Marwan Tahoun

The exposure to Ophthalmology in my undergraduate medical training was quite limited. Worldwide, the time spent in ophthalmology courses is decreasing, with the longest exposure by continent being recorded in Africa, with the shortest being recorded in North America (1).

Visualisation of the back of the eye may be paramount to an inexperienced resident doctor’s job, where the ability to perform a simple technique such as fundoscopy may help to rule out raised intracranial pressure by checking for signs such as papilloedema (2).

Basic skills with few real-life opportunities to practice are often taught, often students may perform all of medical school without looking into a real patient’s eye.  This is replaced by methods such as practicing ophthalmoscopy on a model head which is not

representative of reality. In the case of the author’s medical school, these model heads would also have the images of the fundus visible to the naked eye, thus negating the skill required for the viewer to focus on the fundus with the ophthalmoscope and follow the retinal vessels to reach the optic cup. This anecdotally led to a lot of medical students being aware of the procedure required to pass their exam, however when presented with a real patient they were unable to determine any findings of clinical benefit. Below, in order to help combat this, we outline the steps of how to correctly perform fundoscopy on real patients:

1. Preparing for the Examination

1. Explain the Process:
   • Provide the patient with a clear explanation of what the examination entails to ease any concerns and encourage cooperation.
2. Optimize the Environment:
   • Dim the lights in the room to enhance pupil dilation, making it easier to view the retina.
3. Position the Patient:
   • Seat the patient comfortably in an upright position and ask them to fix their gaze on a point in the distance to maintain a steady eye position.
4. Set Up the Examiner’s Position:
   • Position yourself at eye level with the patient, ensuring a stable and ergonomic stance throughout the procedure.

2. Adjusting the Ophthalmoscope

1. Choose the Correct Lens:
   • Begin with a higher dioptre setting (+10 to +15) to inspect the anterior structures, then adjust to zero or a slightly negative setting (-1 to -3) for the retina.
2. Select the Aperture Size:
   • Use a medium or large aperture for a comprehensive view of the retina; switch to a smaller aperture for patients with constricted pupils.
3. Fine-Tune the Focus:
   • Adjust the ophthalmoscope to correct for your refractive error to ensure a sharp and clear image.

3. Conducting the Examination

1. Begin with the Right Eye:
   • Use your right eye and hand to examine the patient’s right eye, maintaining steady positioning of the ophthalmoscope.
2. Identify the Red Reflex:
   • Hold the ophthalmoscope approximately 15–30 cm from the patient’s eye and align the light beam with the pupil to observe the red reflex.
3. Move Closer Gradually:
   • Slowly approach the patient, keeping the red reflex in focus, until you are about 2–5 cm from the eye. It can be useful to place a hand on the patient’s head or shoulder to prevent collision and warn the patient you will be getting very close to them.

4. Systematic Examination of the Retina

1. Locate the Optic Nerve Head:
   • Find the optic disc, distinguished by its circular shape and a pinkish hue, with a paler centre known as the cup.
2. Evaluate the Optic Disc:
   • Assess the margins, size, and cup-to-disc ratio, and note any signs of swelling, pallor, or abnormalities.
3. Trace the Retinal Vessels:
   • Follow the blood vessels radiating from the optic disc, observing their structure and any potential abnormalities such as narrowing or haemorrhages.
4. Examine the Macula:
   • Direct the patient to look at the ophthalmoscope’s light, enabling a view of the macula to check for signs of degeneration, oedema, or drusen.
5. Inspect the Periphery:
   • Adjust your angle to scan the outer edges of the retina for potential tears, detachment, or pigmentary changes.

5. Wrapping Up

1. Switch to the Opposite Eye:
   • Repeat the same process for the patient’s left eye using your left hand and left eye to ensure consistency.
2. Record Observations:
   • Document both normal findings and any detected abnormalities, such as haemorrhages, swelling, or detachment, in a systematic format.
3. Discuss Results with the Patient:
   • Share your findings with the patient and provide recommendations for follow-up or additional testing if necessary.

The above steps were curated using the following references (3-5) listed below for further reading.

We recommend methods such as incentivising for patients with real clinical signs to be examined by students in a supervised learning environment is the optimal way to build doctors with meaningful practical experience in fundoscopy at the time of qualification.

References

1.           Spencer SKR, Ireland PA, Braden J, Hepschke JL, Lin M, Zhang H, et al. A Systematic Review of Ophthalmology Education in Medical Schools: The Global Decline. Ophthalmology. 2024;131(7):855-63.

2.           Friedman DI. Papilledema and idiopathic intracranial hypertension. Continuum (Minneap Minn). 2014;20(4 Neuro-ophthalmology):857-76.

3.           Sharma N, Tandon, R., Chawla, R. Essentials of Clinical Ophthalmology. Indian Journal of Ophthalmology. 2018;66(4):391–8.

4.           Keane PA, & Foster, P. J. Ophthalmology Training: Beyond the Basics. Eye. 2010;24(6):883–9.

5.           Lang SJ, Keeling, E.,  Baker, R. Ophthalmoscopy: A Comprehensive Guide. Medical Practice Today. 2021;12(2):101–10.