Chapter 63

Principles of Ophthalmoscopy
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AUGUST COLENBRANDER
Main Menu Table Of Contents
BASIC PRINCIPLES OF DIRECT OPHTHALMOSCOPY
FIELD OF VIEW IN DIRECT OPHTHALMOSCOPY
EXTENDING THE FIELDINDIRECT OPHTHALMOSCOPY
FIELD OF VIEW IN INDIRECT OPHTHALMOSCOPY
IMAGING IN INDIRECT OPHTHALMOSCOPY
MAGNIFICATION IN DIRECT OPHTHALMOSCOPY
MAGNIFICATION IN INDIRECT OPHTHALMOSCOPY
COMPENSATION FOR REFRACTIVE ERROR
DESIGN OF LENSES FOR INDIRECT OPHTHALMOSCOPY
A CLOSER LOOK AT ILLUMINATION AND REFLECTIONS
ILLUMINATION IN INDIRECT OPHTHALMOSCOPY
LATITUDE OF BEAM PLACEMENT
MONOCULAR INDIRECT OPHTHALMOSCOPY
BINOCULAR INDIRECT OPHTHALMOSCOPY
PERIPHERAL VIEWING
LOCALIZATION IN THE FUNDUS
MEASUREMENT OF FUNDUS LESIONS
OTHER ACCESSORIES OF THE DIRECT OPHTHALMOSCOPE
ILLUMINATION LEVELS IN INDIRECT OPHTHALMOSCOPY
SLIT-LAMP EXAMINATION OF THE FUNDUS
REFERENCES

No other single invention has shaped the evolution of ophthalmology

like the invention of the ophthalmoscope has. Ophthalmoscopy was
introduced by Hermann von Helmholtz in December of 1850.1,2
However, Jan Purkinje (known for the Purkinje images) had described
the complete technique and published it in Latin in 1823,3 but his
audience apparently was not yet ready and his publication went
unnoticed. A quarter of a century later, however, the situation changed.

Like many other important inventions, the ophthalmoscope was not

based on any radically new concepts. Rather, it combined the
appropriate application of various known principles with a recognition
of its potential impact and presentation to an appropriate audience.
Under the leadership of men like Bowman in London, Donders in
Holland, and von Graefe and von Helmholtz in Germany,
ophthalmology was emerging as the first organ-based specialty in
medicine. Bowman (1816 to 1892) is known for Bowman's membrane
and for his work in anatomy and histology. Donders (1818 to 1889)
clarified the principles of refraction and accommodation (1864) and
defined visual acuity as a measurable quantity. His coworker Snellen
developed the Snellen chart. In Berlin, Albrecht von Graefe (1828 to
1870) was a leader in stimulating the clinical application of new
techniques and the careful documentation of new findings. He is
remembered for Graefe's knife and Graefe's Archives (1854) (one of the
first ophthalmic journals), and he founded the German
Ophthalmological Society (Heidelberg, 1857). Several workers had tried
to visualize the inside of the eye but had fallen short of putting it all
together. Kussmaul (known for Kussmaul's airhunger) described the
imaging principles in a thesis in 18454 but failed to solve the
illumination problem. Cumming5 (1846) in England and Brcke6 (1847)
in Germany had shown that a reflection from the fundus could be
obtained by bringing the light source in line with the observer, but they
failed to solve the imaging problem. Babbage,7 the English
mathematician, reportedly constructed an ophthalmoscope in 1847, but
his ophthalmologist friend did not recognize the importance and did not
publish it until 1854, when von Helmholtz' instrument was well known.

In the fall of 1850, von Helmholtz tried to demonstrate the inside of the
eye to the students in his physiology class. On December 6, he
presented his findings to the Berlin Physical Society1; on December 17,
he wrote to his father8:

I have made a discovery during my lectures on the Physiology of the

Sense-organs, which was so obvious, requiring, moreover, no
knowledge beyond the optics I learned at the Gymnasium, that it seems
almost ludicrous that I and others should have been so slow as not to see
it. Till now a whole series of most important eye-diseases, known
collectively as black cataract, have been terra incognita. My
discovery makes the minute investigation of the internal structures of
the eye a possibility. I have announced this very precious egg of
Columbus to the Physical Society at Berlin, as my property, and am now
having an improved and more convenient instrument constructed to
replace my pasteboard affair

Helmholtz' monograph on ophthalmoscopy was published in 1851 and

soon was widely circulated. The next year there were several important
improvements contributed by other workers. Rekoss,9 von Helmholtz'
instrument maker, added two movable disks with lenses for easier
focusing. Epkens, working with Donders in Holland,8 introduced a
perforated mirror for increased illumination. Ruete10 in Germany did the
same and also developed the indirect method of ophthalmoscopy. With
these basic components in place, future generations provided technical
improvements. In 1913, Landolt11 listed 200 different types of
ophthalmoscopes. The most important changes are related to the change
from candle light to gas light, to external electric light and, finally, to
built-in electric light sources. This chapter concentrates on currently
available forms of ophthalmoscopy. For additional information on the
history of ophthalmoscopy the reader is referred to references 8 and 12.

Although the older generation found it difficult to adapt to the new

instrument, the younger generation did so eagerly. One of them was
Eduard von Jaeger (1828 to 1884) from Vienna, best known for his print
samples that were based on the print catalogue of the Vienna State
Printing House. He was the son of a well-known ophthalmologist and an
artistically gifted mother. In 1855, at the age of 27, he published his first
atlas; he continued to add to his collection of authoritative fundus
paintings until his death in 1884.13

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BASIC PRINCIPLES OF DIRECT OPHTHALMOSCOPY
The basic principle of direct ophthalmoscopy is simple (Fig. 1). If the
patient's eye is emmetropic, light rays emanating from a point on the
fundus emerge as a parallel beam. If this beam enters the pupil of an
emmetropic observer, the rays are focused on the observer's retina and
form an image of the patient's retina on the observer's retina. This is
called direct ophthalmoscopy.

Fig. 1. Imaging in direct ophthalmoscopy. If patient and observer are

both emmetropic, rays emanating from a point in the patient's fundus
will emerge as a parallel beam and will be focused on the observer's
retina.

However, there is a problem with this method: Sufficient light for

visualization of the fundus emerges only if the patient's fundus is
properly illuminated. Because of the optics of the eye (Fig. 2), incident
light reaches only the part of the fundus onto which the image of the
light source falls. Conversely, only light from the fundus area onto
which the observer's pupil is imaged reaches that pupil. The fundus can
be seen only where the observed and the illuminated areas overlap; in
the emmetropic eye this can happen only if the light source and the
observer's pupil are aligned optically. Under normal conditions this does
not happen, and the pupil normally appears black. How a reflection can
be seen under abnormal conditions is discussed later in this text.
Fig. 2. The illumination problem in direct ophthalmoscopy. If the light
source and the observer are not aligned optically, the observer views a
part of the fundus that is not
illuminated.

There are several ways in which optical alignment of the illuminating

and observing beams can be accomplished (Fig. 3). Von Helmholtz
solved the problem with a semireflecting mirror made up of several thin
parallel pieces of glass (see Fig. 3A). Epkens and Ruete used a
perforated concave mirror, which places illuminating light rays all
around the observation beam (see Fig. 3B). A modification of this
arrangement is used in the fundus camera. Most hand-held instruments
now have a small mirror or prism (see Fig. 3C), which uses the lower
half of the patient's pupil for illumination and the upper half for
observation.

Fig. 3. Illumination methods in direct ophthalmoscopy. A. Illumination

with semireflecting mirror (Helmholtz). B. Illumination with perforated
mirror (Epkens, Ruete). C.
Illumination with mirror or prism
(modern).

