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Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
DOES DIRECT OPHTHALMOSCOPY HAVE A ROLE IN THE MODERN NHS?
“Medicine is learned by the bedside and not in the classroom. Let not your conceptions of
disease come from words heard in the lecture room. See, and then reason and compare and
control,” William Osler told his students.1 “But see first.”
Introduction
The direct ophthalmoscope was developed by a young German named Hermann Von
Helmholtz in 1851. Credit must be given to the British “father of modern computing”,
Charles Babbage, who first explored the concept of looking into the eye over four years
earlier.2 However, being unable to obtain an image upon demonstration of his instrument, it
was in fact Helmholtz who became the first person to observe a living human fundus.3
Known at the time as an “Augenspiegel” (eye-mirror), it would revolutionise ophthalmology.
Prior to its invention, there was much speculation surrounding fundal physiology with some
theories suggesting a process similar to that which makes fireflies glow was taking place.
This relatively simple invention inspired a golden age of ophthalmology in the midnineteenth century, revealing a wealth of previously unseen medical signs we are familiar
with today, such as papilloedema, disc atrophy and the cherry red spot associated with
central retinal artery occlusion. From its early prototypes in Helmholtz’s workshop to the
modern day, the basic principles of the ophthalmoscope have not changed. What has
changed, however, is its usefulness and role in clinical medicine.
Fig 1 – an Augenspiegel.3
Many say ophthalmoscopy is a dying art, with physicians and medical students alike lacking
confidence in its use.4 It is a skill that is difficult to master and requires considerable hours
of practise. There have also been huge technological advancements across all specialties,
with computers and machinery replacing human skills which were at one time fundamental
to practice. Ophthalmology is no exception, with alternatives to direct ophthalmoscopy such
as fundus photography arguably deeming the skill redundant. Hence, does it still have a key
Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
role in the modern NHS, an arguably stretched healthcare system which is heavily reliant on
cost-effective but good quality care? This essay aims to explore this by looking at three main
themes: fundus photography as an alternative to direct ophthalmoscopy, cost-effectiveness,
and the role of ophthalmoscopy in medical education.
Fundus Photography
Fig 24 –
(A) Fundus photography view
(B) Direct ophthalmoscope view
(x15 magnification)
Fundus photography uses a specialised microscope and camera equipment to take wide
angle, high-quality pictures of the retina, entire optic disc and macula.5 The idea has been
around since Helmholtz was tinkering with his augenspiegel, but only recently has its full
potential been recognised.3 It has been shown to be sensitive and specific in the detection
and diagnosis of ophthalmic disease, importantly without the need for mydratics or
extensive training and practise.5 Additionally, in an ever digitalising world and NHS, fundal
photography makes sense. It is especially useful in monitoring chronic disease such as
diabetic retinopathy, where serial images can be recorded and compared on screen at the
click of a button. Despite its advantages compared to the direct ophthalmoscope, the angle
of view of fundus photography is trumped by the 15x magnification of the direct
ophthalmoscope, allowing detection of more subtle signs (Figure 2). Moreover, direct
ophthalmoscopy can examine dynamic phenomena such as venous pulsations, which would
not be seen on a static photograph.4 Comparison of the advantages and disadvantages of
both methods are summarised below (Figure 3), although it is important to consider these
not in isolation but relative to other compounding factors such as cost-effectiveness and
education.
Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
Figure 3: Table of comparison of direct ophthalmoscopy vs. fundus photography.
Direct ophthalmoscopy
Fundal photography
Angle-of-view in degrees5
5°
45-140°
Availability
Common
Uncommon
Portability
Easily portable
Static
Cost6
~£500
~£10,000 + maintenance
Training
Considerable
Minimal
Digitalised imaging
No
Yes
Dynamic clinical
phenomena
Yes
No
Detection of diabetic eye
disease7
65%
89%
Mydratic needed
Yes
No
Cost-effectiveness
In 1948 the National Health Service was born out of a long-held ideal that quality healthcare
should be available to all. Directly funded by taxation, it relies on cost-effective medical
practice and robust economic management.8 Considering that the NHS is under more
pressure than ever with an aging population, recruitment crises and euro-political
uncertainty9, could fundus photography as common practice be justified?
One study by Khan et al. screened 14,541 patients for diabetic retinopathy using fundus
photography in a primary care setting in South Africa.10 The cost to screen one patient was a
mere $22. They extrapolated this data to a nationwide level and concluded that fundus
photography would be cost-effective in a primary care setting, resulting in major long-term
savings. Whilst it must be noted these findings are limited to a different healthcare system
and only focuses on diabetic screening in primary care, the conclusions are still significant.
