Medical Instruments I
Practical Use of the
Ophthalmoscope and Otoscope
Amanda Kocoloski, OMS IV
Primary Care Associate/DFM Fellow
Objectives
• Understand how to use the following
equipment:
• Ophthalmoscope
• Otoscope
• Learn the fundoscopic exam and
introduce the ear exam
• Begin to appreciate normal eyes and
ears by practicing on colleagues and
instructors
Ophthalmoscope Basics
• Ophthalmoscope Anatomy
• Ophthalmoscope Operation
• Red Reflex
• Examination of the Fundus
Ophthalmoscope Anatomy
View of the scope from the doctor’s perspective
Ophthalmoscope Anatomy
(Continued)
View of the scope from the patient’s perspective
In the Office/SP Lab
Ophthalmoscope Operation
• Turning it on:
• Depress button
and rotate
• Adjust to about
mid-brightness
Ophthalmoscope Operation
• Use the large, round, white beam
• Smaller may be helpful if pupil is not dilated
• Set the wheel used for changing the lens at
zero diopters
Eye Anatomy
Red Reflex
• Reflection of light off of retina
• Pink to red in color
• Should be equal in both eyes
• Presence indicates there are NO opacities
within the following areas:
• Tear Film
• Cornea
• Anterior Chamber – Aqueous Fluid
• Lens
• Vitreous Fluid
Conditions With Absence of the
Red Reflex
• Cataracts
• Opacity of the lens
• Detached retina
• Retinoblastoma
• Artificial globe/eyeball
Ophthalmoscopic Exam: Red
Reflex
• Have your patient
look up and over
your shoulder
• To visualize the
red reflex, stand
about 15 inches
from your patient’s
eye
Ophthalmoscopic Exam:
Fundus
• Your right eye to patient’s right, your left to patient’s
left
• Place your free hand on the patient’s shoulder or
forehead for stabilization
• Beginning from the temporal aspect move in toward
your patient’s eye to begin examination of the fundus
• Keyhole phenomenon
• Focus by adjusting the diopter if necessary
• Should be unnecessary if neither you nor the
patient have uncorrected refractive errors
Ophthalmoscopic Exam:
Fundus
• Identify Vessels
• Veins: Large darker vessels
• Artery: Smaller brighter vessels
• Optic disk
•
•
•
•
Located on nasal aspect
Sharp margins; nasal may be blurred
Yellow/orange
Physiologic optic cup
• Macula and Fovea
• Located on temporal aspect
• Best visualized: stare directly at the light
Ophthalmoscopic Exam:
Fundus
• A:V ratio
• Arteries are 2/3 to 4/5 the diameter of veins
• AV nicking (”Gunn sign”)
• Associated with hypertension
• Pathological arterial circulation impedes venous
flow at their intersection
• Cup to disk ratio
• Cup is caused by central depression
• Divide width of physiologic cup by the disk
• Normal ratio is ≤ 0.5
Ophthalmoscopic Exam: AV
Nicking
Ophthalmoscopic Exam:
Fundus
• Spontaneous venous pulsations
• Normal as veins emerge from disc
• May be reduced or absent in with elevated
pressure
• Papilledema
• Optic nerve swelling
• Often associated with increased intracranial
pressure
• Almost always bilateral
Ophthalmoscopic Exam: Right
Fundus
Photo and corresponding diagram of a normal fundus. Note that the retinal
vessels all stop short of and do not cross the fovea.
Ear Exam
Examination of the External Ear
• Inspect the auricle for
deformities
•
•
•
•
Skin tags/pits
Lymph nodes
Epidermoid cyst
Squamous/basal cell
CA
• Pain, discharge, or
inflammation?
• Perform the tug test
Otoscopic Basics
Otoscopic Examination of the
EAC and TM
• Straighten the ear canal
• Adults- pull superior and posterior
• Children– pull posterior and maybe inferior
• Hold otoscope between your thumb and
fingers; rest hand on patient’s face
• Handle may point downward or toward patient’s
eyebrow
• Right hand when looking in the right ear, left
hand when looking in the left ear
Otoscopic Examination of the
EAC and TM
• Under direct
visualization: Insert the
speculum into the ear
canal, directing it
forward and downward
• Inspect the canal with
insertion
• Inspect the tympanic
membrane
• color
• contour
• anatomical structures
Otoscopic Examination of the
EAC and TM
Incus
Pars flaccida
Incus
Malleus
Umbo
Pars
tensa
Pars
tensa
Normal right ear
Cone of light
Normal left ear
References
• Bates’ Guide to Physical Examination, Chapter 5.
• http://emedicine.medscape.com/article/120
1779-overview
http://www.medicine.ucsd.edu/clinicalmed
/introduction.htm
• Vaughan & Asbury's General
Ophthalmology, 17e