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FIELD OF VIEW IN DIRECT OPHTHALMOSCOPY
If the patient's fundus is properly illuminated, the field of view is
limited by the most oblique pencil of light that can still pass from the
patient's pupil to the observer's pupil (Fig. 4). In direct ophthalmoscopy
the retinal point that corresponds to this beam can be found by
constructing an auxiliary ray through the nodal point of the eye.11 The
point farthest from the centerline of view that can still be seen is
determined by the angle , that is, the angle between this oblique pencil
and the common optical axis of the eyes.

Fig. 4. Field limits in direct ophthalmoscopy. The maximum field of

view is determined by the most oblique pencil of rays (shaded) that can
still pass from one pupil to the
other.

Angle , and therefore the field of view, is increased when the patient's
or the observer's pupil is dilated or when the eyes are brought more
closely together.

The more peripheral pencils of light use ever-smaller parts of each

pupil. This means that, even if the patient's fundus is uniformly
illuminated, the luminosity of the fundus image gradually decreases
toward the periphery, so that there is no sharp limitation to the field of
vision. In practice, therefore, the effective field of vision is determined
by the illuminating system not by the viewing system. Most
ophthalmoscopes project a beam of light of about one disc diameter.

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EXTENDING THE FIELDINDIRECT OPHTHALMOSCOPY
Even with appropriate illumination, direct ophthalmoscopy has a small
field of view. Figure 5 shows that of four points in the fundus, points
one and four cannot be seen because pencils of light emanating from
these points diverge beyond the observer's pupil. To bring these pencils
to the observer's pupil, their direction must be changed (Fig. 6). This
requires a fairly large lens somewhere between the patient's and the
observer's eye. This principle was introduced by Ruete10 in 1852 and is
called indirect ophthalmoscopy to differentiate it from the first method,
in which the light traveled in a straight, direct path from the patient's eye
to the observer.

Fig. 5. Limited field of view in the direct method. Peripheral pencils of

light do not reach the observer's
pupil.

Fig. 6. Extended field of view in the indirect method. The

ophthalmoscopy lens redirects peripheral pencils of light toward the
 observer.

The use of the intermediate lens has several important implications that
make indirect ophthalmoscopy more complicated than direct
ophthalmoscopy.

The primary purpose of the ophthalmoscopy lens is to bend pencils of

light toward the observer's pupil. Figure 6 also demonstrates one of the
most characteristic side effects of this arrangement: Compared with the
image in direct ophthalmoscopy, the orientation of the image on the
observer's retina is inverted. For the novice, this often causes confusion
in localization and orientation. Figure 6 further shows that in this
arrangement the patient's pupil is imaged in the pupillary plane of the
observer. In optical terms the pupils are in conjugate planes. This fact is
useful later in this discussion.

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FIELD OF VIEW IN INDIRECT OPHTHALMOSCOPY
The field of view in indirect ophthalmoscopy is determined by the rays
emerging from the patient's eye that can be caught in the
ophthalmoscopy lens. With optimal placement of the lens and of the
observer's eye, the distance from the patient's eye to the lens is only
slightly more than the focal length of the lens. (The exact distance will
be calculated later.) The field of view, therefore, is determined by the
ratio of lens diameter and focal length. This ratio can also be written as
a product:
Lens diameter/Focal length = Lens diameter dioptric power

This provides an easy formula for comparing the field of view of

various lenses.

Given lenses of equal power, a larger lens provides a wider field of

view. If lenses have equal diameters, a stronger lens provides a wider
field of view; however, because stronger lenses often have a smaller
diameter, a stronger ophthalmoscopy lens does not always provide a
larger field. A 20-diopter (D) lens of 30 mm provides about the same
field of view as a 30-D lens of 20 mm or as a 13-D lens of 45 mm
(because 20 30 = 30 20 = 13 45).

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IMAGING IN INDIRECT OPHTHALMOSCOPY
Figure 6 shows that light emerging from the patient's fundus is directed
toward the observer's eyes. It does not specify whether the observer sees
a focused image or just an unstructured red reflex. Figure 7 traces the
rays within one of the pencils of light from the patient's fundus to the
observer's retina.

Fig. 7. Imaging in the indirect method. A pencil of rays (shaded) is

traced from the patient's fundus to the observer's retina. An
intermediate, inverted image of the patient's fundus is formed in the
focal plane of the ophthalmoscopy lens. The observer must
accommodate on this image.

If the patient is emmetropic, the pencils emerging from the eye are
composed of parallel rays, but this changes once the pencils pass
through the ophthalmoscopy lens. In fact, because the rays within each
pencil enter the ophthalmoscopy lens with zero vergence, they are
brought to a focus in the focal plane of the ophthalmoscopy lens.
Proceeding beyond that point, the rays within each pencil are divergent.

Considering all pencils emerging from the patient's eye together, an

aerial image of the patient's fundus will be formed in the focal plane of
the ophthalmoscopy lens. This image is inverted with respect to the
patient's fundus, and it is this image that the observer is viewing. To
focus the aerial image on his or her own retina, the observer must
accommodate for the aerial image plane and hence cannot approach too
closely.

It may be useful to recall the difference between tracing of pencils and

tracing of rays. In any optical system, tracing of pencils is necessary to
determine the limits of the field of view; tracing of rays is necessary to
determine the position of the image plane.Optical diagrams may confuse
the uninitiated, because they generally trace only one ray per pencil (see
Figs. 5 and 6) and may use theoretic auxiliary rays beyond the
physically existing pencils (see Fig. 4) to facilitate the construction of
object and image planes.

In direct ophthalmoscopy, peripheral pencils of light are increasingly cut

off by the observer's and patient's pupils (see Fig. 4). In indirect
ophthalmoscopy (see Fig. 7) this does not happen; only the observer's
pupil limits the diameter of the pencils that reach the observer's retina.
The apparent luminosity of the fundus image, therefore, is constant
throughout the field (provided, of course, that the fundus is illuminated
evenly). This is one reason fundus cameras are built around the imaging
principle of indirect ophthalmoscopy.

In summary, the purpose of the ophthalmoscopy lens in indirect

ophthalmoscopy is to redirect diverging pencils of light emerging from
the patient's pupil toward the observer's eye. In doing so, the lens also
focuses parallel rays within each pencil into an inverted aerial image of
the patient's fundus. The existence of an inverted aerial image is one of
the most prominent and unavoidable characteristics of indirect
ophthalmoscopy.

Another characteristic of indirect ophthalmoscopy is that it requires a

considerable distance between the patient and the observer. This is in
contrast to direct ophthalmoscopy, in which close approximation is
advantageous. When tuberculosis and other respiratory infections were
common, the arm's length distance between observer and patient was
considered an additional advantage of the indirect method. In Europe,
indirect ophthalmoscopy has been the preferred method; direct
ophthalmoscopy is used mainly for additional detail. In the English-
speaking countries the opposite has occurred; indirect ophthalmoscopy
did not become popular until the introduction of the binocular indirect
ophthalmoscope by Schepens.14

The indirect method offers a wider field of view than does direct
ophthalmoscopy, but this advantage is at the expense of decreased
magnification. How do the two methods compare?

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MAGNIFICATION IN DIRECT OPHTHALMOSCOPY
If the patient and the observer are both emmetropic, the optical diagram
for direct ophthalmoscopy (see Fig. 4) is completely symmetric. It is
easy to see that the size of the retinal image in the observer's eye will
equal the size of the fundus detail seen. In this sense the magnification
is 1/1, that is, the image of the patient's disc will measure one disc
diameter on the observer's retina.

Another more conventional way of defining magnification is to compare

the observer's view of a given object with the view that would be
obtained when looking at the same object from a standard distance. The
usual standard for comparison is 25 cm. How much larger does the
patient's disc appear than does the disc of a dissected eye viewed at 25
cm?

For this calculation the optics of the reduced eye (discussed elsewhere
in these volumes) may be compared with a linen tester or other hand-
held magnifier of 60 D (Fig. 8). Such a lens allows a viewing distance
of 0.0167 m, 15 times shorter than the reference distance of 0.250 m.
Thus, the viewing angle is 15 times larger, and the magnification is said
to be 15 times.

