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Um Yeah, hello. Can everyone hear me? Is that all? OK. I OK, let's get started. So, yeah, so um hello everyone. My name is Janica. I'm one of the four P medics. I'm currently integrating in my cardiovascular science BC. And today and so today I'm going to do a talk on ophthalmoscopy and oscopy. So these two were stations that have come up in the ESI in the past two years at Imperial ophthalmoscopy actually came up in mind last year and otoscopy came the year before that. So, yeah, let's get started. So in terms of today's structure, we're going to go through the introduction, the um of all the examinations, we're going to go through the um how to conduct the ophthalmoscopy and autoscopy exam. And then we'll talk about presenting the findings. And at the end, we'll also look at a few common findings that you may see in clinical practice. So we're gonna start with ophthalmoscopy. So essentially what ophthalmoscopy is is going to look inside the eye using an ophthalmoscope. So this is a really common um exam that we do and it's really helpful in seeing any pathology inside the eye. OK. So yeah, so to start off with, I've got a, I've actually got a meter. So if you guys can join by scanning the QR code or inputting the code up top, that would be really helpful and I will share the slides. Yeah, the Yeah. Um Yeah, if you guys can just join give a minute. Yeah, yeah, I'm just gonna wait for a couple more of you guys that yes. OK. Let's get started. So yeah, let's start with the first question. So which of these is not an indication for an ophthalmoscopy exam? Headache with visual changes, suspected raised ICP longstanding hypertension and acute otitis media. Yeah. Fantastic. Um Yeah. Moving on to the next one question. Number two. So what's the primary purpose of ophthalmoscopy to measure intraocular pressure to assess retinal and optic nerve health to visualize and uh the cornea and the iris and to diagnose external eye infections. Yup. Fantastic. Moving on to the next one. Yeah. What does the presence of a red reflex indicate? Ok. Yeah. And the final question, why should patients with diabetes have regular ophthalmoscopy exams? And yeah, for this one, it is to detect diabetes, diabetic retinopathy. Um Yeah. And so going back to the slides one second. Yep. So going back to the slides. Um let's start with the introduction. So like all clinical skills exams, you always have to start by washing your hands with alcohol gel as you enter. Ok. So you always want to just remember and just make sure you do that next, introduce yourself. So saying something like hi, I'm Janica Raja. I'm a third year medical student from Imperial College. London should fully suffice. Then you want to confirm the patient's identity. So you want to ask about their name and their date of birth. And you would also ask, how old does that make you? This is particularly helpful when uh you have to present at the end and you need to know how old they are and to avoid, avoid doing the maths yourself, you can just ask them to tell you after this, you want to obtain consent. So this is when you'll say something like today, the doctor's asked me to perform an examination of the eyes. Um I'll be looking at both your eyes with and without this instrument, this might be slightly uncomfortable because that'll be a bright light and I will have to get quite close to you. Would this be ok? And normally the patient will agree, especially in the os you and the final things to double check is make sure the patient is in the correct position and exposure. So, um in this particular case, the patient should just be sat in the chair. Um Just make sure you remember to dim the lights of the room and finally just make sure that you say that the examiner will act as chaperone. Um an easy way to remember. This is wiper. So W for wash hands, I for introduce yourself, P for um getting permission, E for exposure and R for reposition if needs be OK. The next thing that I like to do is saying what brings you in today? So this is particularly effective because it helps build rapport with the patient. It also identifies the abnormal and the normal eye and this is helpful because we want to start with the normal eye and then look at the abnormal eye. Then a good way of signposting into the next section would be, would be saying something like before we start, I need to check a few things. So the things that we need to check are number one, has the pupil been dilated. So this is something that in the ay should already have been done for you. So in the case of the osk, all you have to do is ask, oh has my colleague come in and administered the eye drops and ask when they administered them? So there should be around a 15 to 20 minute wait for that to have happened in the um But if you were to administer them yourself, then you tend to use one drop tropicamide, 1% in each eye. The key thing to remember here is the side effects. So there's three key things that the patient should know. Number