Taking Your Fundus Exam to the Next Level

Taking Your Fundus
Exam to the Next Level
Dr. Kelly Thompson
Cincinnati VA Medical Center
Taking Your Fundus Exam to the
Next Level
► Resident
► Student
Assistants
Subjects
Fundus Biomicroscopy
► Indirect
 High plus Auxiliary lenses
 Aerial, reversed, and inverted image
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Fundus Biomicroscopy
► Indirect
►
Higher power lenses results in larger field of view, less
magnification
►ONH evaluation
 78D, Super 66, 60D
►Posterior
pole evaluation
 90D, 78D, Super 66, Superfield
►Peripheral
retina evaluation
 90D, Superfield, Super Vitreo Fundus
Fundus Biomicroscopy
► Direct
 Contact lenses-uses fluid
 Neutralizes power of the eye
 Non-mirror or Mirrored
►Mirrors-
peripheral retina
3 Mirror Goldmann Lens
► Contact
lens
lens for examining posterior pole
with mirrors at varying angles for viewing
from mid-periphery to anterior chamber
angles.
► Central
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Fundus Biomicroscopy
► Goldman
lens
 Central lens
►64
Diopter
for examining macula
and optic nerve
►Useful to detect subtle macular
changes
►Excellent
 i.e. mild CME and elevation
Fundus Biomicroscopy
► Goldman
lens mirrors
 59 degrees
► Smallest
mirror
ora serrata, pars plana
► Gonioscopy,
 67 degrees
► Middle
sized mirror
equator to posterior ora
► Anterior
serrata
 75 degrees
► Largest
mirror
► Equator
► Image
inverted anterior to
posterior but not laterally
Goldmann Lens
► Technique
 Patient is dilated, anesthetic instilled
 Place viscous ophthalmic soln or gel on lens,
avoiding air bubbles
 Instruct patient to look up, insert lens onto
lower lid then bring the lens into contact with
cornea as patient returns to primary gaze
 Fundus opposite the mirror is being viewedrotate on eye as needed to position mirrors
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Goldmann Lens Tips
► To
obtain more peripheral views, have
patient look toward clock hour being
examined while keeping lens in contact with
cornea
► To remove have patient blink forcefully
Binocular Indirect Ophthalmoscopy
► Configuration
 Headband with light source, low plus oculars,
and prisms or mirrors to effectively reduce PD
 Condensing lens to focus light source, form
aerial image of retina, and further reduce
examiner’s effective PD
►BIO
with 20D lens together effectively reduce
examiners IPD to 3mm
►allows examiner’s pupils to be imaged within
patient’s pupil allowing stereopsis
Binocular Indirect Ophthalmoscopy
► Optics
 Condensing lens = real, inverted aerial image
 14D, 20D, 28D, 30D
 As condensing lens power increases:
►Image
size and stereopsis decrease
of view increases
►Higher power condensing lenses (eg. 28D, 30D)
effectively reduce IPD even further = better for
smaller pupils
►Working distance decreases
►Field
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Binocular Indirect Ophthalmoscopy
► Procedure
 Dilate pupil
 Position patient- seated or reclining
 Put on headband, adjust rheostat and position
of light, center oculars
 Direct light to pupil and insert condensing lens
with more convex lens surface facing examiner
 Adjust condensing lens to clarify and maximize
image
BIO Tips
► Move
your head,
condensing lens, and
light beam as one
system on an axis
► Use a protocol
regarding fields viewed
for retina examination
BIO Tips
► Familiarize
and orient
yourself to peripheral
fundus landmarks
 Vortex Vein Ampullae
 Long Ciliary Nerves
 Ora
► Regions/terminology
 Posterior pole
 Midperiphery
 Far Periphery
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BIO Tips
► Estimating
distance
size and
 20D fov ~ 8DD across
 Nearly 3 widths of a
20D lens from optic disc
to ora
Scleral Indentation
► Palpates
retina through light pressure on
the sclera
► Allows visualization of:
 More anterior retina
 Vitreo-retinal interface
►Aids
detection in small retinal breaks
 enhances the contrast of the RPE and choriocapillaris
compared to surrounding sensory retina
 Retina in profile
►Appreciate
elevation
Scleral Indentation
► Instruments
 Thimble style
 Pencil style
►Dual
heads
 Cotton tip applicator
► Depression
through
lids vs conjunctiva
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Scleral Indentation
► Procedure
 Position- reclined vs seated
 examined with BIO and condensing lens 180
degrees from area of observation
 Instruct patient to look in direction opposite of
desired area of observation, position the
depressor, then have the patient look back
toward the desired field while rotating the
depressor back into place.
 The BIO, condensing lens and depressor must
all be positioned along the same axis.
 Observe “roll” or “mouse under the rug” effect
Scleral Indentation
Patient Comfort
► Greatest
concern for many clinicians is causing
undue discomfort
► While some pressure sensation is expected,
procedure should not be painful with correct
technique
► Only light pressure is needed- focus not so much
on “depressing” the eye as simply “laying” the
instrument along the globe
► Proper positioning is essential
Scleral Indentation
Patient Comfort
► Anatomic
considerations:
 On average the ora serrata begins less than 1 cm
posterior to limbus and the equator is only 13mm
posterior to the limbus
 Apply instrument 7-14mm from the limbus
 Applying pressure within 7mm of limbus will depress the
ciliary body and cause pain
 Position above the tarsal plate for superior indentation
 Do not use the orbital rim as a lever-this could exert
undue pressure and cause pain if skin is pinched or the
supraorbital nerve is compressed.
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Scleral Indentation
► Tips
 If elevated retina not observed, do not press
harder!! Adjust yourself, light source, and
condensing lens so that you are lined up
correctly to view depressed area
 Higher power condensing lens will increase field
of view, i.e. 28D, 30D
Scleral Indentation
► Indications




Recent onset of flashes/floaters
New PVD
Schaeffer sign
Retinoschisis
► Useful
in differentiating schisis cavity from detachment
 Vitreous hemorrhage
► With
no history of trauma
 Lattice Degeneration
► small
holes within lattice or tears along the edges of lattice
Scleral Indentation
► Contraindications:
 Recent intraocular surgery
 Potential open globe
►i.e.
suspected penetrating trauma, globe rupture, or
corneal melt
 Hyphema
 Orbital injuries
 Caution with advanced glaucoma
►Do
not depress over bleb
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References
► 1.
Atlas of Primary Eyecare Procedures
 Linda Casser, Murray Fingeret, H. Ted Woodcome
 Copyright 1997 by Appleton and Lange, pp 234-237, 74-87
► 2.
Clinical Procedures in Optometry
 J. Boyd Eskridge, John F. Amos, Jimmy D. Bartlett
 Copyright 1991 by J.B. Lippincott Company, pp 462-469
► 3.
A Better Way to Do BIO
 John W. Potter, O.D.
 Review of Optometry 9/15/1999, pp 69-76
► 4.
Peripheral Ocular Fundus, 3rd ed.
 William L. Jones
 Copyright 2007, 1998 by Butterworth-Heinemann, pp 1-13
Thank you
► Special
thanks to:
 Char Robinson (Volk Optical Inc.)
► Supplying
lenses
 Linda Fette
► Coordinating
student volunteers
 Dr. Patrick Till
► Help
coordinating this workshop and presentation
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