Fig. 8. Magnification in the direct method. Viewing the fundus through

the optics of the patient's eye (60 D in the reduced eye) can be
compared with viewing a specimen
under a 60-D magnifier.

If the patient and the observer are not both emmetropic, the calculations
are more complex. Axial length of both eyes, refractive power of both
eyes, and the position of the compensating lenses in the ophthalmoscope
must all be considered; the eyes of myopic patients have extra plus
power and the ophthalmoscope must carry a negative lens. This
combination, in part, acts as a Galilean telescope for the observer, and
fundus details are seen larger. In aphakia the reverse happens: fundus
details are seen smaller, as through a reversed Galilean telescope.

In direct ophthalmoscopy the image on the observer's retina is about as

large as the fundus detail viewed and is 15 times larger than it would be
if the same fundus detail were viewed from 25 cm.

An additional 2 magnification can be achieved by placing a small

Galilean telescope on the ophthalmoscope, but fundus microscopy with
the slit lamp and a contact lens is a better way to achieve this level of
magnification.

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MAGNIFICATION IN INDIRECT OPHTHALMOSCOPY
Magnification in indirect ophthalmoscopy can best be understood if
broken down into two components: magnification from fundus detail to
aerial image and magnification from aerial image to the observer's
retinal image. Magnification in the first step depends on the power of
the ophthalmoscopy lens; magnification in the second step depends on
the observation distance.

If the patient is emmetropic, the aerial image is formed in the focal

plane of the lens (compare Fig. 7). Figure 9 shows that
Fig. 9. Magnification of the aerial image in the indirect method. Aerial
image size is found through construction of an imaginary, auxiliary ray
(dotted line). Fundus detail f sin
. Aerial image is f sin .

Aerial image/Fundus detail = flens sin /feye sin = flens/feye

converting from focal length to diopters and assuming 60 D as the

power of the eye

Aerial image/Fundus detail = flens sin /feye sin = flens/feye = Deye/Dlens

= 60/lens power

Thus the aerial image formed by a 20-D lens will be 60/20, or three
times larger than the corresponding fundus detail; with a 30-D lens it
will be 60/30, or two times larger.

When the aerial image is viewed from 25 cm, no further magnification

is involved, because 25 cm is the reference distance for magnification. A
25-cm viewing distance from the aerial image requires 4 D of
accommodation on the part of the observer; a more common viewing
distance is 40 cm, requiring 2.5 D of accommodation. Changing from
25 cm to 40 cm reduces the observer's retinal image size by 25/40 or
5/8.

Combining both steps we obtain the following: With a 20-D lens and a
distance of 25 cm from aerial image to observer, the patient's disc is
seen 3 timeslarger than the disc of a dissected eye at 25 cm. With direct
ophthalmoscopy this would have been 15 times larger. Indirect
ophthalmoscopy in this case provides five times less magnification than
does direct ophthalmoscopy. For a 40-cm viewing distance the
magnification becomes 5/8 3, which is approximately 2, or 8 times
less than direct ophthalmoscopy.

Similar calculations can be made for other lenses. Figure 10 summarizes

data for lenses of 30 D, 20 D, and 13 D. As the magnification becomes
less, the area of the patient's fundus that can be imaged on a given area
of the observer's retina increases quadratically; for instance, 8 times less
linear magnification potentially results in a 64-times larger area seen.
Whether this potential is realized depends on the factors mentioned in
the discussion of the field of view in both methods: width of the
illuminating beam in direct ophthalmoscopy and diameter of the
ophthalmoscopy lens in indirect ophthalmoscopy.

Fig. 10. Total magnification in the indirect method. Total magnification

depends on lens power and observation distance and is always less than
in the direct method.

In summary, in indirect ophthalmoscopy the observer's retinal image is

considerably less magnified than in direct ophthalmoscopy. The stronger
the lens, the less magnified is the image. This is the price paid for the
enlargement of the field of view. For any given ophthalmoscopy lens,
some extra magnification can be gained by reducing the viewing
distance, but this requires extra accommodation by the observer.

An alternative calculation compares the size of the observer's retinal

image with the size of the patient's fundus detail. This ratio, as we have
seen, is 1:1 in direct ophthalmoscopy. This calculation, which bypasses
the size of the aerial image, is explained in Figure 11 and the
accompanying table. The observer's retinal image size and the size of
the corresponding fundus detail in the patient are determined by the
angles and . These, in turn, are proportional to the distances a and b.
The relationship of a and b follows from the requirement that the
patient's and the observer's pupils must be in conjugate planes (in
diopters: 1/a + 1/b = lens power).
Fig. 11. Calculation of distances and magnification for various lenses
and viewing distances, in the
indirect method.

The steps in the calculation are as follows. Given the patient's refractive
error and the lens power, the distance c from the lens to the aerial image
can be calculated. If the patient is emmetropic, c is the focal length.
Given the observer-to-aerial-image distance (d), b can be calculated (b =
c + d). Given b, a can be calculated, and subsequently a/b and a + b.

The last column (a + b) indicates the total distance from patient to

observer. The a/b ratio indicates the ratio of the observer's retinal image
to the patient's fundus detail. In direct ophthalmoscopy, as we have seen,
this ratio is 1:1. The values in this column thus are the same as those in
Figure 10. The a/b ratio will be used in later calculations on the latitude
of beam placement.

Through these calculations the field of view formula can now be

refined. The proper formula is lens diameter/a instead of lens
diameter/focal length. The actual value of a, and hence the field of view,
varies somewhat with the patient's refractive error and the observer's
viewing distance. The effect of this refinement is small and the earlier
formula remains a useful rule of thumb.

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COMPENSATION FOR REFRACTIVE ERROR
The discussion so far has assumed that both the subject and the observer
are emmetropic. This obviously is not always the case.

In direct ophthalmoscopy the problem can be overcome by having

patient and physician wear their respective spectacle (or contact lens)
correction. Each eye with its correction then acts as an emmetropic
system. This method can be used to advantage in the case of high
refractive errors and especially in the case of marked astigmatism. For
small refractive errors, however, it is advantageous to remove the
glasses because the eyes can then be approached more closely, resulting
in an increased field of view. In this case a single lens in the
ophthalmoscope must replace the mathematical sum of the patient's and
the observer's correction. To do this conveniently, Rekoss9 (1852)
devised a system of two disks, one carrying lenses with large steps and
one with small steps, a miniature anticipation of the disks used in the
phoropter. In indirect ophthalmoscopy, compensation for refractive error
can be made without additional lenses. The data for Figure 12 are from
recalculation of the table in Figure 11 for a 20-D lens, 45 cm between
the lens and the observer, and various degrees of patient ametropia.

Fig. 12. Compensation for refractive error. With the indirect method,
minor changes in the observer's accommodation can compensate for
major changes in the patient's
refractive error.

If the patient is emmetropic (E), the aerial image (E') will be 5 cm from
the lens; if the observer is 45 cm from the ophthalmoscopy lens, he or
she must accommodate for 40 cm (2.5 D). If the fundus detail observed
lies in a plane (M) representing 5 D of myopia, the aerial image (M')
will be at approximately 20 + 5 = 25 D = 4 cm. The accommodation
required will be for 41 cm (2.45 D). A fundus detail representing 5
diopters of hyperopia (H) will form an aerial image (H') at 20 - 5 = 15 D
= 6.6 cm, requiring an accommodative increase to 38.3 cm (2.6 D).
Thus, minor changes in the examiner's accommodation can easily
account for major refractive errors that the patient may have. The
presbyopic observer, who cannot change accommodation, can
compensate for the patient's refractive error by changing the observation
distance or by using a near-vision add.

