Clinical assessment of ocular

health

Dr Amy Sheppard, module lead

Contact me: A.Sheppard@aston.ac.uk
Office VS142
 Intended Learning Outcomes
Following this lecture and your practical sessions you should be able to:

Describe how magnification and FoV vary with factors such as

refractive error in direct ophthalmoscopy

Identify key retinal features and some common physiological variations

Perform ophthalmoscopy on a range of pxs, including more

“challenging” cases

Record your clinical findings for ocular health assessment

appropriately
 Reading list

Bennett and Rabbetts Clinical Visual Optics, 4th Edition

pp. 323-329

Clinical Procedures in Primary Eye Care, 4th Edition

David Elliott pp. 252-258

Kanski’s Clinical Ophthalmology. A systematic approach. Any

recent edition

College of Optometrists- Guidance for Professional Practice.

 CoO: Guidance on ‘Conducting
the routine eye examination.’

Developed pre-COVID

[Adequate assessment should include]……examining the eye

internally and externally. As a minimum for internal examination
you should use direct ophthalmoscopy on the undilated eye,
although alternative methods may be used. If you cannot obtain
an adequate view of the fundus you should dilate the patient’s
pupils and/or use indirect methods of fundal examination. You
should use slit-lamp biomicroscopy particularly where a detailed
view of the anterior eye and adnexa is required

If you feel it is clinically appropriate, you may:

e) use fundal or other imaging
GOC Stage 1 competencies
6.2.1. Ability to assess visual function and the appearance of the eye
and adnexa
6.3.1 Ability to interpret signs and symptoms of ocular abnormality

GOC Stage 2 competencies

3.1.3 Examines the fundi using both direct and indirect techniques…..

Optician’s Act
(a) to perform, for the purpose of detecting signs of injury, disease or
abnormality in the eye or elsewhere:
(i) an examination of the external surface of the eye
(ii) an intra-ocular examination….
 Slitlamp biomicroscopy
Excellent method for examining anterior
segment and ocular adnexa in routine
practice:
Variable and high
magnification
Control over illumination
Ability to assess tear film,
anterior chamber angle etc.

Are there any disadvantages?

Covered in detail elsewhere on

Optometry programme
 Ophthalmic Imaging
Digital photography
Ultra-wide imaging (e.g. Optomap)
Optical coherence tomography- anterior and posterior segment,
also OCT-A
https://en.wikipedia.org/wiki/Fovea_centralis#/media/File:Macula.svg
Drusen
CLINICAL APPLICATION OF
DIRECT OPHTHALMOSCOPY
Magnification in direct ophthalmoscopy

M
K’ = dioptric length of eye (power, e.g. 60 D)
K = ocular refraction (e.g. -5.00 for 5D myope)
w= WD (m) e.g. -0.025 m

For an emmetrope: M = x15

For a myope: M = ??

For a hyperope: M = ??
Linear extent of useful field of view

= size of blur circle

j (m) = g (K – W)
K`
g = pupil size
W = reciprocal of wd
K` = dioptric length of eye (eg 60D)
K =ocular refraction
What does this equation mean?

j (m) = g (K – W)
K`

If WD is  - field of illum is 
If pupil size is  - field of illum is 
If Rx is + ve - field of illum is 
If Rx is - ve - field of illum is 
Common apertures in DO

4 7
1

5
2

3 6
Routine for DO

Lights off
Remove px’s specs (? Put back on for fundus evaluation)
Raise chair for practitioner comfort
Give px fixation target- spotlight
Hold the ophthalmoscope in your right hand in front of your RE
for patient’s RE, swap all to the left side for LE

Explain technique:

I’m going to check the health of your eyes. The light will be quite
bright, and I will come close to you. Please keep looking at the
spot of light for now, but I will ask you to look in different directions
in a moment.
Start with anterior/ external eye

+10D- eye in focus at 10 cm (if you are emmetropic)

Mag = 2.5 x
Adjust for your Rx- px’s Rx not important for anterior eye exam
Widest and brightest beam
1. Check red reflex, look at iris, pupil, cornea
2. Ask px to close eyes- check lid margins & lashes
3. Ask px to look up/ down/ left/ right.
Hold lid when necessary
Check conjunctiva/ sclera etc not visible looking straight

4. SLOWLY reduce positive power as move through the media-

switch to medium white beam
Anterior Eye

RIGHT Anterior Segment Examination LEFT

Clean, full - lids/lashes - Clean, full
Clear - cornea - Clear
Quiet, smooth - conjunctiva - Quiet, smooth
Clear/ Optically empty - anterior chamber - Clear/ Optically empty
Brown, even colour - iris - Brown, even colour

