Although the visualization of the ocular fundus yields important clinical information regarding the optic nerve and retinal vasculature, proficiency in using the traditional handheld direct ophthalmoscope by both practicing physicians and medical students continues to deteriorate. A replacement for the direct ophthalmoscope is long overdue. The authors suggest a role for non-mydriatic fundus photography as having potential to resurrect the dying art of visualizing the fundus in both clinical practice and medical education. This chapter reviews the substantial barriers in both patient care as well as graduate and undergraduate medical education created by technical difficulties encountered using the direct ophthalmoscope to visualize the ocular fundus. The authors propose that a smartphone-compatible adaptor to view the ocular fundus will replace the direct ophthalmoscope.
TopA Changing Landscape
Advances in technology have been a primary driving force in medical progress. The direct ophthalmoscope introduced by Herman von Helmholtz in 1851 dramatically changed the practice of ophthalmology and provided the first view of the human fundus and the first in vivo views of central retinal artery occlusion in 1855 and papilledema in 1860 (Swanson, Ku, & Chou, 2011)
The handheld version of this device was introduced in 1915 and traditionally medical students have been expected to own and carry this instrument with the goal of becoming proficient in its use in examining patients. Over time technical difficulties using the direct ophthalmoscope have frustrated medical students and non-ophthalmologists to a point where funduscopy is now routinely omitted from the physical exam. The magnitude of these technical difficulties has created avoidance behavior in clinicians allowing crucial clinical findings such as papilledema, optic disc swelling due to increased intracranial pressure, to escape detection with tragic consequences including blindness.
The authors, practicing neurologists, routinely encounter pseudotumor cerebri syndrome (PCS). This condition frequently seen in obese females is characterized by increased intracranial pressure not associated with a tumor or mass. Over time, this pressure can damage the optic nerve. Brain imaging findings are often negative or non-specific and the only diagnostic marker is a swollen optic nerve visualized on funduscopy. These patients present with headaches associated with visual complaints who often have been evaluated in multiple emergency rooms, undergone normal computed tomography (CT) scanning and magnetic resonance (MR) brain imaging without their medical providers even attempting to visualize the fundus.
Rarely this can end tragically in permanent visual loss. Equally disturbing is that review of these patient’s medical records documents a templated notation in the physical exam as 'normal eye exam'. The patient when questioned is firm in their contention that 'no one ever looked in my eyes '. This practice ultimately can form the core evidence for an unpleasant medical malpractice action and provides a glimpse into the dismal state of clinical funduscopy outside of ophthalmology.
A solution to this problem, the digital non-mydriatic fundus camera, has been available for 20 years. The first photographs of the human fundus were captured in the late 1800s. Fundus photography became available for clinical use in the 1950s and eventually became digital and diagnostic even through an undilated pupil (Mottow-Lippa, Boker, & Stephens, 2009). Until recently these nonmydriatic fundus cameras were available only in the offices of ophthalmologists and optometrists despite the fact that high-quality images can be obtained within minutes even by non-physicians with minimal training (Lippa, Boker, Duke, & Amin, 2006).
his chapter reviews the technical difficulties with the direct ophthalmoscope, the advantages of available non-mydriatic fundus cameras and the recent experience with their use beyond ophthalmology in the emergency room and neurology clinic. A portable and affordable modification of the standard fundus camera reduced to the size of a cellphone attachment is now positioned to replace the handheld direct ophthalmoscope.