An interesting case exists for a patient with 20-D myopia. Here, the eye
forms its own aerial image at 5 cm, that is, in the plane of the
ophthalmoscopy lens. The ophthalmoscopy lens does not change the
location of this image. This image could be viewed without the
ophthalmoscopy lens, but the field of view in that case would be limited
to the patient's pupil (Fig. 13). With the lens the field of view becomes
far larger. This demonstrates that the field-enlarging function of the
ophthalmoscopy lens can indeed be separated from its aerial image-
forming function. Another example is found in the section on contact
lens methods.
Fig. 13. Indirect ophthalmoscopy of a high myope. The myopic eye
forms its own aerial image (dotted lines) without the help of the
ophthalmoscopy lens. Without the lens, only the central part of this
image would be visible (dashed lines, limited by the patient's pupil).
With lens (solid lines) the image is
limited by the lens rim.

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DESIGN OF LENSES FOR INDIRECT OPHTHALMOSCOPY
In principle, ophthalmoscopy can be performed with any lens, but as the
lens diameter is increased, the peripheral aberrations tend to increase
and will degrade the clarity of the peripheral image. In binocular
viewing it is important that there be no image distortion. A difference in
distortion between the two eyes (which look through the lens in slightly
different directions) would interfere with proper stereoscopic
perception. Because of this, practically all ophthalmoscopy lenses,
especially the larger and stronger ones used in binocular
ophthalmoscopy, are now of aspheric design. They have two differently
curved surfaces; the surface with the steeper curvature should face the
examiner. A doublet lens may further reduce distortion but increases the
number of reflecting surfaces. Rodenstock has made such a lens.

Because the illuminating light passes through the ophthalmoscopy lens,

it will be reflected from the lens surfaces (reflections and scatter in the
patient's eye will be discussed later). These reflections can be reduced,
but not completely eliminated, by antireflective coating; most lenses
today are coated to minimize reflections. Some lenses (Volk) are also
colored to reduce unwanted radiation on the patient's retina.

When the lens is perpendicular to the line of viewing, the reflections

from both front and back surfaces are in the center and are most
bothersome. By tilting the lens a little, these reflections can be moved
out of the line of view without degrading the image. Indeed, such tilting
sometimes improves the image. When the peripheral retina is viewed,
oblique astigmatism of the ocular media is present. Tilting the lens
perpendicular to this astigmatism improves the image.

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A CLOSER LOOK AT ILLUMINATION AND REFLECTIONS
Scattered light superimposed on the fundus image can seriously
interfere with the visibility of fundus details in both direct and indirect
ophthalmoscopy. Reflections not only arise at the ophthalmoscopy lens
but also result because the illuminating beam and observation beam
must pass through the same optical system of the patient's eye. These
reflections are most bothersome when viewing along the optical axis, as
is necessary in examination of the macular area.

For direct ophthalmoscopy, a solution was provided by Thorner15 (1899)

and by Wolff16 (1900) who limited the illuminating beam to a small
peripheral part of the patient's pupil. In 1910 Gullstrand17 gave the
definitive account of the optical requirements involved: To avoid both
reflection and scatter of illuminating rays into the viewing beam, both
beams must be completely separated over the trajectory where such
interference might occur. To avoid the corneal reflection, which is the
most brilliant one, the two beams must be separated in the corneal
plane. To avoid reflection from the lens surfaces and scatter by lens
opacities, the beams must also be separated in their trajectory through
the lens.

In a sense, this last requirement is the reverse of the illumination

requirement discussed in the beginning of the chapter. The pupil seen
without an ophthalmoscope appears black because the illuminating and
viewing beams are totally separated at the retinal level and because
there is nothing to reflect light in the areas where they do overlap (Fig.
14A). If a retinal detachment, a tumor, or a vitreous opacity reaches
forward to the area of overlap, a reflection will be visible. When the
pupil is dilated and/or when the light source and observation direction
are brought closer together, the area of overlap will be extended farther
toward the fundus and the spontaneous visibility of an elevated lesion
will be increased (see Fig. 14B). Tumors, detachments, and other
elements equivalent to high hyperopia may thus be seen without an
ophthalmoscope.
Fig. 14. Spontaneous visibility of elevated lesions. A. When the pupil is
small, the area of overlap (shaded) of illuminating and viewing beam is
limited. B. When the pupil is large, the area of overlap extends farther
backward, and elevated lesions may become visible without an
ophthalmoscope.

For reflex-free ophthalmoscopy, we want to achieve the opposite:

overlapping beams on the retina and separated beams through the
cornea and lens where reflections and scatter may be bothersome.

Satisfying Gullstrand's requirement may call for a compromise in the

construction of the ophthalmoscope. Bringing the illuminating and
viewing beams close together (Fig. 15A) allows observation through
small and undilated pupils but creates more visible reflections and
scatter. Reflex-free viewing is achieved more easily if the beams are
separated (see Fig. 15B), but separation of the beams sacrifices the
ability to view through undilated pupils. A compromise can be reached
by including a half-circle diaphragm in the illuminating beam. This
diaphragm reduces the amount of reflection by intercepting the upper
part of the illuminating beam (see Fig. 15C). As a result, only the lower
half of the field of view is illuminated, but the entire field may be
scanned by moving this illuminated area around while viewing. One
ophthalmoscope on which this feature is available is the Propper
instrument.
Fig. 15. Separation of viewing and illuminating beams for reflex-free
direct ophthalmoscopy. A. Beams close: overlap in cornea and lens. B.
Beams separated: Area of overlap moves backward, but a wider pupil is
required. C. Beams close, but illuminating beam restricted: less
overlap, yet
smaller pupil
possible.

This arrangement illustrates the advantage of equipping the illuminating

system with its own optical system of a condensing lens (to intensify the
beam), diaphragm, and projecting lens (to limit the total circumference
of the beam). In modern hand-held ophthalmoscopes, this is always the
case. In the older forms of ophthalmoscope with a mirror and external
light source, this was not possible.

For maximum light effectiveness with small pupils and for the most
even fundus illumination, the narrowest part of the illumination beam
(the area where an image of the filament is formed) should be
positioned within the patient's pupil, that is, 2 to 3 cm outside the
ophthalmoscope head. Some ophthalmoscopes place it closer, for
example, on the patient's cornea or even on the reflecting prism. The
latter position is not optimal. In prefocused ophthalmoscopes the
manufacturer has made the adjustments. In ophthalmoscopes that allow
for some adjustment of the light bulb, the user can choose to adjust the
illuminating beam either toward or away from the edge of the mirror or
prism. Location toward the edge allows small pupil viewing at the
expense of more reflections. Location away from the edge reduces
reflections but requires more dilation. Some ophthalmoscopes have an
illumination system that can slide up and down, thus allowing individual
adjustment for each patient.

Back to Top
ILLUMINATION IN INDIRECT OPHTHALMOSCOPY
Separation of the observation and illumination beams is achieved more
easily in indirect ophthalmoscopy than in direct ophthalmoscopy. In
indirect ophthalmoscopy, the illuminating beam is usually mirrored into
the optical path just in front of the observer's pupil and is projected
through the ophthalmoscopy lens. For maximum light efficiency, the
filament image should be located in the patient's pupil. Because the
pupillary planes are conjugate planes, this requires that the filament (or
an additional intermediate image) be located in or near the observer's
pupillary plane.

The ophthalmoscopy lens projects the observer's pupil and the

illuminating source as reduced images into the patient's pupil (Fig. 16A).
These reduced images and the narrow pencils of light that generate them
allow for more complete separation through the cornea and lens than is
possible in the direct method. Because Gullstrand's requirement is more
easily fulfilled in indirect ophthalmoscopy, media opacities are often
more easily penetrated by this method.

Fig. 16. Illumination and observation beam placement in indirect

ophthalmoscopy. The observer's pupil and the light source are placed
within the image of the patient's pupil. Their image thus must fall
within the actual patient pupil. A. Monocular method. B. Binocular
method.

