[Magnification in ophthalmoscopy. I. Theory of magnification in direct ophthalmoscopy].
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Humans↗
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[Magnification in ophthalmoscopy, II. Theory of magnification in indirect ophthalmoscopy].
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Humans↗
Indirect micro-ophthalmoscopy: intraoperative binocular indirect ophthalmoscopy with the operating microscope.
A hand-held indirect lens and an operating microscope can provide a view of the fundus similar to that provided by the usual binocular indirect ophthalmoscope headpiece. The only modification required is that the working distance must be increased to allow the microscope to be focused on the aerial image created by the hand-held lens. This technique provides a cost-effective means of retinal examination in preparation for intraocular lens implantation. Also, the view of the fundus it provides when complications such as choroidal hemorrhage or lens nucleus dislocation occur, facilitates appropriate management. It also can be used during posterior segment procedures such as foreign body removal, posterior vitrectomy, and retinal detachment repair. The advantages of this method include the possibility of using the microscope's zoom capability to provide greater magnification, and beam splitters for video or still-camera documentation of the findings during examination under anesthesia.
Cataract Extraction↗
Scanning laser ophthalmoscopy in the early diagnosis of vitreoretinal interface syndrome.
BACKGROUND: The purpose of this study was to estimate if and to what extent scanning laser ophthalmoscopy can help in the early diagnosis and follow-up management of the vitreoretinal interface syndrome, which includes disorders such as cellophane maculopathy, pseudomacular hole, macular pucker, and macular hole. METHODS: The 35 fellow eyes of 35 patients with vitreoretinal interface syndromes in the first eye underwent scanning laser ophthalmoscopy microperimetry and argon, helium-neon, and infrared scanning laser ophthalmoscopy. Fellow eyes were defined as clinically positive or negative for vitreoretinal interface syndrome. Fellow eyes then were classified based on scanning laser ophthalmoscopy techniques. Patients were observed for an average of 18 months (range, 10-26 months). RESULTS: Thirty-two of the 35 fellow eyes were classified as clinically negative, and three of the 35 were classified as clinically positive. Fifteen of the 32 clinically negative fellow eyes were redefined as positive on scanning laser ophthalmoscopy. None of the clinically positive eyes proved to be negative on scanning laser ophthalmoscopy. During the average follow-up period (18 months), the condition of five of 18 fellow eyes that were positive on scanning laser ophthalmoscopy worsened. None of the 17 eyes that were negative on scanning laser ophthalmoscopy worsened. CONCLUSION: Scanning laser ophthalmoscopy can produce beautifully clear images of structures that are otherwise difficult to see and document, such as posterior hyaloid and the inner retinal layers. Despite a relatively limited number of cases and the short duration of the follow-up period, the present study suggests that scanning laser ophthalmoscopy has good sensitivity and specificity for the early diagnosis of vitreoretinal interface syndromes.
Eye Diseases↗
A simple device for teaching direct ophthalmoscopy to primary care practitioners.
PURPOSE: Ophthalmoscopy, a valuable skill for primary care practitioners, can be challenging to learn. A simple and inexpensive device for teaching direct ophthalmoscopy to primary care practitioners is described. DESIGN: Device description. METHODS: Cylindrical plastic canisters were altered to have an artificial pupil at one end and a replaceable fundus photograph at the other end to simulate the mechanics of performing direct ophthalmoscopy on a real eye. These were tested for ease of use by primary care students. RESULTS: The devices to aid in teaching ophthalmoscopy proved to be simple and inexpensive to construct. They allowed students to practice direct ophthalmoscopy technique and identification of funduscopic abnormalities. CONCLUSION: This simple device for teaching direct ophthalmoscopy to primary care practitioners is inexpensive to create and is a valuable aid for teaching direct ophthalmoscopy to primary care practitioners.
Eye Diseases↗
The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography.
