CME

EARN CATEGORY I CME CREDIT by reading this article and the article beginning on page 42 and successfully
completing the posttest on page 47. Successful completion is defined as a cumulative score of at least 70%
correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit
by the AAPA. The term of approval is for 1 year from the publication date of October 2009.

LEARNING OBJECTIVES

Describe the components of an ophthalmoscope and how to properly care for the instrument
Review the examination of the eye
Discuss the different settings and lenses of the ophthalmoscope and their uses
Explain how to correct for the refractive error of the examiner and the patient

Beyond the red ref lex: Examining

the eye with an ophthalmoscope
Invented more than 150 years ago, this versatile clinical device has changed little since its
humble beginnings. The use and care of the ophthalmoscope is reviewed.

Samuel Powdrill, MPhil, PA-C

ou were probably first introduced to an ophthalmoscope during your physical examination

training. Most physician assistants are given an
ophthalmoscope and told, This is what you
use to examine the back of the eye. A brief
look at the red reflex of the eye, a few vessels, and perhaps
the optic disc may be the extent of your use of the ophthalmoscope. You are not alone if you come away from an eye
examination feeling as if you really did not gain much useful
information. After your clinical training is complete, however, you may hesitate to ask about how to expand your use of
the instrument. This article aims to provide you with some
tips that will make your use of the ophthalmoscope more
rewarding, accurate, and practical.

THE INSTRUMENT
Cornea

Optic
disk

Lens

Iris

THE SETTINGS

The different light and aperture settings in the head of the

ophthalmoscope change the color and shape of the light

22 JAAPA OCTOBER 2009 22(10) www.jaapa.com

Vitreous

Retina

Jim Dowdalls

Invented by Hermann von Helmholtz in 1851, the instrument was called an augenspiegel (eye mirror). The term
ophthalmoscope (eye observer) came into common use in
1854. Helmholtzs instrument consisted of three essential
elements: a source of illumination, a method of reflecting
the light into the eye, and an optical means of correcting an
unsharp image of the fundus.1 The instrument used in
todays clinical setting is still composed of these basic elements. Used effectively, the ophthalmoscope will enable
you to make an accurate diagnosis in most clinical situations where more sophisticated eye-examination equipment
is not available.

Retinoscopy via an ophthalmoscope

source. Each setting provides the lighting and/or view used

for different diagnostic purposes2 (Figure 1).
White beam This beam can be large or small. The large
white beam is the most frequently used beam of light. At a
very close range, the small white beam only covers a small
area of the pupil and iris. This beam can make visualization
through a small pupil easier because it reflects less light
toward you from the structures around the pupil and directs
less light toward a reacting pupil. Either the small white
beam or the half beam is used to view the retina from
around the opacity of an early-stage cataract. The light just
barely enters the bottom of the pupil while you look through
the area at the top of the pupil.
Half beam This setting is used to examine patients with
early lens opacity. The light is allowed to enter only the
lower half of the pupil; the disc is visible through the upper
half of the pupil, from around the opacity. This improves the
blurriness and offers a clearer view of the retina.
Grid The grid pattern in the beam helps make rough measurements within the eye. For example, this setting can be
used to measure the relative distance between a retinal lesion
and the macula or disc.
Blue light Corneal abrasions or ulcers are revealed by
examining the eye with this setting after fluorescein staining
of the cornea.
Slit beam This setting is used to examine the cornea and
anterior chamber of the eye. If a separate magnifying loupe
is used, the slit beam is directed obliquely towards the cornea
and anterior chamber. The slit beam can be thought of as a
poor mans slit lamp view. The slit beam is also used to examine the contour of structures or abnormalities in the cornea,
lens, or retina.
Red free This setting makes the other beams visible as a
green light. Green is a contrasting color to the red of the
retina; therefore, the view of the retina will appear black
and white. The red free setting is used to examine the
blood vessels. The vessel caliber and distribution appear
more clearly and with better contrast when viewed through
this setting. The red free setting is particularly useful when
looking for nicking in patients with hypertension and new