This greater latitude in beam placement allows the use of two

observation beams, thus allowing binocular viewing and stereopsis. To
achieve this, the images of the observer's pupils must fit within the
actual patient pupil, or the observer's interpupillary distance (PD) must
fit within the (enlarged) image of the patient's pupil. To make this
possible the observer's PD is usually reduced through prisms or mirrors
(see Fig. 16B).

The first binocular ophthalmoscope reportedly was made by Giraud-

Teulon18 in France (1861). To reduce the observer's PD, he placed a set
of prisms behind the perforated hand-held mirror commonly used in
those days. Gullstrand's explanation of the principle of reflex-free
ophthalmoscopy led to the construction of large table-mounted
ophthalmoscopes (made by Zeiss in Europe and Bausch and Lomb in
the United States), which were popular in clinical settings for many
decades. These also allowed binocular vision. Yet binocular
ophthalmoscopy did not gain wide acceptance until 1947, when
Schepens14 introduced his binocular head-mounted ophthalmoscope
with built-in light source. Today in the United States, binocular indirect
ophthalmoscopy has largely replaced monocular indirect
ophthalmoscopy.

Back to Top
LATITUDE OF BEAM PLACEMENT
Because the observer's pupil and the patient's pupil are in conjugate
planes, it is optically equivocal whether we discuss the placement of the
image of the light source and the image of the observer's pupil in the
actual patient pupil (i.e., where reflections occur) or the position of the
actual eyepiece and actual light source (where mechanical adjustments
can be made) in the image of the patient's pupil.

The b/a ratio calculated earlier (see Fig. 11 and table) also indicates the
magnification of the image of the patient's pupil. From this table it
follows that the magnification of the pupil image resulting from a 30-D
lens and a 40-cm viewing distance (47-cm total distance) is 12 times.
Under these circumstances the image of a 7-mm pupil is 12 7 = 84
mm, and the fundus can be viewed binocularly even with a normal PD.
At the same distance, a 4-mm pupil and 20-D lens provide an 8 4 = 32
mm pupil image, which is adequate for most binocular scopes in which
the observer's PD is reduced to 15 to 20 mm. A 2-mm pupil provides an
8 2 = 16 mm pupil image, too small for the binocular scope but still
adequate for the monocular method. With a 30-D lens the image of the
2-mm pupil would be 12 2 = 24 mm, so binocular visibility might be
better than with the 20-D lens. In general, it should be remembered that
a pupil that is too small for viewing with a low-power ophthalmoscopy
lens may be penetrable if a higher power is used.

Back to Top
MONOCULAR INDIRECT OPHTHALMOSCOPY
Many ophthalmologists tend to forget (or never learned) that indirect
ophthalmoscopy does not require binocular viewing and that monocular
indirect ophthalmoscopy can penetrate pupils that are too small for
direct ophthalmoscopy or binocular indirect viewing. The monocular
indirect method also allows the use of low-power lenses through which
small details are seen larger. It was noted earlier that low-power lenses
do not need to have a smaller field of view if their diameter is large
enough.

The original monocular, hand-held indirect ophthalmoscope used an

external light source reflected by a mirror held in front of the observer's
eye. Today the beam of a direct ophthalmoscope can be used, provided
that the beam is strong enough and evenly concentrates all of its light
output on the ophthalmoscopy lens. The Zeiss and Propper/Heine
ophthalmoscopes provide good illumination, the latter in particular
because of its halogen or fiberoptic light source. Ophthalmoscopes with
a more divergent beam, such as the AO giantscope, are less desirable.

Alternatively, a special handle with built-in light source and prism can
be used. The observer looks over the top or along the side of the prism
(see Fig. 19). Oculus makes such a handle with rechargeable batteries.
Propper/Heine makes one with a fiberoptic light source.

Fig. 19. Beam placement in monocular indirect ophthalmoscopy. A. For

the 3 o'clock and 9 o'clock periphery, the observer looks over the top of
the beam. B. For the 6 o'clock and 12 o'clock periphery, looking along
the side of the beam is advantageous.

Using the direct scope as an indirect light source makes it easy to

alternate the two methods for the exploration of peripheral details. The
fundus is first scanned in the indirect mode, and the desired detail is
centered. Then, the ophthalmoscopy lens is removed and the patient's
eye is approached. If orientation and alignment are properly maintained,
the ophthalmologist can automatically zero in for precise examination of
the desired detail.

A major advantage of the monocular hand-held ophthalmoscope is that

the positions of light source and viewing beam are variable. The light
source can be brought very close to the observer's line of view to allow
viewing through very small pupils; more separation can be used with
wider pupils to reduce reflections and to avoid scatter by cataracts. In a
patient with a peripheral iris coloboma, it is sometimes possible to view
through the undilated central pupil, while maneuvering the illuminating
beam through the coloboma (Fig. 17).

Fig. 17. Indirect ophthalmoscopy with a hand-held light. The hand-held

light allows maximum flexibility
of beam placement.

Back to Top
BINOCULAR INDIRECT OPHTHALMOSCOPY
In the more popular binocular, head-mounted indirect ophthalmoscope
this maneuverability is sacrificed, but stereopsis and freeing of one hand
are gained. The free hand can be used to steady or manipulate the eye.
In this case, too, a compromise has to be reached. Bringing the beams
close together allows viewing through a small pupil but increases
reflections and reduces stereopsis. Separation of the viewing beams
increases stereopsis, whereas separation of viewing and illuminating
beams provides better compliance with Gullstrand's requirement;
however, both types of separation require a wide pupil. In most
ophthalmoscopes the distance between the viewing beams is fixed at 15
to 20 mm. The distance between illuminating and viewing beams can be
varied by tilting the mirror. In all instances, binocular viewing requires a
considerably larger pupil than does monocular viewing.
Back to Top
PERIPHERAL VIEWING
Examination of the fundus should not be limited to the posterior pole.
The field of view discussed in the beginning of this chapter is the field
without scanning. Scanning movements can considerably expand the
area that can be seen. How far to the periphery can scanning movements
in each method of ophthalmoscopy bring us? The most important
constraint is that in peripheral viewing the patient's effective pupil
assumes an elliptical shape and that both the viewing and illuminating
beams must fit within this shape. The long axis of this oval remains the
same as the diameter of the round pupil when seen frontally.

In direct ophthalmoscopy of the seated patient, the pupil becomes a

vertically elongated oval when the patient looks to the left or to the right
to allow us a view of the 3 o'clock and 9 o'clock periphery. With the
ophthalmoscope held in its normal vertical position, the viewing and
illuminating beams easily fit into this oval. In viewing of the 6 o'clock
and 12 o'clock positions, however, the pupil becomes horizontally
elongated and it is advantageous to shift the ophthalmoscope to a
horizontal position. This is done almost instinctively because it also
allows closer approximation of the pupils. For other meridians, the
ophthalmoscope has to be tilted accordingly (Fig. 18).

Fig. 18. Beam placement in direct ophthalmoscopy. In peripheral

viewing, the viewing and illuminating beams must fit within the
narrowed appearance of the pupil. For the 12 o'clock and 6 o'clock
positions, the ophthalmoscope is
best tilted.

Peripheral viewing is possible until the projection of the pupil becomes

too narrow to accommodate the beams. Peripheral viewing, therefore, is
better the wider the patient's pupil is dilated and is usually achievable up
to the equatorial area.

In indirect ophthalmoscopy the same restrictions apply, but, because of

the narrower beam in the patient's pupillary plane, it is easier to reach
more peripheral areas. In monocular indirect ophthalmoscopy of the
seated patient, the same conditions apply as for direct ophthalmoscopy.
To view centrally and in the 3 o'clock and 9 o'clock positions, the
observer should look over the top of the illuminating beam. For the 6
o'clock and 12 o'clock positions, he or she will obtain better viewing if
the illuminating beam and viewing beam are side by side (Fig. 19). If
the observer uses the Oculus instrument, he or she will want to look
along the side of the prism. If the observer uses the beam of a direct
ophthalmoscope, he or she will want to change the ophthalmoscope to a
horizontal position. Through a dilated pupil, a skilled ophthalmoscopist
can readily visualize the ora serrata.