PURPOSE: To evaluate single-field digital monochromatic nonmydriatic fundus photography as an adjunct in the screening of diabetic retinopathy. DESIGN: Prospective, comparative, observational case series. METHODS: Patients with type I and type II diabetes mellitus (n = 197) were sequentially evaluated by three different techniques: single-field digital monochromatic nonmydriatic photography; dilated ophthalmoscopy by an ophthalmologist; and seven Early Treatment Diabetic Retinopathy Study (ETDRS) standardized 35-mm color stereoscopic mydriatic images. The seven stereoscopic color photographs served as the reference standard and were compared with either ophthalmoscopy or a single digital photograph transmitted electronically to a reading site. Levels of agreement were determined by kappa analyses. The sensitivity and specificity of the three methods were compared based on a threshold for referral to further ophthalmologic evaluation (ETDRS level > or =35). RESULTS: There was highly significant agreement (kappa = 0.97, P =.0001) between the degree of retinopathy detected by a single nonmydriatic monochromatic digital photograph and that seen in seven standard 35-mm color stereoscopic mydriatic fields. The sensitivity of digital photography compared with color photography was 78%, with a specificity of 86%. Agreement was poor (kappa = 0.40, P =.0001) between mydriatic ophthalmoscopy and the seven-field standard 35-mm color photographs. Sensitivity of ophthalmoscopy compared with color photography was 34%, with a specificity of 100%. CONCLUSION: A single nonmydriatic monochromatic wide-field digital photograph of the disk and macula was more sensitive for diabetic retinopathy screening than mydriatic ophthalmoscopy, the currently accepted screening method. When adjudicated by standard seven-field color photographs, the higher sensitivity of digital photography primarily reflected the reduced sensitivity of ophthalmoscopy in detecting early retinopathy.
Adult↗
Comparing ophthalmoscopy, slide viewing, and semiautomated systems in optic disc morphometry.
PURPOSE: To compare disc measurements obtained by indirect ophthalmoscopy, the Heidelberg Retina Tomograph (HRT), stereoscopic slide viewing (SSV) of color transparencies, and the Topcon ImageNet System (ImageNet). DESIGN: Population-based cross-sectional study. METHODS: From the Rotterdam Study, 324 subjects (567 eyes) were nonselectively included. All underwent a full ophthalmologic examination in mydriasis. Vertical cup/disc ratios (VCDRs) were compared between all four methods and disc area (mm(2)), neural rim area (mm(2)), cup area (mm(2)), and cup volume (mm(3)) between HRT and ImageNet. RESULTS: Mean VCDR for ophthalmoscopy was 0.25 (standard error [SE], 0.007), for HRT 0.42 (SE, 0.008), for SSV 0.39 (SE, 0.010), and for ImageNet 0.50 (SE, 0.006). The correlation for VCDR between ophthalmoscopy, the two devices, and SSV was 0.42, respectively 0.57; between ImageNet and HRT 0.75. The 97.5th percentiles of the VCDR for ophthalmoscopy, HRT, SSV, and ImageNet were 0.80, 0.73, 0.80, and 0.73, respectively; the 99.5th percentiles thus were 0.90, 0.79, 0.86, and 0.79. The mean disc area, rim area, cup area, and cup volume were 2.08, 1.63, 0.45 mm(2) and 0.09 mm(3) for HRT, and 2.39, 1.77, 0.61 mm(2) and 0.16 mm(3) for ImageNet, respectively. The corresponding correlations for these four parameters were 0.67, 0.42, 0.81, and 0.82. CONCLUSIONS: Different techniques lead to considerable differences in disc morphometric values. ImageNet produced higher mean values compared with HRT and ophthalmoscopy. Ophthalmoscopy showed the lowest correlations and SSV the highest ones with the two semiautomated devices. Between ImageNet and HRT the correlation for all parameters was high except for the neural rim area.
Cross-Sectional Studies↗
Does direct ophthalmoscopy improve retinal screening for diabetic eye disease by retinal photography?
