Ophthalmoscope thoughts?

[mrbreakfast]

As a neurology junior, I feel like I have a pretty decent comprehensive exam, but my fundoscopic exam is honestly trash, and it's something I want to focus on this year. While ophthalmoscopes are plentiful in the ED, they're rare on the floors, and most/all of my seniors have their own. I'm looking at my options in purchasing one myself, but I wanted to ask SDN's opinion:

a) As far as I can tell from reading online, Welch Allyn is the Littmann of ophthalmoscopes, but I hear the heart just fine with my off-brand stethoscope. Is a Welch Allyn scope worth it over the much-cheaper-looking scopes on Amazon/eBay?

b) I've heard the panoptic is incredible (never tried it) but even a used head would cost my entire book fund and then some. Also, I've had multiple attendings (including a neuro-ophthalmologist) recommend I focus on proficiency on the standard scope rather than resort to it. Thoughts?

c) Outside of practicing on friends, any recommendations for resources in improving this exam skill? I don't feel comfortable with my exam but also don't feel comfortable blinding my patients while I fumble around trying to get a good look.

Thanks!

---

Members don't see this ad.

 

[Telamir]

A panoptic is ridiculously good. I'd try to use the regular scope and try to get okay-ish at it. That being said, here's my 0.02:

Honestly, I think fundoscopic exam for most neurologist myself included is trash. It's not a skill we practice very often during residency, and it's not that much more common in "attendinghood". I've called ophthalmology based on my "fundoscopic findings" only for me to look like an idiot when they actually dilate the eye. Their experience doing it is vast while ours is only complaint specific and even then not always necessary. You should try to get more comfortable with it but even in the best of cases a neurologist's fundoscopic exam will be hot garbage compared to that of a neuro-ophthalmologist or an ophthalmologist.

I'd recommend trying to get proficient at looking at the optic disc/cup and the retinal arteries. Everything else is best left up to someone from an "eye specialty" anyway.

 

[deathmerchant]

As a neurology junior, I feel like I have a pretty decent comprehensive exam, but my fundoscopic exam is honestly trash, and it's something I want to focus on this year. While ophthalmoscopes are plentiful in the ED, they're rare on the floors, and most/all of my seniors have their own. I'm looking at my options in purchasing one myself, but I wanted to ask SDN's opinion:

a) As far as I can tell from reading online, Welch Allyn is the Littmann of ophthalmoscopes, but I hear the heart just fine with my off-brand stethoscope. Is a Welch Allyn scope worth it over the much-cheaper-looking scopes on Amazon/eBay?

b) I've heard the panoptic is incredible (never tried it) but even a used head would cost my entire book fund and then some. Also, I've had multiple attendings (including a neuro-ophthalmologist) recommend I focus on proficiency on the standard scope rather than resort to it. Thoughts?

c) Outside of practicing on friends, any recommendations for resources in improving this exam skill? I don't feel comfortable with my exam but also don't feel comfortable blinding my patients while I fumble around trying to get a good look.

Thanks!

It certainly helps to have a nice pan-optic scope, but is by no means necessary.
As a neurologist you should be able to look at the disc and detect papilledema. Its good to learn using a regular ophthalmocope- I used to have a bottle of tropicamide in residency that I got from pharmacy and would dilate admitted patients and examine them. It doesn't take long to learn to see the disc.

As mentioned above, unless you are in neuro-ophtha, neurologists suck at rest of the fundus exam.

 

[NOLADO84]

My school required us to buy the Welch Allen that came with the panoptic. Paid off now, but boy was I pissed first year of med school.

 

[GuillainMollaret]

Direct ophthalmoscopes are garbage. The field of view is extremely limited and you really need to scan the retina to get to the disc. After a lot of practice, I can now usually see the disc in 60 to 70% of non-dilated patients.

Panoptics are awesome with a super wide field of view, but certainly less common.

 

[JumpingLumberjacksofMaine]

I got a pan-optic--around 2010, it was around 700 bucks--not cheap, but not a ridiculous amount particularly compared to the cost of training etc. I'm pretty sure that in order to document a full neurologic examination you need to at least attempt to look at the disk--if you do any outpatient, that means that you are practicing seeing the disk at least 3-4x/day (with most new patients). Sure, some of that might be silly, but with most headache patients I feel it's actually pretty important to see the disk (and often you can see spontaneous venous pulsations as well--makes raised ICP very unlikely). I always looked if only to build up my stock of what normal looked like, so that I could at least tell if something looked grossly abnormal. To me, it was definitely worth it to actually feel like I had done a good job at something I was doing so frequently. In addition, while no one will ever mistake you for an ophthalmologist, sometimes you'll run into situations where you can't get that next day ophtho consult.

I never dilated (was nervous about giving somebody acute angle closure glaucoma), though after broaching the question with multiple ophtho's/neuro-ophtho's and they felt it was a generally safe thing to do--you just warn pt's about this SE and to go to the ED if it happens--that would probably really make it much easier.

TLDR: I'd get the pan-optic and use residency as the time to practice the skill and get good at it.

