28

OPHTHALMOSCOPY
Task:
1) Get familiar yourself with the controls and functions of the ophthalmoscope.
2) Examine your colleague's eyegrounds (fundus oculi).
Fig. No.1. Manual ophthalmoscope Zeiss
Description of the manual ophthalmoscope:
1. Handle with the power switch and lead-in current; 2. Changeable nut (of screw); 3. Head of ophthalmoscope; 4. Slit
diaphragm and grey filter discs; 5. Colour filter disc; 6. Correction glass +1 to +9 D disc; 7. Correction glass +40 to -50 D
disc; 8. Reading magnifying glass; 9. Inspection window; 10. Glass cover to protect window; 11. Lever for the
adjustment of distance between the illumination axis and the inspection window; 12. Adjustment of the light beam
divergence
Cross-section of the ophthalmoscope:
13. Illumination bulb; 14. Condenser; 15. Screen (see 4); 16. Filter (see 5); 17. Shifting lens (see 12); 18. Mirror for
illumination of the scale in window No. (8); 19. Illuminating system optics; 20. Illuminating prism; 21. Correction glass
in disc controlled by disc dials 6,7
Position S on the disc of screen (4) is called a screen slot (see the explanation below). Position B1 on the disc (5)
is a blue filter which is capable of examining the blood circulation using fluorescence angiography. When using this
method fluorescein is applied intraarterially. Fluorescein emits luminescent radiation if blue light is used for illumination.
The green filter RF which absorbs the red component of light is used most in ophthalmochromoscopy. The grey
filter indicated F is used for the examination of sensitive patients. Optical correction glasses are inserted into the
inspection window (9) using discs 6 and 7. Using disc 6 it is possible to insert lenses from 0 to +9D in steps by one D.
Using disc (7) it is possible to insert lenses from - 50 to +40 D in steps by 10 D. Each revolutin of the disc (6) provides the
moving one step forward of the disc (7), and thus it is possible to reach the continuous change of correction lenses
29
ranged from - 50 to + 50D by one D. The actually set up correction is readable in window (8). This window is diffusely
illuminated by the bulb and equipped with a magnifying glass. Correction lenses are protected against the dust and
pollution by a wipable cover (10), which is easy to clean. The distance of the illumination axis and the observation axis is
adjusted by shifting the lever (11). By the lever (12) is set the divergence of the light beam up.
Introduction:
An untrained eye can identify with an ophthalmoscope the following structures on the eyeground (retina)
without much difficulty: The most striking structures observable are the branches of retinal blood circuit. They converge
at the centre of a light target called the papilla nervi optici, which is a very important diagnostic structure. Its position is
easy to find if we follow the branch of the vein or artery up to its orifice. The yellow spot or macula lutea may be
observed at the retina of a living eye. Its red colour is deeper and richer than the surroundings. Its diameter is
approximately 5.5 mm and there is no vascularity at its centre region. A trained eye, however, can distinguish in its
centre, a darker tinged fovea, which has 1.5 mm in diameter. The foveola (small fovea) with a diameter of 0.35 mm is found
in the centre of the fovea but this cannot be distinguished with an ophthalmoscope. The foveola is packed with cones
which play an important role in colour perception. Visual acuity is extremely high at this point.
The main task of an ophthalmologist during a normal examination of the eyegrounds is to distinguish the
pathological findings from the physiological ones.
For successful and accurate examination of the eyegrounds and the eye refraction (dioptoscopy), it is desirable
to work with the dilated pupil also called mydriasis, when the pupilomotor reflex is pharmacologically cancelled. In case
mydriatics are not used, then the whole investigation is influenced by the pupil reflex - the contraction of pupil. The
parasympatholytics, scopolamine and atropine, also called mydriatics are most commonly used to avoid this difficulty.
Many other short-acting preparations in the form of eye drops are available if needed. Once this has occurred, however,
it is necessary to shift the axis of the illumination bundle closer to the axis of observation using lever (12) (see the
diagram and see also the task 2). As a rule, light reflections of the illuminating source will appear on the surface of the
cornea as the consequence. These reflections significantly complicate the examination. Thus it is necessary to find a
certain compromise between the quality of illumination and disturbing reflections.
Steps of the Work:
Task No.1: Familiarising with the ophthalmoscope.
