Fundoscopic Exam – Physical Exam

Introduction

The retina is the only portion of the central nervous system visible from the exterior. Likewise the fundus is the only location where vasculature can be visualized. So much of what we see in internal medicine is vascular related and so viewing the fundus is a great way to get a sense for the patient’s overall vasculature. But the fundoscopic exam can discover pathological process otherwise invisible, examples are plentiful, and include recognizing endocarditis, disseminated candidemia, CMV in an HIV infected patient, and being able to stage both diabetes and hypertension.

Technique –> Finding the Retina

  1. Darken room, ask patient to look at the same point as far as possible in the room (this will help to dilate the pupil).
  2. Wedge scope against your cheek with hand and then head/hand/scope should move as one unit.
  3. Use your right hand & your right eye to look at the patient’s right eye. (Less important if using the PanOptic.)
  4. Look through the ophthalmoscope, if you are nearsighted and have taken off your glasses, you may need to adjust the focusing wheel towards the negative/red until what you see at a distance is in focus.
  5. Direct the ophthalmoscope 15 degrees from center and look for the red reflex. Simply follow the red reflex in until you see the retina. If you lose the red reflex, come back until you find it again and repeat.
  6. To look around the retina using a traditional direct ophthalmoscope, you should “pivot” the ophthalmoscope, angling up, down, left and right. If using the PanOptic, you can slightly “pivot” or ask the patient to look up to see upper retina, down to see lower retina, medial to see medial, latereral to see lateral and finally to look at the light to visualize the macula.

Clinical Images of the Retina

Normal fundus
Vessels emerge from nasal side of disc. Arteries are narrower than veins.

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Pathological Optic Cupping
Note cup-to-disc ratio at least 0.8 (physiologic limit of 0.5).

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Optic Disk Edema
The optic disc is elevated and its surface is covered by cotton wool spots (damaged axons) and flame hemorrhages (damaged vessels). Four I’s: increased intracranial pressure (papilledema), infarction, inflammation, infiltration (by cancer).

The first picture below was taken simply by holding smartphone in front of the Panoptic opthalmoscope!

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Copyright © Stanford Medicine 25

 

Arterio-Venous (AV) Nicking
Chronic hypertension stiffens and thickens arteries. At AV crossing points (arrow) arteries indent and displace veins

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Cotton Wool Spots
Caused by microinfarcts. Exploded ganglion cell axons extrude their axoplasm into retina. Long DDx: hypertension, diabetes, HIV, severe anemia or thrombocytopenia, hypercoagulable states, connective tissue disorders, viruses, and others.

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Emboli and Infarcts
Small fleck a ‘Hollenhorst’ plaque caused from platelet/fibrin/cholestorol embolus. Resulting in an infarct (gray area above and right of the plaque).

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Roth Spot
Pale-centered hemorrhage. Caused by several conditions, but usually bacterial endocarditis. This image was from a patient with staph endocarditis.

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Reference:
https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html

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