How do I perform fundoscopy using a direct ophthalmoscope?

How to Perform Direct Ophthalmoscopy

Master the motor skills first before worrying about what you're seeing—hold the ophthalmoscope in your right hand for the patient's right eye and left hand for their left eye, position yourself at arm's length initially, dial to "0" for both you and the patient if neither wears glasses, then move in close (within inches) while keeping both your eyes open and looking through the small aperture at the red reflex, following it inward until fundal structures come into focus.

Preparation and Setup

Patient Positioning

• Darken the room to allow pupil dilation
• Have the patient fixate on a distant target straight ahead
• Dilate the pupil when possible for optimal visualization of the optic nerve, macula, and peripheral retina 1, 2, 3

Ophthalmoscope Settings

• Start with the lens dial at "0" (no correction)
• If you wear glasses, keep them on and adjust the dial accordingly
• If the patient is myopic (nearsighted), you'll need negative (red) numbers
• If the patient is hyperopic (farsighted), you'll need positive (black) numbers
• Use the large white light for general examination

The Examination Technique

Step-by-Step Approach

1. Hold the instrument correctly:

• Right hand, right eye for patient's right eye
• Left hand, left eye for patient's left eye
• Rest your other hand on the patient's shoulder for stability
• Keep your examining eye open AND your other eye open (closing one eye makes it harder)

2. Find the red reflex:

• Position yourself at arm's length (about 15 inches away)
• Look through the ophthalmoscope at the patient's pupil
• You should see an orange-red glow (the red reflex)
• This confirms light is reaching the retina

3. Move in close:

• Follow the red reflex inward, moving straight toward the patient
• Get within 1-2 inches of the patient's eye
• Maintain the same angle of approach
• This proximity is essential—staying too far away is the most common error

4. Focus the image:

• Rotate the lens dial to bring structures into focus
• Start at "0" and adjust as needed
• The optic disc should appear as a yellow-orange oval structure

What to Examine

Systematic fundus examination 1, 4, 3:

1. Optic disc:

   • Color (normally yellow-orange to pink)
   • Margins (should be sharp)
   • Cup-to-disc ratio (normally <0.5)
   • Presence of neovascularization

2. Retinal vessels:

   • Follow vessels from the disc outward
   • Note caliber, tortuosity, and any abnormalities
   • Look for hemorrhages, emboli, or "boxcarring"

3. Macula:

   • Ask patient to look directly at the light
   • Located about 2 disc diameters temporal to the optic disc
   • Should appear slightly darker than surrounding retina

4. Peripheral retina:

   • Have patient look in different directions (up, down, left, right)
   • Note: Indirect ophthalmoscopy is superior for peripheral examination 5, 4

Common Pitfalls to Avoid

• Staying too far away: You must get within 1-2 inches of the patient's eye
• Closing your non-examining eye: Keep both eyes open
• Not dilating when indicated: Undilated examination severely limits your view
• Wrong hand/eye combination: This creates an awkward position and poor visualization
• Examining through an undilated pupil in dim light without first checking for neovascularization: Gonioscopy should be performed before dilation when iris neovascularization is suspected 1

Alternative Approaches

For posterior pole examination: Slit-lamp biomicroscopy with appropriate lenses provides superior visualization and is the preferred method in many clinical scenarios 5, 4

For peripheral retina: Indirect ophthalmoscopy with scleral indentation is the gold standard 5, 4, 3

Learning the Skill

A structured 7-step teaching approach has proven successful 6:

1. Have your fundus examined first (ensures no impediment)
2. Examine your teacher's eye
3. Practice holding the ophthalmoscope correctly
4. Read printed text through the ophthalmoscope to master focusing
5. Re-examine your teacher with guidance
6. Examine an older cooperative patient
7. Finally examine a young child

Teaching ophthalmoscopes that allow a third person to observe your view significantly improve learning outcomes and confidence 7