Large white

Grid

Small white

Blue light

Half beam

Slit

FIGURE 1. Aperture settings of the ophthalmoscope

vessel growth in patients with diabetes. Retinal bleeding

appears as black.
THE LENSES

An understanding of the lenses is helpful when examining

the structures inside the eye, such as the vessels and the retina. What do the numbers in the small window of the ophthalmoscope head signify? You might want to read this section with an ophthalmoscope in hand for reference.
The red numbers are concave or minus lenses. The green
numbers are convex or plus lenses. A convex lens converges
or focuses beams of light to a spot on the opposite side of the
lens from the light source. A concave lens diverges or directs
the beams that pass through the lens apart from one another.
An imaginary line drawn from where the light rays start to
diverge backwards to a point where the light rays would
meet will lead to a theoretical focal point (Figure 2). This
point is called a virtual image because the light rays theoretically focus between the light source and the lens.
Lens power is measured in diopters. The numbers on the
ophthalmoscope represent the power of the lens you are

KEY POINTS
Invented by Hermann von Helmholtz in 1851, the instrument was called an augenspiegel (eye mirror). The term ophthalmoscope (eye observer)

came into common use in 1854. Helmholtzs instrument consisted of three essential elements: a source of illumination, a method of reflecting
the light into the eye, and an optical means of correcting an unsharp image of the fundus.
Lens power is measured in diopters. The numbers on the ophthalmoscope represent the power of the lens you are looking through. The
focal length is the distance between you and the object you are focusing on when you look through the ophthalmoscope. To find the focal
length of the lens you are using, divide 100 by the diopter number seen in the ophthalmoscope window.
If there is cupping in a patient with chronic glaucoma, the center of the optic disc will be out of focus because it is at a greater depth than
the retinal surface. By adding 1 or 2 to the diopter setting, the cup of the disc is now in focus and the rest of the retina will be out of focus.
This is a way to evaluate the depth of the cup from the rim and thereby the severity of glaucoma damage.
The ophthalmoscope setting needs to correct for the refractive error of the examiner first, then be adjusted to correct for the refractive
error of the patient. You do this by changing the diopter setting of the ophthalmoscope to compensate for your refractive error. For example,
if you know you have a refractive error of 2, you would set the ophthalmoscope at 2 before you begin examining the patients eye.

www.jaapa.com OCTOBER 2009 22(10) JAAPA 23

CME Ophthalmoscope
looking through.3 The focal length is the distance between
you and the object you are focusing on when you look
through the ophthalmoscope. A 1-diopter lens has a focal
length of 1 m. To find the focal length of the lens you are
using, divide 100 by the diopter number seen in the ophthalmoscope window. For instance, a 4-diopter lens focuses
on an object 25 cm away (100 / 4 = 25). Likewise, a 5diopter lens focuses on an object 20 cm away; a 10-diopter
lens focuses on an object 10 cm away.
To see corneal detail up close, set the ophthalmoscope lens
on +20 and view the eye at a distance of 5 cm from the

