Red Reflex
- When i perform the fundoscopic exam, i start my focusing on the pupil and red reflex, and then try to focus backwards on the retina. However, most times I try to do this, all i keep seeing is blurry red, and not a clear view of the retina. What's going wrong here?

Shadows and Glare
- Also, sometimes I get a crescent shaped shadow or glare in the middle of the field i'm trying to visualize. Somebody has previously told me i should use the smallest diameter light setting, but this still doesn't solve the problem.

In both instances I am not medically dilating the pupils, I'm just in a dark room.

Thanks,
SH

I assume you are talking about fundoscopy with a direct ophthalmoscope. Keep working at it -- it's tough until you get that first view. Here are a few tips that might help:

* Try practicing on some dilated eyes if you can. You don't learn to ride a bike without training wheels first.

* Make sure you give the patient a good fixation target, make sure they are fixating on it, then try your best not to get in their way. Also, tell them to blink normally. Oh, and so should you.

* Start at about arms length, find the red reflex, then make your approach toward the patient, keeping the red reflex in view.

* Remember that the optic nerve is about 10-15 degrees nasal to the macula, so you should be a little bit lateral to the patient's direct line of sight when you get the nerve in view.

* Keep both eyes open. This is very important.

* When you are up in your patient's face with the scope, their retina will physically be a few inches from your eye. However, the optical system of the patient's eye + the focusing lenses in the scope should make it so that optically the retina is at infinity. So you relax your eyes; it helps to imagine that you are looking at something far away. Keeping both eyes open will help this.

Best of luck.

Make sure you don't have the light intensity cranked all the way up! Turn it down as much as you can. Once you get the ability to focus on the retina and optic nerve you can turn it up a bit, but if the patient is undilated bright light will just cause their pupil to constrict a lot (plus it can worsen reflections and provoke the patient to move their eyes).

There is a decent video on how to use the direct on this webpage:
http://www.med-ed.virginia.edu/courses/pom1/PhysicalExamLinkPage.cfm

The most important error that I corrected in myself is that when the image wasn't good, I used to move my head closer the patient. It's the natural thing to do. I found, however, that by moving backward (i.e. keeping my arm as straight as possible), my view improved.

I realize now that the question was related to the direct ophthalmoscope and my reply was regarding troubleshooting the indirect. Oops!

The video linked above was very good.

My main problems were:
1. I had light on full intensity
- i think the smaller pupil diameter created the shadows
i was seeing and the glare
2. I didn't know what setting was right for me, before I began
- To remedy this I focused on something, with the lights on, that was across
the room from me
- I used this setting (red 1 for me) to view the fundus

The above solutions, found in the video, worked magnificently and I have a much better view of the fundus, even with my Welch Allyn pocketscope

Thanks to all that replied