Fundoscopy: eye examination with an ophthalmoscope

PLAB 2 & PRES 3 · practical skills / ophthalmology · medium · 8 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Mr David Achebe, 54, has type 2 diabetes and attends for his annual review. His visual acuity, checked by the nurse, is 6/6 in both eyes with his glasses. A model eye is provided for the fundoscopy. Please perform fundoscopy, verbalising each step, describe your findings on the model, and explain to the patient what you have found and what happens next.

What examiners look for

Visual acuity before ophthalmoscopy, always: it is the functional measure the fundus findings must be interpreted against, and "6/6 with visible retinopathy" is not a contradiction — diabetic eye disease damages the retina silently long before it touches acuity. That single fact is why screening programmes exist. Dilation is a decision, not a default. Tropicamide blurs vision for hours (a man who drove himself here cannot drive home), and dilation in an eye predisposed to narrow angles can precipitate acute angle closure — so ask about haloes, eye pain and glaucoma first, and be ready to examine undilated and leave dilation to the screening photographers. Red reflex first, disc second, vessels third, macula last. Follow a vessel "upstream" to find the disc; sweep all four quadrants because pathology hides in the periphery of your view; and keep the macula brief — patients cannot tolerate the brightest direct light for long, and you only need a short look. Speak diabetic retinopathy fluently: microaneurysms (earliest sign), dot/blot haemorrhages, hard exudates (leaked lipid), cotton-wool spots (nerve-fibre infarcts), and the sight-threatening trio — new vessels (proliferative disease), macular oedema, vitreous haemorrhage. The grade is built from which of these are present AND absent, so say both. Be honest about the instrument's limits: direct ophthalmoscopy gives a small, monocular field and cannot exclude maculopathy — screening uses photography (and OCT where indicated). A competent candidate states what their examination cannot do; an overconfident one discharges pathology they never saw. And notice the missed screening, because that is the actual clinical problem in this consultation: the findings are early and manageable, but a man who has drifted out of the screening net is how preventable blindness happens. The referral you make today matters more than the description you give.

Guideline references

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