Performing Fundoscopy (Stanford Medicine, n.d.;  Schneiderman, 1990)

Developing a consistant approach to fundoscopic examinations will improve the speed and efficiency with which you are able to perform this procedure.
 

1. Ask the patient to remove their eyeglasses. Contact lenses may remain in place.
2. Dim the lights, however the room shouldn’t be completely dark.
3. Explain the procedure to the patient.
4. Patient should be in an upright sitting position.
5. Ask the patient to focus on a specific point about 3 feet away, looking slightly away from you.
6. Hold the scope in your right hand, up to your right eye and press it against your right cheek. Rest your other hand on the patient’s head with your thumb on the patient’s right eyebrow.
7. Look through the ophthalmoscope into the patient’s right eye. Keep your other eye open.
8. Begin at arm’s length and shine the scope into the patient’s pupil. Move the scope 15 degrees away (laterally) from the center and look for the red reflex. Then follow the red reflex medially (toward the nose) until you see the retina.
9. Slowly move toward the patient until the instrument is about 1-2 inches away from the patient’s eye. You may rest your head on your left thumb.
10. You should see the optic disc. If out of focus, adjust the lens dial up or down until you achieve focus.
11. Move the light around the retina until you have visualized all areas. Ask the patient to look directly into the light to view the macula last.
12. Repeat procedure with the left eye.

Mydriatic (pupil dilating) drops may be used to facilitate the procedure, typically in specialized ophthamology settings. If dilating drops will be used, inform that patients that they’ll need someone to drive them home. Ask the patient to report an inability to regain accommodation (focus) within two hours after the procedure. They should also report any eye pain or unusual headache that day.
 

Normal Anatomical Landmarks

Once you master the ability to view the retina, work on observing these normal anatomical landmarks.

• Optic disc – yellow-pink in color and stands out from the red/orange background; this is the optic nerve head.
• Optic cup – pale-white, central area of the optic disc, normally less than one-third the diameter of the optic disc.
• Macula – dark spot on the retinal surface free from arteries or veins. It is responsible for central vision and is comprised of the fovea and perifovea areas.
• Fovea – central area of the macula; better seen with a red-free filter and is typically 2 disc diameters away from the optic disc. It is responsible for high-acuity vision.
• Vessels
  • Start at the disc and follow the vessels out inspecting for hypertensive and arteriosclerotic changes.
  • Central retinal artery branches off the optic nerve. Arteries are smaller, narrower, and lighter in color than veins.
  • Central retinal vein branches off the optic nerve and appears pulsating.

PEARLS

• An increased size in the optic cup may indicate glaucoma.
• An obscured red reflex may be caused by corneal scars, cataracts, or vitreous hemorrhage.
• Neovascularization (new vessels)on the optic disc are a sign of proliferative diabetic retinopathy.
• Retinal detachment is best viewed with pupils dilated under indirect fundoscopy.