filter: Decreases intensity by decreasing the ambient light bouncing back into the
system without decreasing colour.
The ophthalmoscope should be held like this with the index finger free to change the lens. It should be held right
up against your eye. The hand, head and instrument should be moved as one, a rigid unit when examining to
prevent loss of the image. The right hand and right eye should be used when looking at the pt’s right eye and
the left hand and left eye used when looking at the patient’s left eye.

When selecting the lens you can calculate which strength to use by adding your refractive error to that of your
patient’s. In the example of you having a refractive error of -3 and your patient having
+1 you would turn the knob anti-clockwise to achieve -2
Another commonly used method and perhaps better for medical students is to turn the dial to the highest
positive reading and then dial down until the part of the eye you’re trying to see comes into focus. Students
must remember that because of the curve in the retina when moving along the arcades from optic disc to
peripheral areas they must continue to change the lens strength to keep the arcades in focus.

THE EXAMINATION Introduce yourself to the patient, explain what you are going to do and ask their
permission to examine their eyes. You should ensure both you and the pt are as comfortable as possible before
starting the examination. The examining room should be darkened to prevent pupillary constriction and the
patient should be sitting down. You should approach from the side, using your right hand and R eye in
examining the pts R eye, and your left hand and L eye in examining the pt’s L eye.
Ask the pt to fixate on a specific point across room, looking slightly up. This ensures that accommodation is
prevented – so stopping accommodation’s associated pupillary constriction, and keeping your view to the retina
as wide as possible. It also gives the patient something to concentrate on doing during the examination, making
them less likely to move the eye around. Both you and the pt should take off any spectacles.
Standing about a meter away and looking through the ophthalmoscope, you should check for the red reflex
which is a red reflection in the area of pupil. It may be distorted or blocked by pathology such as cataracts or
vitreal haemorrhage.
Place your hand which isn’t holding the ophthalmoscope either on pt’s head or shoulder to help you judge
distance and avoid hitting into their eye socket. Still looking through the ophthalmoscope, follow the red reflex in
at a small angle towards the pt’s nose.
Get as close as possible to pt’s eye to get the best field of view. Any small distance away will significantly
decrease the field of view. With the lens set to its most positive value, dial down until the portion of the eye you
are looking at comes into focus. Examine the anterior segments [the cornea, the iris] and then focus back by
changing to a more negative setting to look at the retina.
Focus on the optic disc using the downward Vs of the arcades to guide you in. Look at the disc for its cup colour
and contour.
Starting on the optic nerve head, the disc, then check out the vessel arcades following the major vessels out to
the periphery. Examine the superonasal, inferonasal, superotemporal and inferotemporal arcades, always then
following back to the optic nerve head. The arteries are smaller than the veins. And while looking at vessels
also look at the underlying retina for any pathology.
Have a final sweep around the periphery and then focus on Macula, which is found temporal to the disc. Do this
last as it causes the pupil to constrict.
You can then ask the pt to look directly into the light which should bring the fovea into the centre of your focus.
This may not happen in pts with macular disease.