Diabetes and its complications have been approximated to take up 10% of the entire £116.4
billion NHS budget for 2015-16,11 and Public Health England has recognised the importance
of fundus photography in diabetic screening.12 With a 5% growth per annum in the number
of patients diagnosed with diabetes in the UK, direct ophthalmoscopy is not a sustainable
solution to screen this ever-expanding patient group.
Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
Education and Training
Ophthalmoscopy has been performed as part of a routine physical or detailed ophthalmic
exam for over a century, and can swiftly yield a number of important signs before one can
say “Hermann Von Helmholtz”. Whilst healthcare professionals recognise its place in
detecting ophthalmic disease, its use is often overlooked investigating severe hypertension,
suspected raised intracranial pressure and cerebrovascular accidents.13 As such, it has been
shown to be of particular value in headache assessment.14 Whatever its indication, the
ophthalmoscope can detect valuable signs, when used correctly. This is important: due to
the inherent technical difficulty in using an ophthalmoscope, it can be challenging to detect
pathology if not used correctly.
Medical schools of today devote little of their syllabus to ophthalmology and therefore
ophthalmoscopy. Indeed, in 2011 a clinical placement in ophthalmology was not even a
requirement in all UK schools and even in those where it was compulsory, an average of
only 7.6 days was dedicated to the speciality.15 In an attempt to combat this, numerous
teaching methods have been trialled to hone in on medical students’ skills, such as
ophthalmoscopy simulation, online tutorials and fundus photography analysis. Several
teaching trials have shown beneficial outcomes to students’ ability in using the direct
ophthalmoscope.16 Interestingly however, the TOTeMS Study in 2013 showed that medical
students still preferred and were more accurate analysing fundus photographs in
comparison to patient directed or simulated ophthalmoscopy.17
Let us reconsider the common complaint of headache. Direct ophthalmoscopy has always
been an essential part of the workup in these patients, being able to detect signs of sinister
causes such as optic disc pallor and papilloedema associated with raised intracranial
pressure. To highlight the importance of fundus examination, Thulasi et al. studied patients
presenting to accident and emergency with headache who were investigated with both
fundus photography and neuroimaging.14 Of the patients who had abnormal fundi on
fundus photography, fourteen out of thirty four (41%) had normal neuroimaging. This shows
that fundus examination can detect serious disease that radiological studies (that we so
often rely on) may miss. Although studies have evaluated the feasibility of fundus
photography in A&E and concluded that it potentially could replace ophthalmoscopy,18
fundus photography is still not widely available. In these hospitals, therefore, direct
ophthalmoscopy must not only suffice, but be used with absolute competence to ensure the
best outcome for the patient.
Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
Conclusion
Having considered the use of the direct ophthalmoscope, the decline of its proficiency in
clinical practice, its role in medical education and an arguably more effective alternative,
should its place in the modern NHS be preserved at all?
One could argue that the most important role of the ophthalmoscope within the modern
NHS is its use in medical education. Medical history tells us many practices have become
redundant with newer, cheaper or more efficient techniques, such as ultrasound replacing
Pinard’s stethoscope to examine the foetal heartbeat.1 Indeed, fundus photography has
numerous benefits, but the theory and understanding of the principle of fundus
examination lies with the direct ophthalmoscope. Not only this, but the ophthalmoscope
requires the doctor to see the patient by the bedside, which is central to medical education.
The context of a patient’s history and examination should always be considered before
retiring behind a computer screen to study fundal photographs. For this reason, medical
students must continue to learn and practise the direct ophthalmoscope examination.
Research has shown proficiency with direct ophthalmoscopes, as with many skills, decreases
without regular reinforcement.19 Modern medical school curricula, using intuitive and
creative teaching methods, must emphasise its importance. Finally, in the current economic
climate, fundus photograph cameras are not commonplace in the NHS, regardless of
whether they can be proven to be cost-effective or not. So for now, the trusty augenspiegel
may be your most useful tool at 2am in A&E when Mrs Smith has a severe headache.
References
1
Porter R. Blood and guts – a short history of medicine. London, United Kingdom: The Penguin Group; 2003. p.