one, they'll be experiencing blurred for the next 4 to 6 hours. Number two, they must not drive. So in the case of the osk, it's really nice to ask. Oh, how did you get here? Do you have a way of getting home? And if they say no, then you can say something along the lines of, oh, I can ask a nurse to book a taxi for you, et cetera. That's quite helpful. And number three is no use of heavy machinery for the next 24 hours. So that's also really important to mention as well. Then again, back to the before we start, the key things that you wanna ask in this particular case are um do you wear glasses or contact lenses? Cos that really matters in terms of using the ophthalmoscope. Have there been any changes to the vision lately? Are you in any pain? If they're in pain? It's always nice to offer analgesia. Then um for example, painkillers and then ask them if they have any allergies, ask if there's been any discharge from the eye. And finally, do they have any questions for you? Normally they shouldn't really. So as all the examinations go, you always kind of start with general inspection. So you want to inspect the eyes and the eyelids. Um a good way to do this is just ask the patient to look straight ahead and look at the eyes and eyelids for any changes. So things you could be looking out for are obvious abnormalities such as trauma or maybe a prosthetic eye, um any foreign bodies, so any debris in the eye surface SCLE of color, um signs of inflammation or periorbital swelling and then pupil abnormalities. So um are the pupil sizes equal or irregular, any signs of ptosis or even exophthalmos and enophthalmos. So, yeah, that's how you would go about the general inspection. Now, taking a closer look at the ophthalmoscope itself. So normally this will be um sort of assembled for you. If not, you will have to assemble it yourself. So that's something I recommend looking at during your clinical skills session and becoming really familiar with this um tool. But essentially, if we take a look at the clinician side here on the right side, there's a brow rest for where you rest your brow. The viewing window is how you'd look is where you'd look through. We've got the diopter power display and the on off switch. So essentially what the diopter power display refers to is when you should really start at zero. And depending on the refractive index of yours and your patients, you do the maths and make sure you're looking at a current um at an appropriate level for you to be able to see inside the eye clearly. But we'll get into that in a few minutes anyway. Um The other thing that's quite um important is the aperture dial and the reat. So the Ryat actually controls the brightness. So in this case, we want it as bright as possible. And the aperture, this will control the filter er so this will control the um the size of the light. So sometimes you can have a vertical line or a, a bigger beam or a smaller beam. So it's just to do with that and also the filter switch. So there's many different filters with different purposes. In the case of the OSI, you really just want the white color um light. So yeah, so how would we set it up? So number one, always switch on the ophthalmoscope. You want to make sure the brightness is at maximum setting just so that we have the best visibility possible. We then select the white light. Again, we want accurate color representation inside the eye. We choose a small round aperture. So we want a small round beam, almost a similar size to the pupil and we set the diopter to zero. So um uh this is probably easier to do and avoid trying to account for yours or the patient's prescription. And in the case of the Os, you um you are speaking to a person but you do it on the mannequin. So the mannequin doesn't really have a refractive index to consider. Um If you do wear glasses, um what I personally did was I wore contact lenses and this just saved me the hassle of having to work that out as well. Again, remember to switch on your ophthalmoscope. This is a really um often this is a mistake that a lot of people make. So in terms of how you go about the exam, make sure that you have um one hand on the patient's forehead. So this is when you come in closer, you don't want to come in too close and bump foreheads you. When you're holding it, you wanna make sure your index finger is on the dial, the di up to dial, and this will help adjust as you go closer for maximum visibility. And you also will look through the ophthalmoscope using your right eye. So your right eye for the patient's right eye, your left eye for the patient's left eye. But yeah, in terms of a normal fundus, these are the things that you could expect to see. So you'll expect to see the optic disc, the optic carp fovea, macular retinal vein and retinal artery. So the retinal vein, this carries deoxygenated blood from the retina back to the heart. The artery carries oxygen a bit oxygenated blood from the heart to the retina. We've got the optic disc is which is where the optic nerve exits the eye. So this is