1. Connect the ophthalmoscope to the source of electricity (transformator) and turn on the lever switch located on the
source. Switch on the source of light very briefly using the push-button located in the middle of central power switch
on the handle (1) of the ophtalmoscope.
2. Using diagrams and descriptions, find all components and controlling elements of the ophthalmo- scope.
Task No.2: Make the examination of your coleague's eyegrounds
Note: You will perform the examination without the use of mydriatics blocking the pupilomotor reflex, so that the pupil is
extremely contracted. Further, it is necessary to realize that during the ophtalmoscopic examination a very intensive light
source is used. This light will not injure the eye but it is very uncomfortable for the examined patient. Thus it is
necessary to perform as short-lasting examination as possible. To examine the patient quickly, it is essential to acquire
practice and skill when manipulating the instrument and proficiency when orientating on the retina. It is obviously
impossible to become a professional after only one contact with this examination method. The main purpose of this
practical is to give you at least a basic information about ophthalmoscopy and the optical principle upon which the
method is based.
1. Attach the ophthalmoscope to the source of electricity (transformator), turn on the lever switch of the source.
2. Setting the controlling elements of the ophtalmoscope: Briefly illuminate the optical correction scale in the window
(8) by pressing the push-button (1) on the ophthalmoscope handle. Turning the discs (6) and (7) adjust the optical
correction equal to the sum of your and colleague's eyes. Adjust a convenient distance between the light beam axis and
the observing axis (cca 15 mm) using the shifting button (11). Adjust the narrowest light bundle [upper position of the
sliding button (12)]. Also adjust the disc of filters (5) and disc of diaphragms (4) to position 0.
3). The examination of eyeground: Left eye of the "patient" is examined by physician's left eye and vice versa. Hold the
ophthalmoscope in the right hand. Switch the bulb on. The observation are made of the immediate vicinity. The
30
instrument must be very close to the patient's eye if possible. Aim the light beam into the patient's pupil, and try to
orientate it as conveniently as possible in order to minimize disturbing light reflections on the cornea surface. Using the
observing window (9) for inspection, try to catch the light spot of the bundle on the retina. If you are not succesfull
reduce the distance between the light beam axe and observing axe - shifting button (11)
6. In case you catch any arbitrary details on the eyegrounds attempt to focus them by turning the discs (6) and (7). As a
result, however, the optical corrections previously set will be slightly changed. Do not forget to check the position and
the direction of the light beam. This must enter into the eyebulb via the pupil. The cross-section of the light beam must
cover with the area of the pupil. Try to work fast to avoid exciting the patient as a consequence of the intensive light.
7. Follow the rule of examining the right eye of the patient with your right eye (for purely practical reasons) and also the
patient's left eye with your left eye. During the whole examination neither the patient nor the physician should
accommodate. The examined person should fixate his sight on a fixed point in the room.
8. To inspect the largest area of retina you need to change direction of illumination by turning the ophthalmoscope and
simultaneously the direction of observation. In normal conditions you can observe a small area of the retina
(optomeninx) with a diameter approx. 6 mm. using direct ophthalmoscopy. The ophthalmoscope must be in close contact
with the patient's eye (almost touch their heads). Eyegrounds are enlarged approx. 16 times.
9. Try to perform an eyeground examination in your colleague and find the above mentioned structures: branches of the
central retinal artery and vein, papilla n. optici, macula lutea, fovea.
After the tutorial is over, do not forget to turn off the illuminating source of the ophthalmoscope.
Appendix:
The inspection of a larger area of the retina is possible with an indirect ophthalmoscopy when a lens approx. 5 -
15 D is placed between the patient's eye and the ophthalmoscope. The observation is then held at a distance of 40 cm.
During this method the eyegrounds are enlarged approximately 4 times. The picture is distorted at the edges and so is
the height. Special optical mirrors offer a larger visual angle.
The direct ophthalmoscope is the most used instrument in ophthalmology. However, there is one essential
disadvantage here. Since the physician uses only one eye during the examination of the patient, stereoscopic vision
cannot be used and it is impossible to distinguish formations which appear above or below the surface like neoplasms,
tumours and excavations of the papilla and so on. A compromise to this situation is the use of the slot screen [position
"S" of the disc (4)] in partial substitution when these formations can be distinguished.
A more advanced and modern method is stereoophthalmoscopy, which is able to perform binocular examination
with stereoscopic perception. The stereoophthalmoscope is however a big and expensive instrument lacking the
readiness of the manual ophthalmoscope.