In binocular indirect ophthalmoscopy with a head-mounted scope, the

same flexibility of beam placement is not available. Because the
arrangement of the viewing and illuminating beams is generally
horizontally elongated, viewing toward the 6 o'clock and 12 o'clock
periphery of the eye of the seated patient will be relatively easier than
toward the 3 o'clock and 9 o'clock periphery. Indirect binocular
ophthalmoscopy of the peripheral retina is easier if the patient is
reclining and looking upward and the observer can move around the
patient's head. Under these conditions the patient's pupil always
becomes a horizontally elongated oval and visualization up to the ora
serrata is usually possible. Some ophthalmoscopes offer minor
adjustments of the relative position of the illuminating and viewing
beams through tilting of the mirror. The most flexible ophthalmoscope
is the Schepens/Pomerantzeff model (Fig. 20). The adjustability is
advantageous for the expert, but it also increases the possibility of
inadvertent maladjustment. The novice should use an ophthalmoscope
that is permanently adjusted for a reasonable compromise setting.
Fig. 20. Adjustments in the Schepens Pomerantzeff ophthalmoscope. A.
Standard setting. B. Additional separation in an extra-wide pupil. C.
Less separation in a narrow pupil. D. Illuminating beam shifted for
peripheral viewing. (Redrawn from Schepens Pomerantzeff
Ophthalmoscope: The Unique Optimized Ophthalmoscope. Waltham,
MA:

Medical Instruments Research Associates, Inc, 1977.)

To view the pars plana beyond the ora serrata, a technique first
described by Trantas12 (1900) is useful. It brings the far peripheral areas
into view by depressing the sclera, either with one's finger or, more
commonly, with a thimble-mounted scleral depressor as described by
Schepens14 (1950).

Back to Top
LOCALIZATION IN THE FUNDUS
To indicate the location of retinal lesions for descriptive reference, it has
become customary to estimate the meridian in clock hours and the
distance from the posterior pole in disc diameters or to refer to
landmarks such as the equator and the ora serrata. Such localization
obviously is only approximate.

Novice observers often find that attempting localization by indirect

ophthalmoscopy is confusing. They should remember that only the
central ray through the ophthalmoscopy lens passes undeflected. A
lesion seen in the center of the lens is seen in the same direction in
which it would be seen on direct ophthalmoscopy. It is around this
center that the image is inverted (up is down, left is right) (Fig. 21).
These relationships can easily be verified by viewing the inverted image
of a room seen through an ophthalmoscopy lens.

Fig. 21. Relative localization in indirect ophthalmoscopy. Only the

detail seen through the center of the ophthalmoscopy lens (ray 2) is
seen in the proper direction. The rest of the image is inverted around
this point.

In retinal surgery, precise localization is necessary for the treatment of

retinal holes or for the removal of foreign bodies. This is not a simple
matter, because the relationship between the ophthalmoscopic viewing
angle (in degrees from the optical axis) and the external measurement
(in millimeters behind the limbus) is not a linear one and varies
according to the refractive error of the eye.

Considerable ingenuity has been applied to this problem. Measuring

devices have been built to record the exact viewing angle under which a
lesion is seen. Tables have been constructed to convert these data to
external scleral measurements. Figure 22 summarizes the relationships
for an emmetropic eye.
Fig. 22. Absolute localization through ophthalmoscopy. This figure
summarizes the relationship of viewing angle and scleral localization.
(Data from Arruga, quoted by Duke-Elder S: In System of
Ophthalmology, The Foundations of Ophthalmology. Vol 7. Heredity,
Pathology, Diagnosis and
Therapeutics. 1962:290325.)

Because these measurements have to be verified at the time of surgery,

surgeons have generally preferred direct localization during surgery.
During surgery the indentation made by a scleral depressor on the
outside of the globe can be localized ophthalmoscopically and compared
with the location of the tear or foreign body. The position of the
depressor can then be adjusted until coincidence is reached. Fiberoptics
have made it possible to use local transillumination for the same
purpose. In dealing with metallic foreign bodies, the use of a metal
detector during surgery is a further alternative or adjunct to
ophthalmoscopic localization.

Back to Top
MEASUREMENT OF FUNDUS LESIONS
When the development of fundus lesions are followed over time, it often
is desirable to obtain measurements for future comparison. This
problem also stimulated the ingenuity of numerous observers, until the
advent of fundus photography made comparison over time much easier.
For most purposes a visual comparison of successive photographs is
adequate. If absolute measurements are needed, photogrammetric
techniques can be applied to obtain exact measurements, even in three
dimensions if stereo photographs are available. Ultrasound has further
extended the measurement capabilities.

In indirect ophthalmoscopy, nonphotographic fundus measurements can

be made by engraving a scale on the surface of the ophthalmoscopy
lens. In direct ophthalmoscopy, measurements of width can be made by
projecting a scale or reticule in the illuminating beam. For absolute
measurements, corrections have to be applied for axial length and for
ametropia; for the follow-up of a specific lesion, relative measurements
are sufficient. Projection of a reticule in the illuminating beam is simple
if the eye to be observed is emmetropic. If this is not the case, the
reticule will be out of focus and measurement will be difficult. Focusing
of the reticule can be achieved in the following ways:

1. An independently movable condensing lens can be incorporated

in the illuminating optics. In this arrangement two focusing
movements have to be made, one for the Rekoss disks to focus
the viewing optics and one for the sliding lens to focus the
projected image. Keeler has built an instrument of this type.
Most ophthalmoscopes of this type lack a scale to read the
sliding lens setting.

2. The sliding lens and the Rekoss disk are connected through a
contoured template. The two focusing movements are thus
combined, and only one setting must be made. This mechanism
is used in the Propper/Heine Autofoc ophthalmoscope (the
coupling can be disconnected if desired). This simplification
introduces a different restriction: No differential setting is
possible, as may be required in the case of an ametropic
observer. The observer who needs glasses is thus forced to keep
them on.

3. A third way to achieve combined focusing is to project the

illumination beam through the Rekoss lenses. This is done in the
Oculus Visuskop. This is more accurate than coupling by
template, but a disadvantage is that more scatter may occur if
dust accumulates on the Rekoss lenses.

To estimate depth, one may observe movement parallax when the direct
ophthalmoscope is moved across the pupil or may judge stereopsis
when a binocular indirect ophthalmoscope is used.

To measure depth in direct ophthalmoscopy, one may notice the

difference in focusing required for details that lay in different planes, for
example, the bottom of the disc, the normal retina, or an elevated lesion.
For this measurement the observer must keep his or her accommodation
constant, which is not easy for nonpresbyopic observers. Accurate
measurement is facilitated if the focusing of a reticule or of fine lines
can be observed. This technique (as is possible with the Oculus
Visuskop and Propper Autofoc) eliminates the accommodative factor.
The Visuskop is especially well suited for this measurement because it
is can be focused in half-diopter steps throughout its -24 to +24 range.

All of the methods discussed previously involve relative measurement.

If measurements are to be related to standard units, the following
approximations can be used: for lateral measurement, in which 1 disc
diameter is approximately 1.5 mm; for depth measurement: 3 D in an
emmetropic eye is approximately 1 mm and 3 D in an aphakic eye is
approximately 2 mm. For more exact conversions, elaborate corrections
for ametropia have to be made. Ultrasound measurements offer an
alternative that is independent of ophthalmoscopy.

Back to Top
OTHER ACCESSORIES OF THE DIRECT OPHTHALMOSCOPE
The construction of the hand-held electric ophthalmoscope has made it
possible to incorporate various accessory functions in the illuminating
beam. The use of a reticule for measurement and of a line figure such as
an astigmatic dial for accurate focusing have been discussed. Other
accessories include the following.