CONVEX LENS
Ray of
light

Ray of
light
Real image
Focal length

CONCAVE LENS
Ray of
light

Ray of
light
Focal length
Virtual image

FIGURE 2. Concave and convex lens views

+20

+10

+8

+6

+4

+2

0 -1

FIGURE 3. Diopter settings for focal points by depth into the eye

24 JAAPA OCTOBER 2009 22(10) www.jaapa.com

cornea. You should be able to see a sharp, magnified image

of the cornea. Adjust the focus by moving slightly toward or
away from the patients eye until your view is at its sharpest.
At this level, the eye is magnified approximately 6 times,
which should give you a clear view of any foreign bodies on
the cornea or eyelid. If you view the red reflex of the eye
from 25 cm away at +4, the pupil margin comes clearly into
focus and the iris detail can be seen quite well. This is an
excellent distance from which to examine the red reflex, as it
will also let you see shadows caused by opacities in the lens.
This provides much more diagnostic information than just
looking at the red reflex at 0.3
All the distance settings change when looking inside the
eye because you are now looking through the cornea and the
lens as well. Figure 3 illustrates the approximate depth into
the eye that is in focus at each diopter setting. When looking
into the eye from a very close distance, changing the lens
power can allow the structures at various depths inside the
eye to come into focus. Start with +20 at the cornea, and
decrease the diopter setting gradually (+10, +8, +6, etc.),
you will be able to see structures, opacities, floaters, and even
foreign bodies in the anterior chamber, lens, vitreous, and
finally, arrive at a clear view of the retina.3
When examining the emmetropic eye (no refractive error,
therefore, the patient does not need to wear corrective
lenses), the ophthalmoscope will focus on the retina at 04
(Figure 4). This number is usually white in the ophthalmoscope window. This is, of course, assuming that the examiner also has no refractive error. The minus, or red, numbers are rarely used when both the examiner and the
patient have emmetropic eyes. However, a minus setting
may be used to observe the depth of the optic cup from the
rim of the optic disc.
At a very close range (the ophthalmoscope is almost touching the patients eyelashes [2 cm]) and a 0-diopter lens setting, the retina of an emmetropic eye is in focus. If there is
cupping in a patient with chronic glaucoma, the center of the
optic disc will be out of focus because it is at a greater depth
than the retinal surface. By adding 1 or 2 to the diopter
setting, the cup of the disc is now in focus and the rest of the
retina will be out of focus. This is a way to evaluate the
depth of the cup from the rim and thereby the severity of
glaucoma damage.
Another example of using focus to examine the intraocular
structures is in the patient with papilledema. We are taught
that papilledema is present when the optic disc appears hazy
or out of focus with the retina. In an emmetropic eye, the
optic disc is at the same level as the retina.3 If the optic disc
appears hazy, first bring the retina into focus; then add +1 or
+2 to the diopter setting until the disc comes into focus. At
this point, the retina will be out of focus. The number of
diopters required to bring the disc into focus will give you an
idea of the degree of optic nerve head elevation from the retinal surface. This measurement should be documented. This
procedure can also be used to diagnose a retinal detachment
or assess an intraocular tumor. The slit beam can be used to

evaluate the contour of the disc in a patient with papilledema

or retinal tumor. Shine the slit beam across the diameter of
the disc or tumor while looking at the retina, and note any
deviations from the normal contour.
The ophthalmoscope can also serve as a makeshift otoscope. At a diopter setting of +10 or +12, the ophthalmoscope can give a reasonable view of the tympanic membrane. If you are presbyopic, this will allow you the option
of focusing on the tympanic membrane at a comfortable
distance (a feature that is only available on some newer
otoscope models).

View of retina through

a 5 mm pupil with
the ophthalmoscope
2 cm from the eye

THE ROLE OF REFRACTION

Up to this point, we have discussed the focus of the ophthalmoscope with an emmetropic eye in both the examiner and
the patient. In reality, neither the examiner nor the patient
may have emmetropic eyes. The ophthalmoscope setting
needs to correct for the refractive error of the examiner first,
then be adjusted to correct for the refractive error of the
patient. You do this by changing the diopter setting of the
ophthalmoscope to compensate for your refractive error. For
example, if you know you have a refractive error of 2, you
would set the ophthalmoscope at 2 before you begin examining the patients eye. If you wear contact lenses, your
refractive error should be 0. If your eyeglasses have a high
refraction, you should keep your eyeglasses on when using
the ophthalmoscope. The patients refractive error is not
known; therefore, when you look inside the patients eye,
you should be adjusting the ophthalmoscope for the patients
refractive error.
A patients refraction can be closely approximated with the
ophthalmoscope if you also know your own eyeglass prescription (or refractive error). The best way to do this is to
look at the patients retina and move the dial 1 or 2 diopters

Often, a patient complaining of

blurred vision may simply have
a refractive error. An exception is
the patient with diabetes.
in each direction until it begins to come into focus. Continue
to turn the dial in that direction until the sharpest focus of
the retina is achieved. Note the power of the lens you are
looking through and subtract the power of your own refraction from that number. The difference will be the patients
approximate refraction.
Alternatively, you can hold the ophthalmoscope up to the
patients eye and have the patient look at an eye chart
through the ophthalmoscope. Change the lens to the setting
that offers the patient the best clarity. Knowing this lens
power will give you a rough estimate of the eyeglass prescription the patient may need, depending on the distance from

Central retina

FIGURE 4. The retina in an emmetropic eye

the eye chart. Often, a patient complaining of blurred vision

may simply have a refractive error and need eyeglasses. One
possible exception, however, is the patient with diabetes. In
these patients, the lenses become edematous when the blood
glucose is elevated, and the refraction changes. Therefore,
sending these patients to an optometrist for refractive correction is only necessary when the glucose level has remained
stable for several weeks.
THE EYE EXAMINATION