AIMS: To identify whether after performing retinal photography, direct ophthalmoscopy can improve the yield of screening for the detection of sight-threatening diabetic eye disease (STDED). METHODS: Patients (n = 408) who had previously received both dilated direct ophthalmoscopy by a diabetologist and retinal photography graded by a diabetologist within 3 months of each other were included. The results of the other screening modality were not available to the grader/screener. The first 308 patients were consecutive attendees at the clinic who fulfilled the study criteria and 100 were selected because they were identified as having potential STDED by either one of these modalities. An ophthalmologist using slit lamp biomicroscopy then examined patients identified with potential STDED. RESULTS: In 357 (88%) patients there was agreement between the two modalities about whether referral to an ophthalmologist was required (kappa 0.62). Retinal photography identified 38 patients for referral to ophthalmology which ophthalmoscopy missed. Of these, the ophthalmologist agreed that STDED was present in 32 (84%) and four patients required early laser. Ophthalmoscopy identified 13 patients for referral who were not identified by photography. Of these, the ophthalmologist agreed with the diabetologist that STDED was present in seven (54%) and one patient required early laser. CONCLUSION: Ophthalmoscopy may identify the occasional patient with diabetes who has STDED which is missed by retinal photography. For a systematic retinal screening programme, adding ophthalmoscopy to retinal photography will increase false-positive referrals and is likely to detect only a few extra patients requiring laser.
Chi-Square Distribution↗
Comparison of non-mydriatic retinal photography with ophthalmoscopy in 2159 patients: mobile retinal camera study.
OBJECTIVE: To determine whether non-mydriatic Polaroid retinal photography was comparable to ophthalmoscopy with mydriasis in routine clinic screening for early, treatable diabetic retinopathy. DESIGN: Prospective study of ophthalmoscopic findings according to retinal camera screening and ophthalmoscopy and outcome of referral to ophthalmologist. SETTING: Outpatient diabetic clinics of three teaching hospitals and three district general hospitals. PATIENTS: 2159 Adults selected randomly from the diabetic clinics, excluding only those registered as blind or those in wheelchairs and unable to enter the screening vehicle. MAIN OUTCOME MEASURES: Numbers of patients and eyes correctly identified by each technique as requiring referral with potentially treatable retinopathy (new vessel formation and maculopathy) and congruence in numbers of microaneurysms, haemorrhages, and exudates reported. RESULTS: Camera screening missed two cases of new vessel formation and did not identify a further 12 but indicated a need for referral. Ophthalmoscopy missed five cases of new vessel formation and indicated a need for referral in another four for other reasons. Maculopathy was reported in 147 eyes with camera screening alone and 95 eyes by ophthalmoscopy only (chi 2 = 11.2; p less than 0.001), in 66 and 29 of which respectively maculopathy was subsequently confirmed. Overall, 38 eyes received laser treatment for maculopathy after detection by camera screening compared with 17 after ophthalmoscopic detection (chi 2 = 8.0; p less than 0.01). Camera screening underestimated numbers of microaneurysms (chi 2 = 12.9; p less than 0.001) and haemorrhages (chi 2 = 7.4; p less than 0.01) and ophthalmoscopy underestimated hard exudates (chi 2 = 48.2; p less than 0.001). CONCLUSIONS: Non-mydriatic Polaroid retinal photography is at least as good as ophthalmoscopy with mydriasis in routine diabetic clinics in identifying new vessel formation and absence of retinopathy and is significantly better in detecting exudative maculopathy.
Adolescent↗
Medical students' self-confidence in performing direct ophthalmoscopy in clinical training.
BACKGROUND: Although direct ophthalmoscopy is an important skill that medical students must practice to gain proficiency, limited time is generally available in medical school curricula. More targeted and effective teaching could result from a clearer understanding of medical students' self-reported needs and weaknesses in performing direct ophthalmoscopy. METHODS: A cross-sectional survey was conducted at a Canadian university to determine the confidence of medical students in their skill in performing direct ophthalmoscopy. The responses of 208 participants who volunteered to complete a 21-item questionnaire were analyzed. RESULTS: Although clerks were significantly more confident in their overall skill (chi2=28.03, p<0.001) than were first- and second-year students, 47% of clerks were "not at all" or only "a little" confident in performing direct ophthalmoscopy on an undilated pupil. Respondents who had practiced on more than 10 occasions outside of formal teaching were significantly more confident in their overall skill than those who had not (chi2=22.94, p<0.001). Overall, 87% (77% of clerks) were "quite" or "extremely" interested in more practice and training on direct ophthalmoscopy. INTERPRETATION: A large proportion of medical students reported not being confident in various aspects of their skill in performing direct ophthalmoscopy. Self-confidence was significantly greater among students who practiced outside of formal teaching sessions. Most students were interested in additional training, and medical schools should emphasize the importance of practicing whenever appropriate.