our natural blind spot. The optic cup is like a small depression in the disc. So this is helpful in assessing the risk um of glaucoma. Then we also have the macular, which is where we have our central high resolution vision. And we also have our phobia, which is where we have the sharpest vision. So here, um there's the diagram on the left, on the right, we can see an image and you can see how the optic disc is usually quite easy to see. And we'll go into how you'd identify it. But yeah, so moving on to the red reflex. So this is the thing that you should start with when you're doing this exam. So in terms of steps, first of all, you would start away from the person. So you would hold your ophthalmoscope, you'd look for the red reflex, which will appear as a red or orange color in the pupil, you then follow inwards. So at this stage, you should really put your opposite hand on the patient's forehead and you um just to make sure you're keeping enough space, you would then locate the optic disc and I'll talk a bit about about this a little bit more detail and we will adjust the a diopter dial if necessary. So sometimes you might see that as you're coming closer, the image in the fundus isn't that clear if it isn't you um play with the dial. So you turn in one direction if it becomes clearer, keep turning, if it becomes blurrier, turn in the opposite direction. So yeah, that's that in terms of how you'd identify the red reflex, when the red reflex is um absent, this can suggest um perhaps a opacity of the lens, for example, a cataract or in um other cases, maybe a tumor like a retinoblastoma. So yeah, in terms of how you would uh talk to the patient at this stage, you would say something like look over at that wall behind me and keep your eyes stiff, sorry, keep your eyes and your head still. Um And then also signpost it because because you're coming in a bit closer just to make sure your patients aren't overwhelmed or alarmed, just say I'll now be placing my hand on your head to come in close to have a close look. However, uh please let me know if you're uncomfortable and we can stop at any stage moving on to the optic disc. So in terms of the optic disc, it's actually quite easy to identify the, um the way in which you do. So is you locate any sort of blood vessel and then you trace its path. Normally, the blood vessels tend to be a sort of V shape and the V tends to point towards the optic disc. So once you've located this optic disc, you assess its size margin and color and I'll give a small and easy acronym to remember this, but a healthy optic disc, this tends to be a pale pink or yellow color and it has a lighter central area, which is the cup in terms of remembering this. So when you comment on the optic disc, remember the three CS, so this would be the color, the contour and the cup to disc ratio. Um So in terms of pathologies that are related to the optic disc, we've got glaucoma. This is when the cup becomes enlarged, the pink r becomes thinner and this causes an increased cup to disc ratio. We've got papilledema. Uh papilledema is one of those cases where once you see it, you won't forget it. But this is when the disc, um the cup isn't visible, the disc looks pink and this tends to be due to increased pressure in the brain. And we also have optic atrophy where the disc looks pale. The bone loses its pink color indicating nerve damage. Um An large optic cup ratio would be when it's more than 0.5. So, yeah, after you've assessed the disc and the cup, you would look at the four quadrants. So this is when you would just systematically examine the retina. So you would just ask the patient to look up down left and right and you'll sort of move your ophthalmoscope with that to make sure that you've covered all the four quadrants. You'd also um assess the vessels looking at their color and their width and you'd also check for any abnormalities as well such as hemorrhages, exudates and look at looking at their location and appearance. Um Yeah. So finally, you'll ask the patient to look into the light. So it's nice to keep this stage at the end just to make sure the patient's comfortable throughout and this will help you assess the macular um any changes to the macular tend to be significant because this is where we have a high resolution vision, but this will be how you would conclude that part of the exam. So yeah, and that will be it in terms of the ophthalmoscopy exam. So now you'd conclude it. So again, always wash your hands at the end of the exam. You should thank the patient for being so cooperative. Um You can have, you can also for an added touch. You could say something like thank you for being so cooperative. I know the exam was very uncomfortable, but you've been like amazing throughout again, remind them of the side effects. So um they should already be aware of the blurred vision, the um no heavy machinery and the no driving, but some people also tend to have an allergic reaction to the drops. So just make sure you've signposted them, telling them to seek