The examination of the eye should begin by assessing the

patients visual acuity. The physical examination with an
ophthalmoscope starts at the anterior of the eye. You should
observe the extraocular movements. Next, examine the eyelids, conjunctivas, and corneas from in front of the patient
with oblique light, achieved by shining the ophthalmoscope
light from the temporal side of the eye. Direct light is used
for pupil constriction and coaxial light (looking through the
ophthalmoscope) is used for the red reflex and the retinal
examination.
Retinal examination Dim the room lights and instruct the
patient to look at a distant point away from any direct light.
Dim the ophthalmoscope to approximately three-quarters
brightness. This will keep the pupil dilated and maximize
your view of the retina. You should be able to find the disc
immediately with an approach slightly from the temporal
side, shining the ophthalmoscope light toward the nasal retina of the eye (approximately 15 from center).3 At this angle,
the light is on the blind spot, which also helps keep the pupil
open. This will make the examination easier for you and
more comfortable for the patient, as well. Remember to
examine the patients right eye with your right eye, and the
patients left eye with your left eye.
Start the retinal examination by looking at the corneal light
reflex and the red reflex at about 1 m (approximately 40
inches) away from the patient with the lens set at 0. Now, set
the lens at +4 and look at the red reflex and lens opacities
from 25 cm (10 inches) away. Reset the lens to zero and

www.jaapa.com OCTOBER 2009 22(10) JAAPA 25

CME Ophthalmoscope
examine the fundus by coming in very close to the patients
eye. You may have to adjust the ophthalmoscope lens until
you can see the fundus clearly.5
CARE OF THE OPHTHALMOSCOPE

Care of the ophthalmoscope is a very important part of its use.

Its greatest enemies to a long life are being dropped and the
head being left exposed to dust. The ophthalmoscope is most
commonly damaged when it is left standing upright and/or
placed near the edge of the countertop, where it can be
knocked over. Dust can collect in the head if the instrument is
left for long periods of time uncovered or not in a case. Dust
can obscure the lenses and make using it very difficult.
CONCLUSION

Richard Keeler, a special adviser on ophthalmic instruments

to the British Optical Association Museum, described the
device this way: The ophthalmoscope is the staple instrument introduced in the 1850s, it was the first proper
device for examining the interior of the human eye by means
of a beam of light which illuminates otherwise invisible tissues.1 The ophthalmoscope is an excellent source of illumination for oblique, direct, and coaxial light; however, it is
really several useful instruments in one. The ophthalmoscope is often overlooked as an available source of magnification. In fact, the device contains a whole set of magnifying

lenses of different strengths that you can use to examine any

part of the body where magnification may be necessary. For
example, the excellent white light and magnification makes
the ophthalmoscope an excellent tool for close examination
of lesions in the mouth or on the skin. It makes a good pen
light when you have left yours at home, too. With care and
lots of practice, your ophthalmoscope can be a great asset to
your patient care. JAAPA
Sam Powdrill is assistant professor in the physician assistant program at the
University of Kentucky, Lexington. He practiced for 13 years at a rural hospital
in Kenya as a midlevel eye surgeon and refractionist, the only surgical subspecialty offered in Kenya for their equivalent of a PA. He has indicated no
relationships to disclose relating to the content of this article.
REFERENCES
1. Keeler R. A brief history of the ophthalmoscope. The College of Optometrists Web site.
http://www.college-optometrists.org/index.aspx/pcms/site.college.What_We_Do.museyeum.
online_exhibitions.optical_instruments.ophthalmoscopes.ophthalmoscopes_home/. Accessed
September 2, 2009.
2. A guide to the use of ophthalmoscopes in the eye examination. WelchAllyn Web site. http://
www.welchallyn.com/documents/EENT/Ophthalmoscopes/Traditional%20Ophthalmoscopes/
technique_20070320_traditional_opthalmoscope.pdf. Accessed September 2, 2009.
3. Timberlake GT, Kennedy M. The direct ophthalmoscope: how it works and how to use it.
http://www.kumc.edu/ophthalmology/timberlake/pdf/TheDirectOphthalmoscope.pdf. 2005.
Accessed September 2, 2009.
4. Charters L. Direct ophthalmoscope a valued tool for examining optic disc. Ophthalmol Times.
2006;31(2):38.
5. Cozma I, Frazer S, Nambiar AK, et al. How to use an ophthalmoscope. Student BMJ. 2004;12:
309-348. http://student.bmj.com/issues/04/09/education/320.php. Accessed September 2, 2009.