Clinical Clerkship↗
Effectiveness of non-mydriatic retinal photography and direct ophthalmoscopy in detecting diabetic retinopathy.
This is a prospective study to compare the effectiveness of non-mydriatic photography with that of direct ophthalmoscopy in screening for diabetic retinopathy in 153 patients attending a hospital clinic in Hong Kong. Retinal photography under physiological mydriasis and direct ophthalmoscopy of patients with dilated pupils were compared with the ophthalmologists' examination results as a reference standard. The prevalence of diabetic retinopathy in this sample population was 15%. The sensitivity of detecting diabetic retinopathy by retinal photography was higher than that of direct ophthalmoscopy (64% versus 41%; 95% confidence interval of difference, 1.2%- 44.3%). Of five patients who had serious retinopathy, retinal photography failed to detect the disease in two; direct ophthalmoscopy failed to detect the disease in all five patients. Specificities of retinal photography and direct ophthalmoscopy were 90% (95% confidence interval, 84%-96%) and 93% (95% confidence interval, 88%-97%), respectively. We conclude that retinal photography is significantly more effective than direct ophthalmoscopy in detecting diabetic retinopathy. In addition, the non-mydriatic camera is easy to use and is the preferred method of screening.
Journal Article↗
Screening for diabetic retinopathy by general practitioners: ophthalmoscopy or retinal photography as 35 mm colour transparencies?
In order to assess the relative ability of general practitioners (GPs) to detect diabetic retinopathy (DR), especially sight-threatening diabetic retinopathy (STDR) by direct ophthalmoscopy or by examining, on a separate occasion, retinal images as 35 mm colour transparencies, a South and Mid Wales primary care-based study was performed in four general practices (six GPs). The participating GPs were provided with standardized training and equipment. Both methods were compared to the 'reference' grade of DR provided by the Diabetic Retinopathy Reading Centre (London), based on the same retinal images. Ophthalmoscopy and retinal photography (Canon CR4 45NM) with mydriasis were all practice based. The clinical assessments were based on a protocol developed for screening for DR in Europe. A total of 996 people with diabetes were identified, representing a prevalence of known diabetes of 2.1%. After exclusions on medical grounds, 897 patients were available for screening, of whom 605 (68%) were photographed. Based on the retinal images, the reference centre identified DR in 43% and STDR in 14.4%. In total, 597 valid comparisons between GPs and the reference centre were obtained; of these, 462 (77%) were high quality photographs which were used in subsequent analysis. The sensitivity for detecting any DR increased from 62.6% (95% CI 55.9-69.4) with ophthalmoscopy to 79.2% (95% CI 73.6-84.9) using retinal photographs, specificity remaining essentially unchanged at 75.0 (95% CI 69.5-80.5) and 73.5% (95% CI 68.0-79.1) with the positive predictive value (PPV) increasing from 67.2 (95% CI 60.4-74.0) to 71.0% (95% CI 65.0-77.0), respectively. The detection of STDR sensitivity increased from 65.7 (95% CI 54.4-77.1) with ophthalmoscopy alone to 87.3% (95% CI 79.4-95.2) based on retinal photographs with specificity falling from 93.8 (95% CI 91.4-96.3) to 84.8% (95% CI 81.2-88.5) and PPV from 65.7 (95% CI 54.4-77.1) to 51.2% (95% CI 42.1-60.3), respectively. We conclude that the use of standardized 35 mm colour transparency retinal photographs for screening by trained GPs in a primary care setting achieves an acceptable detection rate (>87%) for STDR, contrasting with ophthalmoscopy alone (66%), which was below the proposed UK standard of 80%.
Diabetes Mellitus, Type 1↗
Comparison between ophthalmoscopy and fundus photography in determining severity of diabetic retinopathy.