43, 119
2
Charles Babbage Institute. Who was Charles Babbage? University of Minnesota [internet]. 2016 [cited 30
September 2016]. Available from: http://www.cbi.umn.edu/about/babbage.html
3
Keeler CR. A brief history of the ophthalmoscope. Royal College of Ophthalmology [internet]. 2003 [cited 15
September 2016]. Available from: http://www.college-optometrists.org/filemanager/root/site_assets/oip/42/a_brief_history_of_the_ophthalmoscope.pdf
4
Mackay DD, Garza PS, Bruce BB, Newman NJ and Biousse V. The demise of direct ophthalmoscopy – a
modern clinical challenge. Neurol Clin Pract [internet] 2015 [cited 02 September 2016]; 5(2): pp. 150–
157. doi: 10.1212/CPJ.0000000000000115
5
Ophthalmic Photographers Society. Fundus Photography Overview. [internet]. 2016 [cited 24 September
2016]. Available from: http://www.opsweb.org/?page=fundusphotography
6
Optical Marketplace. Cost of ophthalmic equipment. [internet]. 2016 [cited 22 September 2016]. Available
from: http://www.opticalmarketplace.co.uk/new-equipment/optical-equipment/ophthalmoscopes/
Matthew Hartley FY2
North Yorkshire and East Coast Foundation School
7
Harding SP, Broadbent DM, Neoh C, White MC and Vora J. Sensitivity and specificity of photography and
direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ
[internet]. 1995 [cited 10 September 2016]; 28; 311(7013): pp. 1131–1135.
8
NHS Choices. About the NHS. [internet]. 2016 [cited 26 September 2016] Available from:
http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx
9
McKee M. Brexit: A confused concept that threatens public health. J Public Health (Oxf) [internet]. 2016
[cited 27 September 2016]; 38 (1): pp. 3-5 doi: 10.1093/pubmed/fdv205
10
Khan T, Bertram MY, Jina R, Mash B, Levitt N and Hofman K. Preventing diabetes blindness: cost
effectiveness of a screening programme using digital nonmydriatic fundus photography for diabetic
retinopathy in a primary healthcare setting in South Africa. Diabetes Res Clin Pract [internet]. 2013 [cited 27
September 2016]; 101(2): pp. 170-6. doi: 10.1016/j.diabres.2013.05.006
11
Diabetes.co.uk. The Cost of Diabetes. [internet]. 2016 [cited 06 October 016]. Available from:
http://www.diabetes.co.uk/cost-of-diabetes.html
12
Department of Health. Public Health Functions agreement 2015-16 no. 22 – NHS Diabetic screening
programme. Page 16, Section 2.6. [internet]. 2016 [cited 11 September 2016]. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/383196/1516_No22_NHS_D
iabetic_Eye_Screening_Programme_FINAL.pdf
13
Wang JJ, Baker ML, Hand PJ, Hankey GJ, Lindley RI, Rochtchina E et al. Transient ischaemic attack and acute
ischaemic stroke: associations with retinal microvascular signs. Stroke, a Journal of Cerebral Circulation
[internet]. 2011 [cited 15 September 2016]; 42(2): pp. 404-8. doi: 10.1161/STROKEAHA.110.598599
14
Thulasi P, Fraser CL, Biousse V, Wright DW, Newman NJ and Bruce BB. Nonmydriatic ocular fundus
photography amongst headaches patients in an emergency department. Neurology [internet]. 2013 [cited 22
September 2016]; 80(5): pp. 432-7. doi: 10.1212/WNL.0b013e31827f0f20
15
Baylis O, Murray PL and Dayan M. Undergraduate ophthalmology education - A survey of UK medical
schools. Medical Teacher [internet]. 2011 [cited 04 October 2016]; 33(6):pp. 468-71. doi:
10.3109/0142159X.2010.540594
16
Mackay DD, Garza PS, Bruce BB, Newman NJ and Biousse V. Selected direct ophthalmoscopy studies in
medical students published between 2004 – 2014. Neurology in Clinical Practise [internet]. 2015 [cited 02
September 2016]; 5(2): pp.150–157 doi: 10.1212/CPJ.0000000000000115
17
Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ and Biousse V. Teaching ophthalmoscopy to medical
students (the TOTeMS study). Am J of Ophthalmol [internet]. 2013 [cited 04 September 2016]; 156(5): pp.
1056-1061.e10. doi: 10.1016/j.ajo.2013.06.022
18
Bruce BB, Lamirel C, Biousse V, Ward A, Heilpern KL, Newman NJ et al. Feasibility of nonmydriatic ocular
fundus photography in the emergency department: Phase I of the FOTO-ED Study. Acad Emerg Med [internet].
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19
Mottow-Lippa L, Boker JR and Stephens F. A prospective study of the longitudinal effects of an embedded
speciality curriculum on physical examination skills using an ophthalmology model. Acad Med [internet]. 2009
[cited 28 September 2016]; 84(11): pp. 1622-30. doi: 10.1097/ACM.0b013e3181bb2d51.
Figure 3 – Hartley, M.J. – author creation
Total word count excluding references and title – 1,486