Dr Akshay Narayan MBBS BSc
Foundation Year 2 Doctor, Aberdeen Royal Infirmary, NHS Grampian
The direct ophthalmoscope was invented in 1851 and ophthalmologists were first able to visualize retinal detachment through it in 1853 (1). Subsequently, the first viewings of central retinal artery occlusion and papilloedema were obtained in 1855 and 1860, respectively. Despite being around for more than a century, today’s medical students still lack the confidence and competence to perform it well (2,3). Concerningly, this lack of confidence is not exclusive to medical students. Amongst junior doctors, only one in five foundation year doctors felt confident identifying papilloedema by the end of foundation year (4). Amongst more senior doctors, up to 43% of General Practitioners admitted to lacking confidence in performing direct ophthalmoscopy (5).
Challenges in performing direct ophthalmoscopy
As non-ophthalmology doctors of varying levels of clinical experience all share this deficiency in performing direct ophthalmoscopy, it seems highly likely that there are inherent challenges in performing it. Although these challenges will be unique to each individual, the following are some reasons why students and clinicians are likely to find direct ophthalmoscopy a challenging skill to grapple with.
There are inherent challenges with actually performing direct ophthalmoscopy. Some students may find the close proximity of their face of that with the patient uncomfortable. Others may find it frustrating that they are only able to focus on an eyelash instead of the macula.
Decline in ophthalmology teaching at undergraduate level
Over the past 30 years, there has been a decline in the amount of time dedicated to ophthalmology in the undergraduate curriculum. This ‘global pandemic’ has been observed in United Kingdom, United States, Europe and Asia (6,7). This limits the amount of time spent in ophthalmology outpatient clinics to practice and hone this skill.
Poor representation in undergraduate exams
Understandably, medical students will choose to focus their efforts on aspects of the undergraduate curriculum that are likely to appear in their exams. Analysis of examination content released by UK medical schools has revealed that direct ophthalmoscopy is very rarely featured in examinations. Hence, there will very little incentive for medical students to focus their efforts on performing it well.
Hefty price tag
There is little doubt that medical school can be an expensive time period and financial considerations are often at the heart of what clinical equipment medical student can buy and practice. Traditionally, grants have been offered to medical students to fund direct ophthalmoscopes as there are an expensive piece of kit. Ever since the withdrawal of these grants in 1986, ownership of direct ophthalmoscopes has dwindled (8).
Lack of clear consensus on the standard of proficiency
There is very little guidance on how to incorporate it into the undergraduate medical curriculum. Most recently, the 2018 GMC outcomes for graduates makes no mention of ophthalmology as a specialty at all. Hence, medical schools are finding it challenging to determine what actually constitutes a standardized level of competence in direct ophthalmoscopy (9).
Infrequency of use
In a survey conducted in 2012, they found that 71% of Foundation Year 2 doctors used the direct ophthalmoscope less than 10 times in their final 6 months of Foundation Year 2 training (4). Similarly, GP and Emergency Department (ED) doctors also admitted to performing it very rarely10. Due to the lack of practice with the direct ophthalmoscope, understandably junior and senior clinicians are not confident in their abilities.
Unfortunately, most medical students only get to spend 5-10 days on a dedicated ophthalmology placement in medical schools across the UK (4). Given the time constraints imposed on them by the undergraduate curriculum, it may seem counterintuitive to expect them to be competent at this direct ophthalmoscopy l given that even senior trainees and consultants find this a challenging skill. Senior ophthalmology registrars often find it to be demanding station in their Part 2 FRCOphth examination (11). Reports have emerged where even consultant ophthalmologists find it challenging to screen for common eye conditions like diabetic eye disease using direct ophthalmoscopy (9).
Benefits of direct ophthalmoscopy
Given the challenges associated with performing direct ophthalmoscopy, it can be tempting to consign direct ophthalmoscopy to the ‘non-essential skills’ list. However, that would be a myopic approach as it fails to account for the prevalence of ophthalmic disease in primary care and accident and emergency. With ophthalmology estimated to be relevant in up to 19% ED admissions (12), direct ophthalmoscopy offers the following benefits.