Diabetic retinopathy was assessed in a population-based study of 2708 diabetic persons in southern Wisconsin. The retinopathy levels as determined by ophthalmoscopy and by the grading of stereoscopic fundus photographs were compared in the eyes of 1949 persons. Ophthalmoscopy was performed by an ophthalmologist and a specially trained optometrist and ophthalmic technician. Consultation among the three examiners was permitted. There was exact agreement between ophthalmoscopy and grading for detecting retinopathy (none, nonproliferative, proliferative) 85.7% of the time. The kappa statistic, which corrects for chance agreement, was 0.749. There were no significant differences among the three ophthalmoscopists. Ophthalmoscopy was more likely to disagree with fundus photography grading in eyes with less severe forms of retinopathy and in patients examined early in the study. Other factors found to influence the degree of agreement were age, visual acuity, and duration of diabetes. It is concluded that with proper training ophthalmoscopy can be an acceptable alternative to fundus photography in certain situations.
Aneurysm↗
The diagnosis of diabetic retinopathy. Ophthalmoscopy versus fundus photography.
PURPOSE: To compare fundus photography with ophthalmoscopy in the detection of diabetic retinopathy. METHODS: Ophthalmoscopy and fundus photographs with a nonmydriatic camera, both performed through dilated pupils, were compared to diagnose retinopathy in a cohort of 410 Oklahoma Indians with noninsulin-dependent diabetes mellitus. A total of 795 eyes were examined using both methods. The mean age of participants was 60.3 years, with a mean duration of diabetes of 17.3 years. RESULTS: An overall agreement of 86.3% with a kappa statistic kappa of 0.74 was found between ophthalmoscopy and fundus photography with a nonmydriatic camera. For the diagnosis of proliferative diabetic retinopathy, kappa = 0.84 with an agreement of 98.1%. With a total of 61 cases of proliferative retinopathy diagnosed by either method in our study, ophthalmoscopy alone detected 88.5% and fundus photography, 78.7%. When compared on a lesion-by-lesion basis, agreement between the two diagnostic methods was highest for nonproliferative retinopathy, as well as fibrous proliferation. CONCLUSION: The fundus photography with a nonmydriatic camera, performed with mydriasis, is comparable to ophthalmoscopy for the detection of retinopathy. It may prove to be a suitable, cost-effective method for routine screening in diabetes clinics, provided ophthalmologic referral is ensured for those with a diagnosis of any form of retinopathy, questionable retinopathy, nondiabetic retinopathy, those with poor quality photographs, as well as those with acute changes in visual acuity.
Diabetes Mellitus, Type 2↗
Use of refractive direct ophthalmoscopy for estimation of refractive error.
The purpose of this study was to find if direct ophthalmoscopy, a simple technique, could be used to give an approximate value of the refractive correction for a patient. This would shorten the time and lessen the effort to be expended during the following retinoscopic examination done for finding the patient's refractive correction. The use of direct ophthalmoscopy for this specific purpose is especially desirable where retinoscopic examination is quite tedious, e.g. uncooperative patients like children, bed-ridden patients and mentally retarded subjects, in patients with a large central corneal opacity and in patients having a large refractive error. The study was divided into two phases. In phase I, refractive direct ophthalmoscopy followed by classical retinoscopy was done for 92 subjects (184 eyes) in the age group of 11-35 years. The method of regression analysis was used to find a regression equation relating the readings to refractive error determined by the two above techniques. In phase II of study, the refractive correction needed for 50 other subjects in the similar age group was estimated using this regression equation by inserting their respective direct ophthalmoscopy readings. Then, these estimated values and classical retinoscopic examination values were compared. The refractive error determined after retinoscopy and that derived from regression equation (incorporating direct ophthalmoscopy readings) was statistically comparable (t = 0.52, p = 0.60). The correlation coefficient (r value) between the two methods was 0.37. Direct ophthalmoscopic lens reading can be used to give a fairly accurate estimate of refractive error in a patient's eye by using a linear regression equation, which relates these two examination techniques. The magnitude of astigmatic error, however, cannot be obtained.
Adolescent↗
Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study.
