A fundoscopic exam, also known as ophthalmoscopic or retinal examination, is a test used to screen for eye disorders, injuries, and diseases. Advanced practice nurses working in primary care and emergency departments should develop and sharpen their fundoscopy skills as it can be one of the more challenging procedures performed during both routine physical examinations and emergency care evaluations. Use our pocket card, The
Fundoscopic Exam to review anatomy, equipment and the steps to perform fundoscopy.
Abnormal Findings (Stanford Medicine, n.d.; Schneiderman, 1990)
Once you are comfortable performing a fundocopic exam and familiar with normal anatomical landmarks, begin to hone your skills to detect abnormal findings. Be on the lookout for the following:
- Papilledema: swollen optic disc with engorged veins and retinal hemorrages. This is a medical emergency and a sign of increased intracranial pressure that may be due to a tumor, hemorrhage, or thrombosis.
- Retinal hemorrhage: bleeding due to ruptured deep capillaries or large vessels that occur with endocarditis, pernicious anemia, diabetic retinopathy, leukemia, and subarachnoid hemorrhage.
- Optic disc edema: the optic disc will appear elevated and covered by cotton wool spots (fluffy gray-white or yellow patches with indistince borders) that may be seen with chronic conditions such as hypertension, diabetes, HIV, severe anemia or thrombocytopenia, hypercoagulable states, connective tissue disorders, and viruses.
- Arterial-venous (AV) nicking: chronic hypertension stiffens and thickens the arteries. Where arteries and veins cross, arteries will “indent and displace” veins. This is observed in chronic vascular disease.
- Emboli and infarcts: caused by platelet, fibrin or cholesterol emboli that result in a gray area above the plaque.
- Chorioretinitis: eye inflammation of the uveal tract (iris, ciliary body, and choroid) that can involve the retina, retinal vessels, vitreous, optic nerve head, and sclera. Appears as a yellow-white lesion with blurred margins, described as a “headlight in fog.” May be caused by toxoplasmosis, cytomegalovirus (CMV), herpes simplex, rubella, West Nile virus, HIV-related eye diseases, tuberculosis, syphilis, and fungal infections among others (Geetha & Tripathy, 2022).
- Obscured red reflex may be caused by corneal scars, cataracts, or vitreous hemorrhage.
- Neovascularization (new vessels) on the optic disc are a sign of proliferative diabetic retinopathy.
- Enlarged optic cup can indicate glaucoma or high myopia.
- Drusen are yellow deposits of lipids and proteins under the retina that occur naturally with age. Presence of a large number of drusen detected is an early sign of age-related macular degeneration (AMD). Late AMD is associated with rapid vision loss.
- Pigmented dome-shaped mass observed on dilated exam may indicate uveal melanoma, the most common primary intraocular malignancy in adults. Most develop in the choroid, ciliar body, and iris (Tarlan & Kiratli, 2016).
- Retinal detachment is best viewed with pupils dilated under indirect fundoscopy. A detachment will have a dune-like appearance and the retina look mobile. The hole that caused the detachment can often be observed.
Good luck focusing on your fundoscopy skills! Continue to practice and develop a standardized approach to this common procedure in order to detect chronic conditions and life-threatening emergencies.
References:
Geetha, R. & Tripathy, K. (2022, August 22). Chorioretinitis. StatPearls [Internet], National Library of Medicine, National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK551705/#
Schneiderman, H. (1990). The Funduscopic Examination. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd Edition. National Institute of Health, National Library of Medicine, National Center for Biotechnology Information.
https://www.ncbi.nlm.nih.gov/books/NBK221/
Stanford Medicine. (n.d.) Introduction to the Fundoscopic/Ophthalmoscopic Exam. Stanford Medicine 25. https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html
Tarlan, B., & Kıratlı, H. (2016). Uveal Melanoma: Current Trends in Diagnosis and Management. Turkish journal of ophthalmology, 46(3), 123–137. https://doi.org/10.4274/tjo.37431
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