The demise of direct ophthalmoscopy: A modern clinical challenge

Abstract

Ocular funduscopy appears to be a dying art. Physicians and medical students alike lack confidence in the use of an ophthalmoscope. As a result, few clinicians perform ophthalmoscopy, and many who do are unable to reliably detect abnormalities of the ocular fundus. Approaches to remediation in undergraduate medical education have included simulators, longitudinal skill reinforcement, Web-based teaching, and other techniques. Preservation of the ophthalmoscopic art has been hindered by technical difficulty, waning enthusiasm for ophthalmoscopy, and even discouragement from preceptors in medical education. Ocular fundus photography may serve a role in medical education to help improve student confidence in interpretation of ocular fundus findings and improve awareness of the importance of examination of the ocular fundus. Because neurology clerkships and clinical practices remain an important forum for honing ocular funduscopy skills, the neurologist should be familiar with novel alternative techniques that facilitate examination of the ocular fundus.

Figure 1. The history of ocular fundus examination

The invention of the ophthalmoscope inspired a golden age of ophthalmology and paved the way for in vivo funduscopy to influence clinical care. Other technological developments, including ocular fundus photography, have been developed more recently and may be useful in preserving the ocular fundus examination.

Figure 2. Nonmydriatic ocular fundus photography vs classic direct ophthalmoscopy

(A) Nonmydriatic ocular fundus photography. (B) Classic direct ophthalmology. The 45° field of view from the nonmydriatic fundus photograph allows simultaneous examination of the optic disc, macula, and major vascular arcades. The 5° view (15× magnification) from the classic direct ophthalmoscope is useful for detailed, but isolated, examination of the optic disc margins, the macula, and dynamic phenomena such venous pulsations when centered on the optic disc, but adds difficulty to the integrated examination of the retina and other details of the ocular fundus.