Medical Instruments IMedical Instruments I

Practical Use of the Practical Use of the Ophthalmoscope and Ophthalmoscope and

OtoscopeOtoscope

Amanda Kocoloski, OMS IVAmanda Kocoloski, OMS IV

Primary Care Associate/DFM FellowPrimary Care Associate/DFM Fellow

ObjectivesObjectives

• Understand how to use the Understand how to use the following equipment:following equipment:• Ophthalmoscope Ophthalmoscope • OtoscopeOtoscope

• Learn the fundoscopic exam and Learn the fundoscopic exam and introduce the ear examintroduce the ear exam

• Begin to appreciate normal Begin to appreciate normal eyes and ears by practicing on eyes and ears by practicing on colleagues and instructorscolleagues and instructors

Ophthalmoscope BasicsOphthalmoscope Basics

• Ophthalmoscope AnatomyOphthalmoscope Anatomy• Ophthalmoscope OperationOphthalmoscope Operation• Red ReflexRed Reflex• Examination of the FundusExamination of the Fundus

Ophthalmoscope AnatomyOphthalmoscope Anatomy

View of the scope from the doctor’s perspective

Ophthalmoscope Anatomy Ophthalmoscope Anatomy (Continued)(Continued)

View of the scope from the patient’s perspective

In the Office/SP LabIn the Office/SP Lab

Ophthalmoscope Ophthalmoscope OperationOperation

• Turning it Turning it on:on:• Depress Depress button and button and rotaterotate

• Adjust to Adjust to about mid-about mid-brightnessbrightness

Ophthalmoscope OperationOphthalmoscope Operation

• Use the large, round, white beamUse the large, round, white beam• Smaller may be helpful if pupil is not dilatedSmaller may be helpful if pupil is not dilated

• Set the wheel used for changing Set the wheel used for changing the lens at zero dioptersthe lens at zero diopters

Eye AnatomyEye Anatomy

Red ReflexRed Reflex• Reflection of light off of Reflection of light off of retinaretina

• Pink to red in colorPink to red in color• Should be equal in both eyesShould be equal in both eyes• Presence indicates there are Presence indicates there are NONO opacities within the following opacities within the following areas:areas:• Tear FilmTear Film• CorneaCornea• Anterior Chamber – Aqueous FluidAnterior Chamber – Aqueous Fluid• LensLens• Vitreous FluidVitreous Fluid

Conditions With Absence Conditions With Absence of the Red Reflexof the Red Reflex

• CataractsCataracts• Opacity of the lensOpacity of the lens

• Detached retinaDetached retina• RetinoblastomaRetinoblastoma• Artificial globe/eyeballArtificial globe/eyeball

Ophthalmoscopic Exam: Red Ophthalmoscopic Exam: Red ReflexReflex

• Have your Have your patient look up patient look up and over your and over your shouldershoulder

• To visualize To visualize the red reflex, the red reflex, stand about 15 stand about 15 inches from inches from your patient’s your patient’s eyeeye

Ophthalmoscopic Exam: Ophthalmoscopic Exam: FundusFundus

• Your right eye to patient’s right, your left to Your right eye to patient’s right, your left to patient’s leftpatient’s left

• Place your free hand on the patient’s shoulder or Place your free hand on the patient’s shoulder or forehead for stabilizationforehead for stabilization

• Beginning from the temporal aspect move in toward Beginning from the temporal aspect move in toward your patient’s eye to begin examination of the your patient’s eye to begin examination of the fundusfundus• Keyhole phenomenon Keyhole phenomenon

• Focus by adjusting the diopter if necessaryFocus by adjusting the diopter if necessary• Should be unnecessary if neither you nor the Should be unnecessary if neither you nor the patient have uncorrected refractive errorspatient have uncorrected refractive errors

Ophthalmoscopic Exam: Ophthalmoscopic Exam: FundusFundus

• Identify VesselsIdentify Vessels• Veins: Large darker vesselsVeins: Large darker vessels• Artery: Smaller brighter vesselsArtery: Smaller brighter vessels

• Optic diskOptic disk• Located on nasal aspectLocated on nasal aspect• Sharp margins; nasal may be blurredSharp margins; nasal may be blurred• Yellow/orangeYellow/orange• Physiologic optic cupPhysiologic optic cup

• Macula and FoveaMacula and Fovea• Located on temporal aspectLocated on temporal aspect

• Best visualized: stare directly at the lightBest 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 Ophthalmoscopic Exam: Right FundusFundus

Photo and corresponding diagram of a normal fundus. Note that the retinal vessels all stop short of and do not cross the fovea.

Ear ExamEar Exam

Examination of the Examination of the External EarExternal Ear

• Inspect the Inspect the auricle for auricle for deformitiesdeformities• Skin tags/pitsSkin tags/pits• Lymph nodesLymph nodes• Epidermoid cystEpidermoid cyst• Squamous/basal Squamous/basal cell CAcell CA

• Pain, discharge, Pain, discharge, or inflammation?or inflammation?• Perform the tug Perform the tug testtest

Otoscopic BasicsOtoscopic Basics

Otoscopic Examination Otoscopic Examination of the EAC and TMof the EAC and TM

• Straighten the ear canal Straighten the ear canal • Adults- pull superior and posteriorAdults- pull superior and posterior• Children– pull posterior and maybe inferiorChildren– pull posterior and maybe inferior

• Hold otoscope between your thumb and Hold otoscope between your thumb and fingers; rest hand on patient’s facefingers; rest hand on patient’s face• Handle may point downward or toward Handle may point downward or toward patient’s eyebrowpatient’s eyebrow

• Right hand when looking in the right Right hand when looking in the right ear, left hand when looking in the left ear, left hand when looking in the left earear

Otoscopic Examination Otoscopic Examination of the EAC and TMof the EAC and TM

• Under direct Under direct visualization: visualization: Insert the speculum Insert the speculum into the ear canal, into the ear canal, directing it forward directing it forward and downwardand downward

• Inspect the canal Inspect the canal with insertionwith insertion

• Inspect the tympanic Inspect the tympanic membranemembrane• color color • contourcontour• anatomical anatomical structuresstructures

Otoscopic Examination Otoscopic Examination of the of the

EAC and TMEAC and TM

Normal right ear

Normal left ear

Pars flaccidaIncusIncus

Cone of light

Pars tensa

Malleus

Pars tensa

Umbo

ReferencesReferences

• Bates’ Guide to Physical Bates’ Guide to Physical Examination, Examination, Chapter 5.Chapter 5.

• http://emedicine.medscape.com/article/1201779-overview http://www.medicine.ucsd.edu/clinhttp://www.medicine.ucsd.edu/clinicalmed/introduction.htmicalmed/introduction.htm

• Vaughan & Asbury's General Ophthalmology, 17e