urgent medical attention. If they have an adverse reaction to that, you then speak to the examiner and say you will now document the procedure. This is important and it's a step a lot of people forget and then you would present the findings. So in terms of presenting findings, a structure I liked to follow is by saying today I completed an ophthalmoscopy examination on Mr or missus uh something year old male or female on general inspection, the patient was calm, comfortable at rest. And um then you talk about on fundoscopy, you'd comment on the optic disc. Remember the three CS, you talk about the quadrants, you talk about the macular and then you would conclude saying this is a normal examination to conclude your examination. You would also do. And here you'd like to say three things. So you would take a full history, perform a cranial nerve exam and check BP in terms of abnormal abnormal findings. What I tend to the way I learned it was um looking at the machine that they use at um at imperial, they uh look at the different pathologies in them. So there should be a booklet with all the different pathologies and that's really important and you should learn based off that. So if you look at the top left, this is a sign of Palo edema. It's a very characteristic finding and it tends to look the same mo in most cases, if you look at the right, we can see that we can see the macular over there be slightly um slightly uncharacteristic. And this is because there's macular degeneration, the bottom left, you should see that large cup to disc ratio. So the disc is here and the cup is almost, it's definitely over 50% of its size. So this again is indicative of a glaucoma. And if you look over here, we've got marks on the red retinal vein. So this is suggestive of retinal vein occlusion. So yeah, so this will be um and the that's the answer is there. So yeah, so now we can take a short break if that's what uh if this is what everyone wants to do for, we can take a 23 minute break and then we'll move on to autoscopy. Um If anyone's got any questions, please pop them. So yeah, everyone can join the meter again. So yeah. Um The first question is what should a normal tympanic membrane look like? So this should be, yeah, 21. So the answer for this one would be pearly gray and translucent. And then the final question, what hand should you use to hold the otoscope when examining the right ear? And that should be same hand. Same e yeah. So going back onto the slides. So yeah. So with the otoscopy exam again, this is when we examined the ears with an otoscope. So the re indications tend to be fever or any sort of um ear related pathology as well to look inside the ear. And this is done very easily in like a GP setting as well. So let's start with introduction. How would you introduce this exam? So again, wash hands with alcohol gel as you enter. Never forget that. Introduce yourself. So say your full name and what grade medical student you are and where you, where you, where you're from and then you would confirm patient identity. So you would ask for their name and date of birth and ask how old does that make them? We then would obtain consent. So you would say something along the lines of, I have been asked to perform an examination of the ears, using this instrument. Here, I'll look at both your ears with and without this instrument. And um this might be slightly uncomfortable, would this be ok? And once the patient has agreed, you will just double check that their position and their exposure is correct. So, again, for this exam as well, they'll just be sat in the chair and the examiner will be acting as chaperone. Um There's nothing too much, there's nothing to worry about in terms of this exam. So, yeah, so like I mentioned for ophthalmoscopy, the first thing you want to do is ask what brings you in today? And again, the main function of this is identifying the abnormal and the normal. If so. Um yeah, so once you've asked that you'll move on to saying before we start, I need to check a few things. So again, this would be when we ask about changes to their hearing, asking them if they're in any pain, asking about allergies, discharge from the ear. And if they've got any questions for you, you always start with the air that isn't in any pain if it's, if they are in pain or for analgesia. So again, general inspection, you want to inspect one ear at a time um you'll look at, you'll look at the pinner the shape the size you'll look for any skin changes, any scars. So for example, if they've got a post auricular scarf that could be suggestive of mastoid surgery, um check if they've got any hearing aids um because this can impact what you see. And also you will check behind the pinner. So of any signs of infection such as mastoiditis, you'll also press on the tragus and see if that causes any pain as well. Again, like I mentioned earlier, you always have to remember to switch on your otoscope. So um make sure you switched on. It's always nice to check on your hand if you can see anything and