OBJECTIVE: To evaluate different methods for community based screening for sight threatening diabetic eye disease. DESIGN: Prospective study. SETTING: Mobile screening unit visiting inner city community clinics; hospital assessment clinic (tertiary centre). SUBJECTS: 395 diabetic patients registered with four general practices in an inner city location. INTERVENTIONS: Community based photography with mydriasis and direct ophthalmoscopy through dilated pupils by an experienced ophthalmologist, both compared with reference standard of slit lamp biomicroscopy by a consultant specialist in medical retinal disease. MAIN OUTCOME MEASURES: Sensitivity and specificity of screening method and prevalence of sight threatening diabetic eye disease (moderate preproliferative retinopathy, circinate maculopathy, exudate within 1 disc diameter of fixation, other diabetes related eye disease). RESULTS: 358 subjects underwent photography, 326 attended hospital clinic for ophthalmoscopy, and six were ungradable on photographs and biomicroscopy, leaving 320 for analysis. Of these 295 (91%) attended clinic within four months of photography. Sensitivity of detection of eye disease by photography was 89% (95% confidence interval 80% to 98%), significantly better than for direct ophthalmoscopy (65% (51% to 79%)). Analysis of patients with false negative results indicated possible improvement of photographic sensitivity to 93% by addition of stereoscopic macular pair photographs. Specificity of detection of sight threatening eye disease was 86% (82% to 90%) for photography and 97% (95% to 99%) for direct ophthalmoscopy. CONCLUSIONS: Since high sensitivity is essential for an effective screening programme, a photographic method should be considered as preferred option in national, community based screening programmes. Even in the hands of an experienced ophthalmologist, direct ophthalmoscopy is limited by weaknesses inherent to the instrument.
Ambulatory Care↗
Do junior house officers routinely test visual acuity and perform ophthalmoscopy?
UNLABELLED: Our objective was to assess junior house officer (JHO) practice of visual acuity testing and ophthalmoscopy in clerking patients. DESIGN: Cross-sectional questionnaire-based study using a standardised structured interview technique. SETTING: A Scottish university teaching hospital employing 65 JHOs. PARTICIPANTS: All medical and surgical JHOs from this hospital were interviewed over a three month period. MAIN OUTCOME MEASURES: Questionnaire-based data on the subjective responses studying current practice of visual acuity testing, and direct ophthalmoscopy with and without topical mydriatics. RESULTS: 18.5% and 4.6% of participants perform daily ophthalmoscopy and visual acuity testing respectively. Most do not routinely use the Snellen chart (80.0%) or topical mydriatics during ophthalmoscopy (75.4%). JHOs claimed these were not easily available in the wards. CONCLUSIONS: The majority of JHOs fail to test visual acuity or perform ophthalmoscopy in clerking patients. This study highlights the poor availability of Snellen charts, functioning ophthalmoscopes, and topical mydriatics in the wards. This warrants further investigation.
Hospitals, Teaching↗
Assessment of the dark-adaptation time required for recovery of electroretinographic responses in dogs after fundus photography and indirect ophthalmoscopy.
OBJECTIVE: To investigate the duration of dark-adaptation time required for recovery of electroretinographic responses after fundus photography or indirect ophthalmoscopy in dogs. ANIMALS: 6 dogs. PROCEDURE: Initially, scotopic-intensity series of electroretinograms (ERGs) were recorded after 20 minutes of dark adaptation. The fundus of the left eye of each dog was photographed (n = 10) or examined via indirect ophthalmoscopy for 5 minutes with moderate- (117 candela [cd]/m2) or bright-intensity (1,693 cd/m2) light; ERGs were repeated after a further 20 or 60 minutes of dark adaptation (6 procedures/dog). RESULTS: Following 20 minutes of dark adaptation after fundus photography, the b- and a-wave amplitudes were reduced in response to brighter stimuli, compared with pretest ERGs; after 60 minutes of dark adaptation, ERG amplitudes had recovered. Following 20 minutes of dark adaptation after indirect ophthalmoscopy (moderate-intensity light), significantly lower b-wave amplitudes were recorded in response to 2 of the brighter flash stimuli, compared with pretest ERGs; after 60 minutes of dark adaptation, ERG amplitudes had recovered. Following 20 minutes of dark adaptation after indirect ophthalmoscopy (bright-intensity light), all ERG amplitudes were significantly decreased and implicit times were significantly decreased at several flash intensities, compared with pretest ERGs; after 60 minutes of dark adaptation, ERG amplitudes and implicit times had returned to initial values, except for b-wave amplitudes recorded in response to dimmer stimuli. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that at least 60 minutes of dark adaptation should be allowed before ERGs are performed in dogs after fundus photography or indirect ophthalmoscopy.
Adaptation, Ocular↗