 

[Cere-berus]

A panoptic is ridiculously good. I'd try to use the regular scope and try to get okay-ish at it. That being said, here's my 0.02:

Honestly, I think fundoscopic exam for most neurologist myself included is trash. It's not a skill we practice very often during residency, and it's not that much more common in "attendinghood". I've called ophthalmology based on my "fundoscopic findings" only for me to look like an idiot when they actually dilate the eye. Their experience doing it is vast while ours is only complaint specific and even then not always necessary. You should try to get more comfortable with it but even in the best of cases a neurologist's fundoscopic exam will be hot garbage compared to that of a neuro-ophthalmologist or an ophthalmologist.

I'd recommend trying to get proficient at looking at the optic disc/cup and the retinal arteries. Everything else is best left up to someone from an "eye specialty" anyway.

Do you think a neuro-ophthalmologist trained neurologist would be equal or close to one ophthalmology trained? I'm curious because you mentioned that most fundoscopic exams are subpar from neurologists...

 

[johnny_bananas]

How many people regularly pharmacologically dilate the eyes?

If you think about it, ophthalmologists do it regularly, not sure why it's so rare among neurologists. Not saying to do this with every patient, but for patients where examining the discs are really important, getting the best possible view makes sense.

 

[Captain_Falcon]

How many people regularly pharmacologically dilate the eyes?

If you think about it, ophthalmologists do it regularly, not sure why it's so rare among neurologists. Not saying to do this with every patient, but for patients where examining the discs are really important, getting the best possible view makes sense.

There are risks with dilating the eyes. You can’t just give someone neomed or tropicamide without checking their angle (so you don’t cause acute angle closure), and that requires slit lamp exam

 

[johnny_bananas]

There are risks with dilating the eyes. You can’t just give someone neomed or tropicamide without checking their angle (so you don’t cause acute angle closure), and that requires slit lamp exam

“You can’t just give someone neomed or tropicamide without checking their angle”

Who says, is that based on some guideline? During my residency, the neuro-ophthalmologist would use dilating eye drops regularly before any eye evaluation.

Say a patient has a narrow angle on slit exam, is that going to stop you from dilating their eyes if you are concerned about optic disc edema and you are having difficulty visualizing the optic disc?

The risk of acute angle closure is extremely low with eye drops, with an estimated risk of 1 in 20 000. Fundoscopy: to dilate or not to dilate?: The risk of precipitating glaucoma with mydriatic eye drops is very small

Even if you provoke a patient into closure with eye drops, you are likely doing them a favour. The fact that it has been precipitated in a healthcare setting, warning the patient of the symptoms and what to do. Rather than the alternative, them developing it spontaneously in the community leading to a delay or a misdiagnosis.

 

[Captain_Falcon]

“You can’t just give someone neomed or tropicamide without checking their angle”

Who says, is that based on some guideline? During my residency, the neuro-ophthalmologist would use dilating eye drops regularly before any eye evaluation.

Say a patient has a narrow angle on slit exam, is that going to stop you from dilating their eyes if you are concerned about optic disc edema and you are having difficulty visualizing the optic disc?

The risk of acute angle closure is extremely low with eye drops, with an estimated risk of 1 in 20 000. Fundoscopy: to dilate or not to dilate?: The risk of precipitating glaucoma with mydriatic eye drops is very small

Even if you provoke a patient into closure with eye drops, you are likely doing them a favour. The fact that it has been precipitated in a healthcare setting, warning the patient of the symptoms and what to do. Rather than the alternative, them developing it spontaneously in the community leading to a delay or a misdiagnosis.

You bring up good points, the practicality of a neuro-ophtho using the drops. And although the risk of angle closure is relatively low (1/20,000 as you pointed out) I have seen it occur first-hand even after necessary precautions. Ideally, if under the slit lamp you see their angle is suspect you do a gonio exam to help assess the risk. Ultimately, if someone is having optic disc edema they are likely already at risk of having permanent vision loss so the risk of AACG is definitely the lesser of two evils when it comes to determining what management is needed for the papilledema.

So maybe you've changed my mind on this, I come from a background that is cautious with dilation gtts however. With that said - the bolded I feel is kindof a silly gesture? I guess spontaneous angle closure in the real world could be worse, though most individuals will present symptomatically to the local ED due to blurred vision, redness, vomiting, etc that I don't think there will be too much of a delay in care.

 

[BlueBleck]

I was garbage at it even though I tried to practice a ton as a student. Didn't practice at all intern year. 6 months into PGY2, if there isn't an eye issue like photophobia, bad refractive issues, hx surg, or cataracts, i can pretty reliably see discs. Diagnosed IIH a month ago based on papilledema confirmed later by optho.

Just looked in every non-emergent eye that I could remember. Probably at about 300 eyeballs now. Nothing beats volume.

I have both panoptic + reg. I mostly use the reg because I didn't always have my panoptic. Now i'm faster with the reg. On maybe 1/5 that I can't get with a reg, i can see with a panoptic. Usually wiggly patients. A glance with a standard is disorienting if you can't scan, but with a panoptic a glance is sufficient for the discs.

Haven't seen enough CRAOs to diagnose pale fundi though. Want to see more CRAO.