then go from there. So the first thing to remember here is the pencil grip. So you want to hold the otoscope like a pencil and you rest the little finger on the cheek and this just helps to angle in your otoscope as you proceed further into the ear in an adult or anyone who's above the ages of three. in an adult. Actually, um you um do it differently. You have to sort of pull on their pinner back and up uh back and up to straighten the ear canal because it's not so uh it's not a really easy part and this will just help to minimize any discomfort. You use the right hand for the right ear and then the left hand for the left ear. And before you do any of the advancing, you always make sure you've got a clean speculum on the end, these will be disposable and there's um adult size speculum and pediatric size speculum as well. So yeah, let's look at setting up the otoscope. So um when once you've turn switched on and you put your speculum on, you want to make sure you are carefully inserting the otoscope into the ear canal whilst looking through it. So, proceed slowly and stop. If the patient experiences any pain, you um tend to aim the tip of the otoscope towards their nose to follow the natural curve of the canal. And once in once inserted, you want to move at different angles to fully expect, inspect the walls and the eardrum, you also want to make sure you can see the tympanic membrane. You want to examine the tympanic membrane, look at, looking at its um color its position and any abnormalities and then you do the same for the other. Once you've finished, you will discard the used otoscope speculum in a clinical waste bin to maintain hygiene. So that's that in terms of setting up in terms of what you want to look for you. Um When you're looking at the tympanic membrane, you want to identify the lateral m process of the mal of the malleus, you also want to identify the pars flaccida and the pars tensor. And also you should be able to see a cone of light um being reflected back to you as well. A normal tympanic membrane should look pearly gray, it should be translucent and it should also have a light re reflex below the l the malleus. OK. Um Yeah, that's that in terms of abnormal findings. Um Does anyone wanna give a shout, what they think any of these might be? They can pop it in the chat? Um OK. Yeah. So in terms of top left, top left is um just acute otitis media. You can kind of see the signs of in sorry um signs of inflammation over there. Um Top right is a grommet. Do you guys know what we use a grommet for? Well, have you seen one in the past? Um Yeah, so grommets are tubes that you pass in to uh into the eardrum. This helps to keep the air pressure either side quite equal. Um at the bottom, we can actually see a perforated tympanic membrane. So you can see that um perforation over there. Um bottom right is just earwax obstructing. So, yeah, that's that. So yeah, so once um you you have finished looking at both eyes, you, once you're finished looking up both eyes, you also um have to conclude the exam. So again, wash your hands after um after discarding the speculums and then move on to thanking the patient. So again, thank the patient for being so cooperative. It's an uncomfortable exam. There might be in a little bit of pain. So you always want to make sure you're building that report, you then want to document the procedure, so speak to the examiner and say um thank you uh for letting me do this exam. And now I would like to document the procedure. Um just to make sure you document any abnormal findings and then you present the findings to the examiner. So in terms of presentation, the way you'd go about that would be um you would say something like today, I completed an otoscopy exam on Mister or missus, a something year old male or female, the patient was comfortable at rest and wore hearing aids. If they wore hearing aids. In terms of general inspection, you would say something like general inspection was unremarkable with no signs of erythema, swelling or discharge or deformities of the external ear. There was no pain when palpating the external ear. So again, this is why it's important you press on the tragus and assess the back of the ear as well. In terms of um when visualizing the external auditory meatus, the canal was clear there was no signs of obstruction, discharge or foreign bodies and the skin appeared healthy with no signs of erythema or swelling. The tympanic membrane was intact. It was a clearly gray color with a good light reflex. Um The landmarks such as the hand of the malleus were clearly visible and there were no signs of retraction, bulging, perforation inclusion. In conclusion, this was a normal examination and to complete my exam, I would take a full history, perform a cranial nerve exam and check hematological findings. So, yeah, that would be it. So, um let me know if you guys have any questions and that will be the end of today's session. Thank you all for joining. If you could please fill out the feedback form, I'd really appreciate it.