A fixation star, a dot or a star-shaped figure, may be used to determine

the patient's fixation. This is useful in determining eccentric fixation not
only in strabismic amblyopia but also in central retinal dystrophies or
macular degeneration. In the latter, it may be found that the patient
fixates with a point considerably outside the area of visible change,
indicating that the area of functional deficit is larger than that of the
ophthalmoscopically visible changes. Knowing which area is used for
fixation and how stable this fixation can be maintained is also useful in
the evaluation of macular scarring, and even minimal fixation
nystagmus can easily be recognized. The patient will be more
comfortable and cooperative during this test if the light level is reduced
and/or a green filter is used.

A slit diaphragm is often provided to allow slit-lamp type observation of

elevated retinal lesions. The value of this gadget is limited, because the
angle between slit beam and observation beam is fixed at zero, precisely
the angle at which no depth measurement on the slit lamp is possible. It
may be used, however, as a hand-held slit lamp with observation from
the side of the ophthalmoscope.

A pinhole or half-circle diaphragm may be used to reduce reflections by

limiting the illumination beam as indicated earlier (see Fig. 15). It is
also helpful in the observation of certain fine retinal details that are seen
best in the transitional zone between illuminated and nonilluminated
retina.

A red-free filter is often included. The spectral characteristics of

various red-free filters vary, but all are low in transmission in the red
part of the spectrum and high in the green and blue part. Lack of red
light makes the red elements very dark so that vessels and pinpoint
hemorrhages stand out more clearly. The relative abundance of shorter
wavelengths, which are scattered more easily in the largely transparent
superficial retinal layers, makes it easier to observe changes in these
layers, such as incipient retinal edema and changes and defects in the
retinal nerve fiber layer.

A blue filter may be provided to enhance the visibility of fluorescein, for

use in fluorescein angioscopy and as a hand-held light source for
fluorescein staining of the cornea.

A set of crossed polarizing filters in illuminating and viewing beam is

sometimes used to reduce reflections if Gullstrand's requirement cannot
be met. Light reflected off the cornea is not depolarized and can be
filtered out by the viewing filter. Light diffusely reflected at the retina is
depolarized and remains visible, but light that is specularly reflected,
such as from the internal limiting membrane, is also filtered out. The use
of these filters considerably reduces the effective light output of the
ophthalmoscope.

Back to Top
ILLUMINATION LEVELS IN INDIRECT OPH
In indirect ophthalmoscopy the viewing beams o
of the pupil. The advantages of this arrangement
The disadvantage is that only a small part of the
fundus enters the viewing beams to reach the obs
lenses are used, the percentage of light reaching
less. To compensate for this, the intensity of the
to be increased.

Technologic advances in light source design hav

deliver almost any amount of light to the fundus;
improve patient comfort, and several studies hav
effects of prolonged intense ophthalmoscopy. Se
been made to eliminate unnecessary radiation, pa
heat filter can be used to absorb the infrared radi
systems also provide cooler light. In the Exete
(Mentor), dichroic mirrors are used, which selec
out of the top of the lamp housing and visible lig
the bottom opening. Volk has introduced yellow-
lenses, which are designed to absorb both infrare
elimination of blue light also reduces scatter and

Back to Top
SLIT-LAMP EXAMINATION OF THE FUNDUS
Although not generally considered as a method of ophthalmoscopy,
fundus examination with the slit lamp offers an important addition to the
traditional methods of direct and indirect ophthalmoscopy. It offers the
advantage of high-power magnification through the microscope and
flexible illumination with the slit-lamp beam. With appropriate contact
lenses, it can offer higher magnification than direct ophthalmoscopy and
a field several times wider than indirect ophthalmoscopy. These
methods have become particularly important in combination with laser
treatment.

Because the slit-lamp microscope has a fixed focus on a plane

approximately 10 cm in front of the objective and because the image of
the fundus of an emmetropic eye appears at infinity, the fundus cannot
be visualized without the help of additional lenses. There are several
options.

NEGATIVE LENS

A negative lens placed in front of the objective of the microscope can

move the microscope focus to infinity. The practical application of this
principle was worked out by Hruby19,20 of Vienna (1942) with a lens
known as the Hruby lens.

The optical principle is best understood if the lens is considered in

conjunction with the eye, rather than as a part of the microscope.
Parallel rays emerging from an emmetropic eye are made divergent by
the Hruby lens and seem to arise from the posterior focal plane of that
lens (Fig. 23A). For a -50-D lens, this would be 20 mm behind the lens
(the usual Hruby lens is -55 D). The slit-lamp microscope is thus
looking at a virtual image of the fundus in a plane somewhere in the
anterior segment and must be moved a little closer to the patient than it
would be for the regular external examination.

Fig. 23. Hruby lens. A. The fundus image (F') is formed in the posterior
focal plane of the lens. B. The field of view is proportional to the size
of the
pupil as
seen from
the
anterior
focal point
of the
lens.
To estimate the field of view in this method, it may be assumed that
only rays emerging parallel to the axis will reach the objective of the
microscope and the observer's eye. When emerging from the eye, these
rays must have been aimed at the anterior focal point of the Hruby lens.
Fig. 23B, in which these rays are traced back to the retina, shows that
the field of view (a) is proportional to the pupillary diameter as seen
from the anterior focal point of the lens. This field is of the same order
of magnitude as the field in direct ophthalmoscopy; it is largest when
the lens is closest to the eye.

With the lens close to the cornea, the fundus image will be close to the
fundus plane and approximately actual size. The magnification to the
observer is thus largely determined by the magnification of the
microscope. At 16, the magnification is about equal to that of direct
ophthalmoscopy; at higher settings, the magnification is greater.
Binocular viewing and slit illumination are advantages over direct
ophthalmoscopy, even at similar magnification. Limitation to the
posterior pole is a disadvantage.

CONTACT LENS

When the Hruby lens is moved progressively closer to the eye, it will
eventually touch the cornea and become a contact lens. If the curvature
of the posterior lens surface equals the curvature of the anterior corneal
surface, the image formation will not change, but two reflecting surfaces
will be eliminated, and image clarity will increase.

The use of a contact lens for fundus examination was perfected by

Goldmann21 of Berne, Switzerland (1938). His contact lens is known for
the three mirrors incorporated in it. These mirrors positioned at different
angles make it possible to examine the peripheral retina with little
manipulation of the patient's eye or of the microscope axis (Fig. 24).

Fig. 24. Three mirror contact lens by Goldmann. Two of the three
mirrors are shown. They allow visualization of different parts of the

fundus.
 observer.

The unit contains a high plus contact lens, which forms an inverted
fundus image (F') located inside a second, spherical glass element.

In this arrangement, as in the previous example of a high myope (see

Fig. 13), the image-forming and field-widening functions of the
ophthalmoscopy lens are separated again. The contact lens forms the
image; the spherical element serves to flatten the image and to redirect
the diverging pencils of rays toward the observer. Because these
elements are so close to the eye, the field of view can be very wide.
Indeed, without moving the lens, the view reaches 200 degrees, that is,
from equator to equator, 4 to 5 times the diameter (16 times the area) of
regular indirect ophthalmoscopy or of the El Bayadi lens.

The size of the image inside the front lens is 70% of the retinal size; for
detailed examination, therefore, 50% more microscope magnification is
required than with the other slit-lamp methods. However, the principal
use of this lens is not for its magnification but for its overview, an
overview previously achievable only in fundus drawings or
photocompositions.

Similar contact lens arrangements are used in specially designed fundus

cameras that allow fundus photography of areas 100 degrees or more in
diameter. With lenses such as these, the spectrum of our examining
methods can be extended not only toward higher magnification than
with direct ophthalmoscopy but also, at the other end, toward an
overview of the fundus considerably beyond that obtainable with regular
indirect ophthalmoscopy.

