DIRECT OPHTHALMOSCOPY:
Basic Workshop
dr. Heru Syahputra, SpM
PENDAHULUAN
• Ophthalmoscope (oftalmoskop)
Alat untuk membantu memeriksa bagian dalam bola
mata atau retina
• ophthalmoscopy ~ funduscopy
LATAR BELAKANG
• Kelainan media refraksi
• Kelainan retina & nervus optikus
• Dibutuhkan oleh: SpM, SpS, SpBS, dokter umum
Klasifikasi
• DIRECT VS INDIRECT
SEJARAH
percobaan sejak abad ke 18
1851
MEKANISME
TECHNIQUE
• Wash your hands.
• Introduce yourself to the patient and explain what you are
going to do.
• Position the patient so that the ophthalmoscope is held directly
at the level of the patient’s eye.
• Turn on the ophthalmoscope and set the light to the correct
aperture.
• Dim the lights.
• Instruct the patient to focus on an object straight ahead on the
wall.
• To exam the patient’s RIGHT eye, hold the ophthalmoscope in
your RIGHT hand and use your RIGHT eye to look through the
instrument.
• Place your left hand on the patient’s head and place your thumb
on their eyebrow.
• Hold the ophthalmoscope about 6 inches from the eye and 15
degrees to the right of the patient.
• Find the red reflex.
• Move in closer, staying nasally until you see the optic nerve.
• Rotate the diopter lens until the optic nerve comes into focus.
• The farsighted eye requires more plus/green number lenses.
• The nearsighted eye requires more minus/red number lenses.
• Measure the cup to disc ratio.
• Scan slightly up, down, right and left to look at the vessels.
• Move out temporally to find the macula and fovea.
• Repeat the same technique on the other eye.
To dilate or not to dilate?
Pupil dilatation (with one drop tropicamide
1% in each eye and wait for 15 minutes)
is useful to acquaint yourself with the
normal fundus but may not always be
possible, especially in neurology patients
or those with a head injury
Apa yang dicari?
Red reflex
• Media opacities obscure the red reflex (corneal scars, cataract and vitreous
haemorrhage, and asteroid hyalosis).
Optic disc
• Look for optic disc size, colour (pallor, congestion), cup disc ratio, margins,
haemorrhages, new vessels, collaterals. Pale and clearly demarcated disc:
optic atrophy. Pathological cupping: glaucoma. New vessels on the disc:
proliferative diabetic retinopathy is the most common cause. Yellow-grey disc
with blurred margins ± haemorrhages: papilloedema—bilateral.
Vessels
• Start at the disc and follow the vessels out to look for hypertensive and
arteriosclerotic changes. Look as far as the mid-periphery for scars
(inflammatory, laser), haemorrhages, exudates, pigment (white, black), and
pigmented lesions. Examine arteries, veins (slightly thicker), and perivascular
fundus. A-V nipping is seen in hypertension.
• Look also for: microaneurysms, blot haemorrhages, hard exudates—
background diabetic retinopathy; cotton wool spots (fluffy white patches),
vessel changes such as venous beading, and venous loops are
preproliferative changes; leashes of new vessels.
Macula
• You will find the macula temporal to the disc. The foveal
reflex is seen better with a green (red-free) filter and is at
two disc diameters away from the disc and 1.5 degrees
below the horizontal (your whole field of view is 8
degrees). A circinate ring of hard exudates, haemorrhage
(dot, blot, or flame), or pigment deposition are the most
common things you will see.
Normal fundus
Vessels emerge from nasal side
of disc. Arteries are narrower
than veins.
Pathological Optic
Cupping
Note cup-to-disc ratio
at least 0.8
Optic Disc Edema
The optic disc is elevated
and its surface is covered
by cotton wool spots
(damaged axons) and
flame hemorrhages
(damaged vessels). Four
I's: increased intracranial
pressure (papilledema),
infarction, inflammation,
infiltration (by cancer).
