Retinal Examination
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University of Milan - Bicocca
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Anthony Cavallerano,
O.D.
O
tf Care System
VA Boston Health
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The New England
College of Optometry
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Boston
D Massachusetts
University of Milan
December 2003
anthony.cavallerano@va.gov
Cavalleranot@ne-optometry.edu
Fundus Anatomy and Landmark of the Retina
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 Posterior Pole: -optic nerve
-macula
 Equator: vortex veins
 Peripheral retina:
ora serrata
long posterior ciliary nerves
short posterior ciliary nerves
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Posterior pole
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Fundus Anatomy and Landmark of the Retina
y
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 Posterior Pole: -optic nerve
-macula
 Equator: vortex veins
 Peripheral retina:
ora serrata
long posterior ciliary nerves
short posterior ciliary nerves
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a
r
+ +
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n
Equator
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Fundus Anatomy and Landmark of the Retina
y
l
 Posterior Pole: -optic nerve
-macula
 Equator: vortex veins
 Peripheral retina:
ora serrata
long posterior ciliary nerves
short posterior ciliary nerves
f
a
r
+ +
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O
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n
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O
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D
Ora
serrata
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Fundus Anatomy and Landmark of the Retina
y
l
 Posterior Pole: -optic nerve
-macula
 Equator: vortex veins
 Peripheral retina:
ora serrata
long posterior ciliary nerves
short posterior ciliary nerves
f
a
r
+ +
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O
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n
D
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There are various methods of examining the
retina.
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These include:
 direct ophthalmoscopy
 monocular indirect ophthalmoscopy
 binocular indirect ophthalmoscopy
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A comparison chart of the 3 instruments can demonstrate
the advantage and disadvantages of the 3 instruments
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1 DD :vertical
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Lesion size/
distance in disc
diameters
Optic nerve
1 DD: horizontal
Eg: lesion is 1/2DD in size Hx V and 2DD away superior
temporal from the optic nerve head
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Direct
Ophthalomoscopy
Image
Upright
Magnification
15x (high)
Field of View
10 degrees
Equivalent in
DD size
2DD
Pupil size
Undilated
Stereopsis
None
Resolution
good
Working
Distance
Very short
Media
Evaluation
Excellent
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Monocular
Indirect
Ophthalmoscopy
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Binocular Indirect
Ophthalmoscopy
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Monocular Indirect Ophthalmoscope
Instrument:
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• Magnifying eyepiece
• Relay system re-inverts image to a real one
• Image is focused using eye piece
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Relay
Lens
System
Examiner
Magnifying
eyepiece
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Light
Source
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Patient
Indication of use:
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•
•
•
•
Small pupils
Uncooperative children
Patients intolerant to bright illumination
One handed technique
•
Person who is monocular
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Direct
Ophthalomoscopy
Monocular
Indirect
Ophthalmoscopy
Image
Upright
Magnification
5x fixed mag
Field of View
40-45 degrees
Equivalent in
DD size
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Pupil size
Stereopsis
Resolution
Working
Distance
Media
Evaluation
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8DD
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Undilated
No stereopsis
Fair
Short distance
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Binocular Indirect
Ophthalmoscopy
Binocular Indirect Ophthalmoscope
Instrument: consists of a:
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 optical viewing system
 rheostat illuminating system
 headband
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Optics:
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• Light from B.I.O. directed into patients eye
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• Reflected beams from retina are focused using
a high plus lens
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• Aerial image produced
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Direct
Ophthalomoscopy
Monocular
Indirect
Ophthalmoscopy
Image
Inverted
Magnification
Field of View
Equivalent in
DD size
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Pupil size
Stereopsis
Resolution
Working
Distance
Media
Evaluation
Binocular Indirect
Ophthalmoscopy
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2.5x (variable)
40-45 degrees
8DD
Dilated
yes
Excellent
Arms length
No
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Condensing Lens:
Magnification:
F eye / F condensing = Mag x
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Magnification versus field of view
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Lens size Magnification
Field of View
20D
30D
3x
2x
less than 30D lens
greater than 20 lens
15D
4x
2.2D
D
less than 20 and 30D
lens
mag equivalent field of view equivalent
of 20D
of 30D
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Technique
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 PD measurement
 Location of light source
 Headband fit vs. spectacle
 Obtain stereopsis
 Holding the condensing lens
 Examiner and patient position
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Technique
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 PD measurement
 Location of light source
 Headband fit vs. spectacle
 Obtain stereopsis
 Holding the condensing lens
 Examiner and patient position
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Technique
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 PD measurement
 Location of light source
 Headband fit vs. spectacle
 Obtain stereopsis
 Holding the condensing lens
 Examiner and patient position
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Technique
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 PD measurement
 Location of light source
 Headband fit vs. spectacle
 Obtain stereopsis
 Holding the condensing lens
 Examiner and patient position
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Technique
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 PD measurement
 Location of light source
 Headband fit vs. spectacle
 Obtain stereopsis
 Holding the condensing lens
 Examiner and patient position
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D
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Binocular Indirect Ophthalmoscopy
• Holding the condensing lens
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• Distance of condensing lens and eye
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• Red reflex
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• Filling the condensing lens image
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Binocular Indirect Ophthalmoscope
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• Examine the retina in a chronological order
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• 9 positions to examine
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• Obtain overlapping views
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3
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eg. To examine the patient’s right eye at the 3 o’clock
position, direct the patient’s gaze to that position (3
o’clock)
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 You record your results in the 3 o’clock position
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 However in your view at this position everything is
inverted and reversed
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Universal (Goldmann) 3-Mirror Lens
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 Contact technique: lens with slit lamp
biomicroscope
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 Lens placed on the cornea
tf
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 3- dimensional view
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 Used both on undilated and dilated pupil
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Virtual Image
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Patient
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Slit Lamp
Light Source
Universal (Goldmann) 3-Mirror Lens
 Central lens:
 Trapezoid mirror:
evaluation
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for equatorial retinal
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 Rectangular mirror:
evaluation
 Gonio mirror:
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used for posterior pole evaluation
for equator to ora retinal
evaluation of the ora serrata
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Posterior pole
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Universal (Goldmann) 3-Mirror Lens
 Central lens:
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used for posterior pole evaluation
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 Trapezoid mirror: for equatorial retinal
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evaluation
 Rectangular mirror: for equator to ora retinal
evaluation
 Gonio mirror:
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evaluation of the ora serrata
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Equator
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Goldmann 3 Mirror Lens
 Central lens:
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used for posterior pole evaluation
 Trapezoid mirror:
evaluation
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for equatorial retinal
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 Rectangular mirror: for equator to ora retinal
evaluation
 Gonio mirror:
evaluation of the ora serrata
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Ora serrata
Equator
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Hand-held Condensing Lens
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Advantages:* non-contact
* provides stereopsis
* use with slit lamp biomicroscope
* well illuminated view of the
posterior pole
* alternative procedure to
Goldmann 3 mirror lens
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Biomicroscope
Light Source
Reversed Inverted
Aerial Image
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O
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90D Lens
Patient
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Condensing Lens
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* double aspheric lens
* clear or yellow coated
* available in many different powers
* pupil dilation desirable
* lens alignment, visual axis centration, vertex
distancing tilting is needed in this procedure
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Comparison of auxillary lenses
Lens size
60D
Magnification
1.09
78D
0.87
90D
0.72
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Superfield
0.76
Super 66
1.00
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Field of View
67 degrees
working
distance from
cornea
11mm
68 degrees
7 mm
69 degrees
6.5mm
116 degrees
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96 degrees
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