As the technology to calculate, design, and manufacture lenses with

aspheric surfaces has improved, it has been possible to make lenses with
higher powers and better light gathering abilities. The number and
variety of lenses for indirect ophthalmoscopy and of contact lenses for
slit-lamp microscopy has grown accordingly.

RELATED IMAGING TECHNIQUES

Several related techniques to produce retinal images will be discussed

briefly.

Fundus Photography

Fundus cameras have greatly improved the ability to document and

follow fundus lesions. Eduard von Jaeger often spent countless hours
drawing a single fundus, but today a photographic image is available in
a fraction of a second. For reasons mentioned earlier, fundus cameras
are built on the principle of indirect ophthalmoscopy. The observer's
lens and retina are replaced by a camera lens and film. Because all
components are enclosed in a rigid housing, more accessories can be
built in. This includes a dual illumination system, which includes a
constant light source for focusing and a flash for photography, and
filters such as for fluorescein angiography. Rather than placing the
viewing and illumination beams side by side, the illumination beam
generally uses the periphery of the pupil and leaves the center for the
observation beam.24

An angled glass plate that can be flipped to the right or to the left can be
used to slightly deviate the observation beam to the right part or the left
part of the patient's pupil to produce photo pairs that can be viewed
stereoscopically.

Because newer lens designs have allowed the construction of wide-

angle cameras, a special challenge has been to construct the optical
system in such a way that the curved retina is imaged in a plane that can
be captured on a flat film.

Adaptive Optics

The optics of the eye are not perfect. Even if major errors are corrected
with spherical and cylindrical lenses, small irregularities across the
pupillary opening persist. The technique of adaptive optics was
developed for astronomical telescopes to counteract image degradation
by atmospheric irregularities. An adaptive optics system uses a grid to
divide the pupillary opening into many small areas and determines a
separate small correction for each area. The information is fed to a
slightly deformable mirror with microactuators. Thus the image quality
can be enhanced to the point at which the cone mosaic can be clearly
visible. The setup is too laborious for use in routine photography.
Because the corrective system has to be fixed in relation to the pupil, it
cannot be implemented in glasses or contact lenses. However, the
technique, also known as wavefront analysis, has found a place in the
refractive sculpting of the cornea.25
Digital Imaging

The advent of digital cameras has replaced the use of film in many
applications. The advantages include easier storage and manipulation, as
well as greater sensitivity, so that less light can be used or fainter images
can be captured.

Scanning Laser Ophthalmoscope (SLO)

This device takes the advantages of digital imaging one step further. In
conventional photography all points of the object are illuminated and
imaged onto corresponding points of the film simultaneously. In the
Scanning Laser Ophthalmoscope (SLO) the points on the retina are
illuminated sequentially by a scanning laser beam; the diffusely
reflected light is not imaged but collected on a photocell that can collect
light from the entire pupillary area. This allows another significant
increase in light sensitivity. In this process the topographic information
is transformed into a sequential modulation of signals over time. The
image information is recovered by feeding the signals to a video
monitor, in which the beam moves in the same way as did the scanning
beam.26

An interesting application results from the fact that the illuminating

beam can also be modulated to put an image on the retina. Thus it
becomes possible to perform microperimetry, relating the areas where a
stimulus is seen or not seen directly to the retinal image and to the
presence of retinal scarring.27

Optical Coherence Tomography (OCT)

A different form of optical imaging is involved in Optical Coherence

Tomography (OCT). This technique does not produce a fundus image
but uses a low-coherence light beam to provide cross-sectional
information in a way that is analogous to ultrasound B-scan. Because
the wavelength of light is so much smaller than ultrasound wavelengths,
it can produce far higher resolution and can be used to identify the
relationship between layers of the retina and choroid.28

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REFERENCES

1. Meeting of the Physikalische Gesellschaft, Berlin, December 6, 1850

(von Helmholtz' paper, read by his friend Dubois-Raymond, has been
lost)
2. von Helmholtz H: Beschreibung eines Augenspiegels zur
Untersuchung der Netzhaut im lebenden Auge, Berlin (1851).
Translation in Arch Ophthalmol 46:565, 1951

3. Albert DM, Miller WH: Jan Purkinje and the ophthalmoscope. Am J

Ophthalmol 76:494, 1973

4. Mark HH: The first ophthalmoscope? Arch Ophthalmol 84:520, 521,

1970

5. Cumming W: On a luminous appearance of the human eye, and its

application to the detection of disease of the retina and posterior part of
the eye. R Med Chir Soc Lond 29:283, 1846

6. Brcke E: Ueber das Leuchten der menschlichen Augen. Arch Anat

Physiol Wissensch Med 25, 1847

7. Jones W: Report on the ophthalmoscope. Br Med Chir Rev 14:425,

1854

8. Rucker WF: A History of the Ophthalmoscope. Rochester, MN:

Whiting, 1971

9. von Helmholtz H: Ueber eine neue einfachste Form des

Augenspiegel. Arch Physiol Heilk 2:827, 1852

10. Ruete CGT: Der Augenspiegel und das Optometer fr practische

Aerzte. Gottingen, Prussia: Dieterich, 1852

11. Landolt E: Die Untersuchungsmethoden. Berlin, 1:234, 1913

12. Duke-Elder Sir Steward: System of Ophthalmology. Vol 7.

Foundations of Ophthalmology: Heredity, Pathology, Diagnosis and
Therapeutics. St. Louis: Mosby, 1962, 290325

13. Albert DM: Jaeger's Atlas of Diseases of the Ocular Fundus.

Philadelphia: Saunders, 1972

14. Schepens CL: A new ophthalmoscope: Demonstration. Trans Am

Acad Ophthalmol Otolaryngol 51:298, 1947

15. Thorner W: A new stationary ophthalmoscope without reflexes. Am

J Ophthalmol 16:330 and 16:376, 1899

16. Wolff: Report of the XII International Medical Congress,

Ophthalmology Section. Z Augenheilkd 4:327, 1900; Ueber die
zentrische reflexlose Mikro-ophthalmoskopie. Z Augenheilkd 28:307,
1912

17. Gullstrand A: Neue Methoden der reflexlosen Ophthalmoskopie.

Ber Dtsch Ophthalmol Gesellsch 36:75, 1910; Die reflexlose
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18. Giraud-Teulon MALF: Ophthalmoscopie binoculaire on s'exercant

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19. Hruby K: Spaltlampenmikroskopie des hinteren Augenabschnittes

ohne Kontakglas. KIm Monatsbl Augenkeilkd 108:195, 1942

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Vienna: Urban and Schwarzenberg, 1950

21. Goldmann H: Zur Technik der Spaltlampenmikroskopie.

Ophthalmologica 96:90, 1938

22. El Bayadi G: New method of slit lamp micro-ophthalmoscopy. Br J

Ophthalmol 37:625, 1953

23. Schlegel HJ: Eine einfache Weitwinkeloptik zur spaltlampen-

mikroskopischen Untersuchung des Augenhintergrundes. Doc
Ophthalmol 26:300, 1969

24. Pomerantzeff O, Webb RH, Delori FC: Image formation in fundus

cameras. IOVS 18:630, 1979

25. Roorda A: Adaptive optics ophthalmoscopy. J Refract Surg 16:S602,

2000

26. Woon WH, Fitzke FW, Bird AC et al: Confocal imaging of the
fundus using a scanning laser ophthalmoscope. Br J Opthalm 76:470,
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27. Schuchard RA, Fletcher DC: Preferred retinal locus and scanning
laser ophthalmoscope. In Albert DM, Jakobiec FA (eds): Principles and
Practice of Ophthalmology. 2nd ed. Philadelphia: WB Saunders, 1998

28. Hee MR, Izatt JA, Swanson EA: Optical coherence tomography of
the human retina. Arch Ophthalmol 113:325, 1995

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