Examine the eyes with an ophthalmoscope

The ophthalmoscopic examination of the eye is a vital part of the complete physical examination. It can reveal the effects of systemic conditions such as hypertension and diabetes mellitus, causes of visual dysfunction such as optic atrophy, and reveal conditions such as raised intra-cranial pressure by demonstrating papilloedema. The ocular complications of conditions such as diabetes mellitus may be asymptomatic until sight-threatening complications have developed; hence the importance of screening examinations.

Optimize the conditions for fundoscopy. Both patients and examiner need to be comfortable. Examine the patient in a darkened room with a good ophthalmoscope producing a bright light and, if necessary use pupillary dilatation. (con-traindicated only in recent head injury when serial pupillary examinations are essential or where there is a risk of acute angle closure glaucoma). If you need to dilate, warn the patient of possible photophobia and visual blurring which will prevent driving.

Ask the patient to fix their gaze on a distant object. Examine their right eye with your right eye and their left eye with your left eye.

Examine from a distance looking initially for the presence of the red reflex and, if absent, consider lens opacities such as cataracts. Then examine the optic disc (shape, colour, edge, physiological cup), the peripheries of the retina following the main vessels outwards from the disc (vessels, venous pulsation, haemorrhages, exudates, pigmentation) and, finally, the macula.

The presence of papilloedema, haemorrhages or exu-dates, or presentation with loss of vision, requires explanation.

A full examination with particular emphasis on the cardiovascular and neurological systems may be required.

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