Prevent the need for invasive investigation
Direct ophthalmoscopy gives us a unique insight into the not just the visual system but also the central nervous system. By performing this painless and non-invasive, we could remove the need for more invasive and uncomfortable investigations. For example, identification of spontaneous venous pulsation may exclude raised intracranial pressure and prevent the need for acute neuroimaging in a child with meningococcal meningitis.
The main aim of medical school is to produce doctors with the necessary skills and knowledge to identify and initiate management in medical emergencies. It is believed of the ophthalmic cases presenting to ED, 65% included disease that was time critical and sight or life-threatening. Direct ophthalmoscopy is a useful tool that could help us identify such ailments and deliver good patient outcomes through timely intervention. For example, direct ophthalmoscopy will enable a clinician to diagnose a central retinal artery occlusion. Reaching a timely diagnosis would enable the clinician to not only reverse the loss of vision but also potentially prevent an impending stroke.
Reveal systemic disorders
Many systemic conditions have an ophthalmic manifestation that may precede their systemic symptoms. Direct ophthalmoscopy provides us with an unique opportunity to detect these signs and reach a diagnosis sooner. For example, a patient with infective endocarditis may have Roth spots visible on direct ophthalmoscopy that may be apparent before they develop any infective or systemic symptoms.
Identification of non-accidental injury
As clinicians, we are entrusted with the responsibility of striving to maintain patient safety. This may not always be straightforward in cases where the patient is unable to advocate for themselves, especially in the paediatric population. In cases were the clinician has suspicion of abuse, the direct ophthalmoscope could be a useful adjunct. Bilateral retinal haemorrhages as seen on direct ophthalmoscopy, could be indicative of non-accidental injury that would warrant further investigation.
Lack of immediate specialist input
It is common for patients with vision-related symptoms to present to primary care, ED or a minor injury unit. In these settings, specialist ophthalmic input may not be available immediately. In such situations, the duty of care to perform a basic competent ophthalmic examination to assess and triage a patient lies with the non-specialist clinician. A useful diagnostic tool that these clinicians may have at their disposal during these times of clinical need is the direct ophthalmoscope.
Alternatives to direct ophthalmoscopy
It is undeniable that the jury is still out regarding whether teaching direct ophthalmoscopy should feature in the core curriculum of medical students. However, it is pretty unequivocal that medical students and clinicians from all medical specialties should be able to interpret fundoscopy images. Making this distinction is crucial as it helps us recognise that although medical student should display proficiency in identifying clinical signs evident on fundus photographs, being able to perform the technical skill of direct ophthalmoscopy may not be essential at undergraduate level. If we are able to reach a consensus on this, alternative methods of obtaining fundus imaging could be explored through the use of technology. Some of possible avenues worth considering include:
1. Nonmydriatic retinal photography (13)
2. PanOptic ophthalmoscope
3. Smartphone ophthalmoscopy (14)
4. EyeSi direct ophthalmoscope stimulator
Studies that have been conducted on medical students and ED clinicians have demonstrated that the main barrier to achieving proficiency direct ophthalmoscopy is the technical difficulties associated with the process, rather than the uncertainty of interpreting the obtained images (15,16). Through the appropriate use of the aforementioned technological tools, medical students and clinicians alike may be able to circumnavigate the technical challenges of direct ophthalmoscopy, whilst obtaining the necessary images to deliver good patient care.
Direct ophthalmoscopy has been in the diagnostic armamentarium of clinicians since the 1850s. Despite being a skill that clinicians have had for years to practice and hone, it is concerning to note that medical personnel of all levels of clinical experience, from medical students to consultants in ED and GP, still lack the confidence and competence to perform it well. Aside from the cost, technical challenges and rarity of its use, it appears that the challenges associated with direct ophthalmoscopy are borne out of limited exposure and importance afforded at undergraduate level. Although it is understandable that increased pressure on clinicians to have an ever-increasing set of diagnostic skills and knowledge has inadvertently contributed to the lack of proficiency in direct ophthalmoscopy, its therapeutic applications and diagnostic utility necessitate it in a clinical setting without immediate or urgent ophthalmic specialist services. Hence, technology should be appropriately harnessed to ensure future clinicians do not lose this potentially life-saving skill.
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