DO NOT USE: NAD

WNL

Normal

Make a descriptive comment about each structure- avoid

“healthy” when possible
Lids/ lashes

Blepharitis

Scales in lashes, moderate blepharitis

Basal Cell Carcinoma

Scab-like lesion on lower lid ~3mm

diameter. Suspect BCC
 Cornea Conjunctiva

Arcus Allergic conjunctivitis

(Previously ‘Arcus senilis’)
Diffuse bulbar hyperaemia Grade 4
Iris

Iris naevi

Hazel, multiple small naevi

 Posterior eye
1. Locate and examine optic disc (~0 D if you and px emmetropic)
2. Check rest of posterior pole
3. Examine more peripheral retina. Ask px to look in 8 directions of
gaze:
Up
Up & right
Right
Down & right
Down hold upper lid
Down & left
Left
Up & left

4. Check macula- switch to macular stop

 Posterior Segment Examination
method (circle): direct BIO
Clear - crystalline lens Clear

Clear - vitreous - Clear

0.2 Shallow- vertical C:D ratio/depth - _____/_____
_____/_____ 0.2 Shallow

Pink/ yellow - disc colour - Pink/ yellow

Distinct - disc margin - Pigment crescent 6- 9 o’clock

ISNT applies - NRR - ISNT applies

Even calibre, no nipping - retinal vessels - Even calibre, no nipping

2:3 or 1:2 - A/V ratio - ______
______ 2:3 or 1:2

Even colour/ tigroid appearance - background fundus - Even colour/ tigroid appearance

Even colour - macula - Even colour

Present - foveal reflex - Present

Cup depth
 Venule

Arteriole

Disc
 CD ratios- does big = bad?

CD ratio tends to be larger in eyes that have

larger discs

Blue Mountain Eye Study (Australia): average

disc diameter was 1.5 mm

Disc size Small Medium Large

(1.0-1.3 mm) (1.4- 1.7 mm) (1.8- 2.0 mm)
Mean CD ratio 0.35 0.45 0.55

Crowston et al. The effect of optic disc diameter on vertical cup to disc ratio percentiles in a
population based cohort: the Blue Mountains Eye Study. Br J Ophthalmol 2004;88:766-770.
CD ratio/ depth- ?
Disc colour- pink/ orange
Colour cup and contour cup

Here, colour cup = contour cup

CD ratio = ?
Here, contour cup > colour cup
CD ratio = ?
ISNT rule

CD ratio/ depth- 0.60, deep

Disc colour- pink
Disc margin- well defined
NRR- ISNT applies
 Blood vessels
Retinal blood vessels
A/V Ratio
Vein • Nothing to do with quantity!
• Represents the relative thickness of the
Artery arteries compared with the veins- make a
judgement
• Here, 2:3
N.B. “SAHARA”

Nipping
• Ocular sign of systemic disease
LONG DURATION
Macula & foveal reflex

Macula- even colour

Foveal reflex- present
Normal variations

Tigroid fundus
Myopic crescent
Normal variations

Choroidal vessels
Tips for DO
Don’t rush!!

Practice both eyes

Do not make any exclamations of surprise/ horror/ shock/ disbelief/

uncertainty

If RE looks OK, make a comment to this effect before moving on to LE

Do not ask the patient to let you know if it gets ‘too bright’
It will do
There isn’t much you can do about it
Small pupils-tips

Get as close as you can

Maybe reduce the brightness of the light source to
reduce reflections
Make sure you give the patient clear instructions
about fixation
Remind the patient that it is OK to blink
? Dilation if poor view
High myope

Ask the patient to wear their glasses/ contact lenses

Everything will look big (magnified)
Field of view is reduced
Therefore easy to miss things
High myopes are at greater risk of retinal
detachment
Dilate?
Use indirect technique?
 MCQ 1

Which of the following statements is TRUE regarding direct

ophthalmoscopy?

a) No cupping of the ONH indicates a pathological abnormality

b) A highly myopic patient should keep their spectacles on when
you are examining the outer eye
c) Field of view reduces as hyperopia increases
d) An uncorrected optometrist with 3D of myopia in each eye
should use a +13 D lens to examine the outer eye
e) For an emmetrope, magnification of the anterior eye (with +10 D)
is around six times less than magnification of the fundus
MCQ 2

Which of the following statements is FALSE regarding fundus

features?

a) The foveal reflex is located temporally to the optic nerve head

b) The macular region may appear darker than the surrounding
retina
c) A normal A:V ratio is 3:2
d) A CD ratio of 0.6 may be non-pathological
e) The disc colour should be documented
SAQs

1. A patient has an ocular refraction of +10.00 D and a 4 mm

pupil size. What would be your expected useful field of view of
the fundus if you perform direct ophthalmoscopy at a working
distance of 2.5 cm? [2]

2. Explain the ISNT rule and why it may be helpful in the

assessment of the health of the optic nerve head [3]