Otoscopy & Ophthalmoscopy

Question 1

Indications of otoscopy

Answer 1

• earache
• hearing loss
• ear discharge
• tinnitus
• dizziness
• viral symptoms
• head injury (basal skull fracture)

Question 2

Key anatomy of the ear

Answer 2

• pinna
• helix
• tragus
• preauricular area
• postauricular area
  (Bony prominence = mastoid process of temporal bone)

Question 3

Anatomy of tympanic membrane (eardrum)

Answer 3

4 quadrants: Antero/postero-sup/inf
Malleus (ossicle) should always be visible
Incus may be visible posterior to malleus

Question 4

Otoscopy step 1

Answer 4

Preparation
- PPE, wash hands, introduce self, explain procedure
- check pt details, gain consent, ask about pain
- ask to remove foreign bodies (hearing aids, large piercings)

Question 5

Otoscopy step 2

Answer 5

Inspection
- symmetry, position
- piercing, hearing aids

• pre-auricular, pinna, EAM, mastoid
• deformity, erythema, swelling, scars, discharge, skin lesions

Question 6

Otoscopy step 3

Answer 6

Palpation
- tragus (press)
- tug pinna gently
- press on mastoid

Check for tenderness

Question 7

Otoscopy step 4

Answer 7

Procedure
- apply speculum to otoscope , turn on light
- right hand right ear (vv)
- start with better ear
- pull pinna up and back with other hand (straighten EA canal) — down and back in children

Question 8

Otoscopy proper

Answer 8

• insert speculum tip to EAM
• rest ulnar border of hand against pt cheek
• slowly advance speculum
• inspect canal for wax, foreign bodies, erythema, oedema, discharge
• inspect tympanic membrane,noting colour, shape, structure, light reflex

(Withdraw & repeat in other ear, discard speculum)

Question 9

Types of ophthalmoscope

Answer 9

Direct - upright image, not inverted, greater magnification (traditional)

Indirect - reversed and inverted image (slit lamp)

Question 10

Key features of an ophthalmoscope (practitioner’s side)

Answer 10

• rheostat (adjusts light beam intensity)
• dioptre dial (alters lens)
• dioptre power display (green close, red far)
• eye window

Question 11

Key features of an ophthalmoscope (patient’s side)

Answer 11

• aperture dial (alters light beam size)
• filter switch (selection of light filter)

Question 12

When to choose different size light beams in ophthalmoscopy?

Answer 12

Large - dilated pupil
Medium - dark room, non-dilated
Small - constricted pupil

Question 13

What do each of the 4 filters of an ophthalmoscope do?

Answer 13

1. Red free - retina b&w, contrast allows visualisation of vessels
2. Slit beam - detect abnormalities in cornea, retina & lens
3. Blue light - ID corneal abrasions (fluorescein eye drops staining)
4. Grid - approx distance btw retinal lesions

Question 14

What are the features of the anterior segment of the eye?

Answer 14

Anterior 1/3
- iris
- conjunctiva
- cornea
- pupil
- lens

Question 15

What are the eateries of the posterior segment of the eye?

Answer 15

Posterior 2/3
- vitreous humour
- retina

Question 16

What is the retina?

Answer 16

The neurosensory layer at the back of the eye that absorbs light energy & converts it to electrical impulses.

Question 17

What is the red reflex of the eye?

Answer 17

Reflection of reddish-orange light from retina

Question 18

What are the four quadrants of the retina?

Answer 18

ST - superior temporal
IT - inferior temporal
SN - superior nasal
IN - inferior nasal

Question 19

What are the arcades of the central retinal artery & vein in the ST quadrant?

Answer 19

Superior temporal retinal arteriolar & venule (etc.)

Question 20

Name the key features of the retina

Answer 20

• optic disc (yellow)
• optic cup (white)
• macula lutea (centre, area of highest visual acuity)
• fovea centralis (centre of macula)

Question 21

What

Question 22

Ophthalmoscopy step 1

Answer 22

• WIPE
• consent & check pain

(Explain:
- eyelids, front & back of eye
- close to face
- no driving for several hours after dilating eye drops (blurry vision, sensitivity to light))

Question 23

Ophthalmoscopy step 2

Answer 23

General Inspection (external eyes)

• eyelids (swelling, drooping, stye)
• eyelashes (loss)
• cornea (abrasions, ulcers)
• conjunctiva (discharge, diffuse conjunctival injection/redness)
• iris (shape, colour)
• pupil (shape, size, symmetry)

Question 24

Ophthalmoscopy step 3

Answer 24

(Dark room, seated, fixed ahead, eye drops)
Dioptre - 0 (normal visual acuity)

Assess Red Reflex

Shine light into pt eye at arm’s length (observe reddish reflecton)

Question 25

Ophthalmoscopy Step 4

Answer 25

Close inspection (ant) = GREEN numbers

• same hand same eye
• free hand on forehead/shoulder
• inspect ant segment

Question 26

Ophthalmoscopy Step 5

Answer 26

Examine fundus

(Add your refractive error to pts refractive error and adjust dioptre)

• 45 deg, move closer, maintain red reflex
  1. Blood vessels
  2. Optic disc

Contours (borders)
Colour (orange-pink = healthy & well-perfused)
Cup (colour, relative vertical size = 0.3)

3. Quadrants (clockwise)

Question 27

Ophthalmoscopy Step 6

Answer 27

Assess Macula
- look into light
- fovea dark

Question 28

Ophthalmoscopy Step 7 (finish)

Answer 28

• examine other eye
• thank, finish, summarise

Suggest further tests:
- CN exam