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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
