From the Guidelines
The ophthalmoscope exam is a crucial tool for primary care providers to screen for ocular pathology and systemic disease manifestations, and it should be performed regularly to prevent or minimize vision loss by detecting and treating diseases at an early stage. According to the most recent and highest quality study 1, a thorough ophthalmic evaluation can detect common abnormalities of the visual system and related structures, as well as less common yet extremely serious issues, such as ocular tumors. The study also highlights that up to 40% of legal blindness found among nursing home residents, as well as in both urban and rural communities, could have been prevented or ameliorated if those individuals had received timely ophthalmic screening and care.
To perform an ophthalmoscope exam, begin by dimming room lights and having the patient fixate on a distant object. Hold the ophthalmoscope in your dominant hand, matching the same side as the patient's eye you're examining, and use your index finger to rotate the lens dial to achieve focus (start with +8 to +10 diopters). Approach from about 15 inches away at a 15-degree angle temporal to the patient's line of sight, looking for the red reflex. Then move closer (about 2 inches from the patient's eye) while adjusting the diopter to maintain focus, systematically examining the optic disc, blood vessels, macula, and peripheral retina. Key findings to document include disc color, cup-to-disc ratio, vessel caliber, any hemorrhages, exudates, or other abnormalities.
The clinical objectives of the ophthalmoscope exam, as outlined in the study 1, include detecting and diagnosing ocular abnormalities and diseases, identifying risk factors for ocular disease, and establishing the presence or absence of ocular signs or symptoms of systemic disease. The study also emphasizes the importance of discussing the results and implications of the examination with the patient and initiating an appropriate management plan. Regular practice improves technique, as this examination requires skill development, and consideration should be given to pupillary dilation with tropicamide 1% for better visualization when indicated, though being aware that this temporarily affects vision and should be avoided in patients at risk for angle-closure glaucoma.
Common pathologies to screen for during the ophthalmoscope exam include:
- Diabetic retinopathy
- Hypertensive changes
- Papilledema
- Glaucomatous changes These conditions can have a significant impact on morbidity, mortality, and quality of life, and early detection and treatment can improve outcomes. As noted in the study 1, with appropriate and timely intervention, visually impairing conditions such as cataract, and potentially blinding diseases such as glaucoma, age-related macular degeneration, and diabetic retinopathy often have favorable outcomes.
From the Research
Ophthalmoscope Exam in Primary Care
- The ophthalmoscope exam is a crucial tool in primary care for evaluating patients' ocular complaints, as 2% to 3% of clinical visits are for eye complaints 2.
- Primary care physicians can use examination techniques such as direct ophthalmoscopy to screen for patients at risk of vision loss from glaucoma, diabetes, and toxic medication 2.
- The ophthalmoscope exam can help identify visual changes, redness, and pain, which are common categories of patient complaints 2.
- Regular ophthalmic examinations are essential for managing diabetic retinopathy, a common microvascular complication of diabetes mellitus 3.
- Innovative ocular imaging techniques like optical coherence tomography (OCT) and OCT angiography (OCT-A) play an important role in assessing diabetic patients and identifying new biomarkers for early diagnosis and long-term prognosis 3.
Role of Primary Care Physicians
- Primary care physicians can play a vital role in preserving vision in their patients by managing systemic diseases that impact eye health and ensuring that patients undergo periodic evaluations by eye care professionals 4.
- Primary care clinicians can optimize management of systemic diseases, such as diabetes, hypertension, and hyperlipidemia, to significantly reduce the risk of related eye disorders 4.
- While the value of routine screening for vision loss in the primary care setting has not been established, timely identification and treatment of eye diseases can substantially reduce the incidence and prevalence of visual disability among older adults 4.
Diagnostic Tools
- Optical coherence tomography angiography (OCTA) has been developed to visualize the retinal microvasculature and has a promising role as an objective tool for quantifying the extent of microvascular damage and identifying eyes with diabetic macular ischemia contributed to visual loss 5, 6.
- OCTA offers numerous benefits over traditional fluorescein angiography, including being non-invasive and safer, and its depth-resolved ability makes it possible to visualize the finer capillaries of the retinal capillary plexuses and choriocapillaris 6.